Paediatric post-traumatic endophthalmitis

Microbiological Landscape and Epidemiology of Endophthalmitis in Children and Adolescents in a Multi-Tier Ophthalmology Network in India: An Electronic Medical Record-Driven Analytics Report

PURPOSE

To study the epidemiology and microbiological landscape in patients (≤21 yrs) diagnosed with endophthalmitis across a multi-tier ophthalmology network in India.

METHODS

This cross-sectional hospital-based study included 1,041 patients (≤21 yrs) diagnosed with endophthalmitis, between April 2012 and May 2022. The data were collected using an electronic medical record system.

RESULTS

Bacteria (24%) was the most common etiology followed by fungus (2%). The majority of the patients were male (66%) with a mean age of 8.37 ± 5.99 years. The most common age group was middle childhood (6-11 years) with 365 (35.06%) patients. The patients were more commonly from the lower socio-economic status (60.81%) and urban geography (49%). The common cause of endophthalmitis was trauma (59.33%) and amongst the 279 culture positive eyes, the predominant bacteria isolated was Streptococcus pneumoniae followed by Bacillus species and fungus included predominantly Aspergillus and Candida species. The most common surgical intervention performed was intraocular antibiotics (74%) followed by pars plana vitrectomy (52%).

CONCLUSION

The most common etiology of endophthalmitis in children is bacterial and traumatic in nature and presented from the lower socio-economic status. A half of the eyes warranted a vitreo-retinal surgical intervention.     .

Pediatric Endophthalmitis Over the Last Five Decades: A Case Report and Systematic Review

INTRODUCTION

Pediatric infectious endophthalmitis is a rare, severe ocular infection that can have devastating consequences. It may be exogenous or endogenous, with exogenous endophthalmitis being more common. Current data on the etiology, microbiology, antibiotic treatments and outcomes in pediatric cases is limited.

PURPOSE

To summarize the etiology, microbiology, visual outcomes and management of pediatric endophthalmitis.

METHODS

A literature review was conducted on cases of pediatric endophthalmitis published from 1980 to 2022, identified through searches of PubMed, Medline, Web of Science and Google Scholar databases.

RESULTS

A total of 796 patients were included. Ocular trauma was the most common cause with 623 patients (78.3%), followed by posteye surgery with 100 patients (12.6%) and endogenous endophthalmitis with 67 patients (70 eyes) (8.4%). Among culture-positive cases, gram-positive microorganisms predominated. Treatment involved pars plana vitrectomy in 608 patients (76%) and intraocular antibiotics in 590 patients (74%). Favorable visual acuity (≥20/200) was achieved in 30.5% of patients, 20% had no light perception and 12.5% developed poor anatomical outcomes with phthisis bulbi.

CONCLUSION

Our review provides insights into the etiology, epidemiology, microbiology, treatment and visual outcomes of pediatric endophthalmitis based on available literature worldwide.

Clinical and pathogenic characteristics of infectious endophthalmitis in children: A retrospective analysis

Infective endophthalmitis is an ophthalmic infection that in severe cases can cause complete loss of vision. In children, the defense against infection is low and eye tissue is not fully developed, leading to increased vulnerability to endophthalmitis. Children may be unable to understand the symptoms; thus, developing a method for prevention and treatment of this disease in children is important. Therefore, we analyzed the clinical and pathogenic characteristics of infectious endophthalmitis in children and provided evidence for clinical treatment. The clinical data of 78 children (78 eyes) with infectious endophthalmitis were retrospectively analyzed. The clinical characteristics, pathogen distribution, drug sensitivity, clinical medication, and treatments were summarized and analyzed. In total, 74 (94.87%) had ocular infections caused by trauma and 75 (96.15%) were from rural townships. A total of 108 sterile specimens were examined, with a positive detection rate of 37.04%. The sensitivity rates of Gram-positive cocci and bacilli to vancomycin were 100%. The sensitivity rates of Gram-negative bacilli to ceftazidime, piperacillin/tazobactam, amikacin, gentamicin, ciprofloxacin, and levofloxacin were 100%. Of the 78 patients, 53 (67.95%) received intravitreal injection and 54 (69.23%) underwent vitrectomy. Trauma is the main factor leading to infectious endophthalmitis in children, wherein Gram-positive bacteria are the most common pathogens. Thus, a timely understanding of the pathogen and drug sensitivity is needed. Intravitreal injection and vitrectomy are effective treatments.

Risk Factors for Development of Endophthalmitis after Open Globe Injury in Children: A Case-Control Study

AIM

To identify risk-factors for developing endophthalmitis following open globe injury (OGI) in children.

METHODS

Retrospective, single-center, case-control study of children aged <18 years who sustained OGI.

RESULTS

Our cohort of 93 eyes consisted of 30 cases (Group A- endophthalmitis) and 63 controls (Group B- no endophthalmitis). Twenty-four eyes (80%) diagnosed with endophthalmitis presented after 24 hours of injury. The presence of central corneal zone-1 injuries (Odd ratio [OR]: 6.64, p= 0.001) and vitreous in wound (OR: 3.53) were associated with the risk of developing endophthalmitis. (p= < 0.05) Additionally the presence of iris prolapse (OR: 4.76) and posterior capsular rupture (PCR) (OR: 5.80) increased the risk of developing endophthalmitis.(p <0.05) . Streptococci was isolated in 15 eyes, Pseudomonas in 3 eyes, and Candida in 1 eye. The visual outcomes at three months were significantly worse in Group A (LogMAR 1.77±1.06) compared to Group B (LogMAR 0.65±0.68)(p<0.05).

CONCLUSION

Central corneal involvement, vitreous/ iris incarceration and PCR were important risk factors for development of PTE in children.

Paediatric traumatic cataracts in Southwest China: epidemiological profile

BACKGROUND

Paediatric traumatic cataracts are an important but preventable cause of acquired blindness. Understanding the epidemiology of paediatric traumatic cataracts is a prerequisite for prevention. This study aimed to characterize the epidemiological profile of paediatric traumatic cataracts in southwest China.

METHODS

The medical records of children (age range, 0-14 years old) who developed traumatic cataracts following open-globe injuries and were hospitalized at the Department of Ophthalmology at West China Hospital, between January 2011 and December 2020 were retrospectively analyzed. The demographic data, causes of injuries, posttraumatic complications, and visual acuity were recorded and analysed.

RESULTS

A total of 716 eyes from 716 patients were analysed in this study, including 521 (72.8%) males and 195 females in a gender ratio of 2.67:1; 117 of the patients were of ethnic minorities. Paediatric traumatic cataracts occurred more frequently in winter (32.5%). Sharp metal objects (scissors/knives/needles/sheet metal/nails/darts) - induced ocular injuries accounted for the highest proportion, followed by botanical sticks (wooden sticks /bamboo sticks /bamboo skewers)-induced injuries, and then stationery items (pencils/pens/rulers/paper)-induced injuries. The majority (68.7%) of the patients were aged 2-8 years, and the peak range of age was 4 - 6 years. The injuries were a result of penetrating trauma in 64.9% of patients, and blunt force trauma in the remainder (35.1%). Additionally, 131 (18.3%) cases developed posttraumatic infectious endophthalmitis after injuries. Patients with eye injuries caused by needles (P < 0.001), wooden sticks (P = 0.016), and bamboo skewers (P = 0.002) were at a greater risk of developing infectious endophthalmitis. The most common identified foreign organism was Streptococcus, which accounted for 42% (21/50) of all culture-positive specimens and was sensitive to vancomycin. Among the children who were younger than 5 years, 44.4% (55/124) of those with traumatic cataracts presented a corrected distance visual acuity less than or equal to 0.1 after undergoing cataract surgery, but among the children who were older than 5 years, this proportion was significantly smaller, just 20.4% of children aged 6-10 years (P < 0.001) and 18.4% of children aged 11-14 years (P < 0.001).

CONCLUSION

The main causative agents of paediatric traumatic cataracts in southwest China were sharp metal objects, botanical sticks, and stationery items. Specific preventive measures are essential to reduce the incidence of paediatric traumatic cataract.

Pediatric endophthalmitis: clinical profile, outcomes, and a proposed protocol

PURPOSE

To investigate the clinical profile and visual outcomes of infectious endophthalmitis in children at a single tertiary hospital in France, and propose an evidence-based protocol for management.

METHODS

This is a retrospective monocentric study that involved children with a history of endophthalmitis between January 2008 and January 2020. The clinical characteristics, etiology, microbiological spectrum from aqueous/vitreous tab, anatomical and visual outcomes, and management were analyzed. The Fischer and chi-square tests were used in the statistical evaluation.

RESULTS

Twenty-six children were eligible for inclusion. The mean patients age at presentation was 4.2 years (range, 8 days-14.3 years). With regard to etiology, patients were divided into posttraumatic group (n = 7 (26.9%)), postoperative group (n = 15 (57.7%)), endogenous group (n = 3 (11.5%)), and infectious corneal ulcer group (n = 1 (3.9%)). Time-to-onset of symptoms was highest in children ≤ 3 years old and in the postoperative subgroup who had at least one glaucoma procedure. Microbiology results showed growth in 12/26 (46.2%). The most common microorganism identified was Streptococcus pneumoniae (5/12 (41.7%)). The antibiotic regimen varied depending on age, organism, and sensitivities. The final visual outcomes were 20/200 or better in 11/26 (42.3%) eyes, and 13/26 (50.0%) eyes had no light perception. Twelve of twenty-six (46.2%) eyes ended up with phthisis bulbi.

CONCLUSION

Pediatric endophthalmitis is a rare but devastating condition with poor visual prognosis, requiring prompt recognition and treatment. Despite aggressive management with antibiotics and vitrectomy, the visual prognosis is generally poor. A protocol for management with an adapted systemic antibiotic therapy is proposed in order to improve outcomes.

Post-traumatic endophthalmitis with Moraxella in a child

Purpose: To describe a case of post-traumatic endophthalmitis with Moraxella in a child. Methods: Case report of an 11-year-old boy who presented with redness and profound visual loss in his left eye for 3 days following trauma with a sewing needle. Detailed ophthalmic examination showed hand movement vision, corneal edema with mobile hypopyon, as well as dot and clump echoes in Ultrasound B-scan. The clinical diagnosis of acute post-traumatic endophthalmitis was made. Result: The patient underwent pars plana vitrectomy and vitreous biopsy, and was given intravitreal antibiotics (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, voriconazole 0.1 mg/0.1 ml). Non-pigmented small colonies growth was observed on culture plates which were identified as Moraxella. Conclusion: To date, no case report has been published regarding post-traumatic endophthalmitis due to Moraxella species in the pediatric age group.

Open globe injuries in children under 7 years referred to a tertiary center in Iran from 2006 to 2016

PURPOSE

Open globe injuries are one of the most common causes of monocular blindness in many countries. The impact of this traumatic event on patients' quality of life and health is considerable. This study describes the characteristics of open globe injury in children younger than 7 years.

METHODS

Six hundred and twenty-two patients were included in this retrospective study. Patients under 7 years with open globe injury were included.

RESULTS

Among 622 patients, 403 (64.8%) were male and 219 (35.2%) were female. The type of material that caused the open globe injury was metallic material in 355 (57.1%) cases, wood in 89 (14.3%) cases, glass in 87 (14%) cases, plastic in 30 (4.8%) cases and other materials in 61 (9.8%) cases. The time between the occurrence of ocular trauma to patient admission was <12 hours in 414 (66.6%) patients and between 12 and 24 hours in 101 (16.2%) patients. The time between patient admission to first surgical intervention was <12 hours in 493 (79.3%) patients, between 12 and 24 hours in 88 (14.1%) patients. The rate of traumatic endophthalmitis in our study was 14.3% at presentation. The most common organism was Streptococcus viridans. Traumatic endophthalmitis was significantly related to the male gender, the time between the occurrence of ocular trauma to patient admission, and time between patient admission to first surgical intervention and wooden material (p < 0.001).

CONCLUSION

This study showed that open globe injuries were more prevalent in boys older than four years. The earlier patient's referral was associated with a lower rate of endophthalmitis. The most common cause of traumatic endophthalmitis in pre-school children was S. viridans.

Traumatic endophthalmitis and the outcome after vitrectomy in young children

AIM

To explore the traumatic endophthalmitis in young children and the outcome of pars plana vitrectomy (PPV).

METHODS

Twenty-two eyes of 22 cases of young children consecutive pediatric traumatic endophthalmitis treated and followed up between September 2014 and May 2018 were included. Aqueous humor or vitreous samples were taken for bacterial culture and sensitivity tests. Intravitreal antibiotics (norvancomycin and ceftazidime) injection, combined with 23-gauge PPV, were administered in 22 eyes. Silicone oil (SO; 5000 centistoke) tamponade or perfluoropropane gas (C₃F₈) was used in all patients. Main outcome measures were best-corrected visual acuity (BCVA) and retinal attachment, the ratio of penetrating injury, and the existence of intraocular foreign body.

RESULTS

The mean age of patients was 6.9±2.2 (range, 3-10)y. All injured eyes suffered from penetrating ocular injury with retained intraocular foreign body in one eye. Bacterial culture was positive in only 2 eyes. The mean follow-up time was 21.1±4.7 (range, 12-30)mo. In the primary PPV, intravitreal antibiotics was administrated in all eyes, SO in 18 eyes, and C₃F₈ in 4 eyes. The secondary operation of SO removal and C₃F₈ endotamponade was performed in 16 eyes and a second SO endotamponade due to emulsification of the oil and retinal detachment (RD) was operated in 7 eyes underwent 3 to 11.5mo after primary PPV. A third operation was done in 7 eyes. The final intraocular pressure (IOP) was 8.9±1.8 (range, 6.9-11.4) mm Hg. The final BCVAs were 20/200 or better in 5, counting fingers in 2, and light perception to hand movement in 8 eyes. Whose (66.7%) had retinal injury exhibited worse BCVA (P=0.019, Fisher's exact test). Eyes underwent SO tamponade exhibited worse final BCVA than that with C₃F₈ in the primary PPV (P=0.026, Fisher's exact test).

CONCLUSION

Traumatic endophthalmitis in children is generally more severe and associated with more complicated surgical procedures. Most patients have retinal injury need multiple operations and the final BCVA is poor. Prevention of ocular trauma, especially in children, is still critical.

Clinical and Microbiological Features of Pediatric Endopthalmitis After Open Globe Injury in the North of VietNam

BACKGROUND

Pediatric endophthalmitis after open-globe injury had its clinical features, microbiological profile different from those in aldults. In Viet Nam, there was no report on the clinical and microbiological characteristics of pediatric posttraumatic endophthalmitis. Therefore, we conduct this study.

AIM

To describe clinical features, ultrasound results, gram stain and culture results of endophthalmitis in pediatric open globe injuries.

METHODS

Prospective non-controlled study. Case series of 30 eyes presenting with post-traumatic endophthalmitis between 2015 and 2016 were reviewed.

RESULTS

Mean age was 8.03 ± 3.99 years. Metallic and organic etiologies were the most common causes for injuries (n = 11). 27 cases had penetrating corneal trauma. Dense opaque vitreous was seen in 25 eyes. Retinal necrosis < 1 quadrant and chorioretinal abscess > 1 quadrant were the most common fundus lesions. Dense vitreous opacity on ultrasound was most common (n = 28). Gram stain bacteria positivity was 93.3%, gram-positive was isolated in 63.3%. Vitreous samples were more often positive than aqueous (P = 0,002).

CONCLUSION

Posttraumatic endophthalmitis in children is more common in boys aged 6-10 years and most often caused by injury with metallic and organic matters. Culture results were very low. Vitreous samples were more often positive than aqueous. Gram-positive bacteria were the most common causative organism.

Paediatric endophthalmitis: a UK retrospective study

INTRODUCTION

Paediatric endophthalmitis is a severe but rare complication of intraocular surgery, penetrating trauma and far less commonly extra-ocular surgery or endogenous origin. We set out to establish the incidence and risk factors of exogenous endophthalmitis in children, and to develop an evidence-based protocol that can be used for treatment of suspected exogenous endophthalmitis in children.

METHODS

Microbiology reports and operation numbers were obtained from two large tertiary referral hospitals sharing 24-h paediatric ophthalmology cover for the period January 2009-December 2016. All cases of aqueous and/or vitreous tap performed on children aged ≤18 years were identified and case notes reviewed for complete information on each case.

RESULTS

Sixteen cases were eligible for inclusion as 'postoperative endophthalmitis': complete data was found on 13 cases. The incidence of postoperative endophthalmitis was 0.17% over 7 years. The mean age of presentation was 5.5 years (range from 7 months to 16 years and 9 months), from 3 days-78 months post operatively. In all, 11/13 had at least one glaucoma procedure. Microbiology results showed growth in 8/13. Most isolates were Gram-positive bacteria but Gram-negatives were also isolated and in one case Candida from a conjunctival swab. The antibiotic regime varied depending on age, organism identified and sensitivities. In all, 9/13 had hand movement or worse vision after treatment.

CONCLUSION

Paediatric endophthalmitis may present to any paediatric/general ophthalmologist. It is a rare but devastating condition with poor visual prognosis, requiring prompt recognition and aggressive management. Previous glaucoma surgery is a long-term risk factor in our local paediatric population. Based on our study, an evidence-based protocol for management is proposed in order to improve outcomes.

Phthisis Bulbi-a Clinicopathological Perspective

Phthisis bulbi denotes end-stage eye disease characterized by shrinkage and disorganization of the eye with the resultant functional loss. The major factors associated with the pathogenesis of phthisis are hypotony, deranged blood-ocular barriers, and inflammation. Common causes include trauma, surgery, infection, inflammation, malignancy, retinal detachment, and vascular lesions. A phthisical globe shows a small squared off shape, opaque and thickened cornea, thickened sclera, neovascularization of iris, cataract, cyclitic membrane, ciliochoroidal detachment, and retinal detachment. Microscopic features include internal disorganization, inflammatory reaction, a reactive proliferation of various cells, calcification, and ossification. Early treatment of the causative etiology is the best strategy available to avoid an eye from going into phthisis. A phthisical eye has no visual potential and cosmetic rehabilitation or symptomatic relief of pain remains the mainstay in the management. The authors present a comprehensive review of the etiopathogenesis, pathology, clinical features, and management of the end-stage ocular disease.

[Posttraumatic endophthalmitis : Complication following severe eye injury]

BACKGROUND

Posttraumatic endophthalmitis is a rare but another extremely threatening complication for quality of vision, which has already been compromised by the trauma after perforating eye injuries. One of the substantial difficulties is the distinction between posttraumatic inflammation and development of a bacterial infection.

METHODS

In a hospital-based study 149 consecutive cases of perforating ocular trauma with open injuries to the eye within a 5-year period were retrospectively investigated. The study included assessment of the relationship between the severity of the injury and the risk of posttraumatic endophthalmitis using the ocular trauma score (OTS), the diagnosis, the therapeutic management and the prognosis concerning visual outcome 1 year after the posttraumatic endophthalmitis.

RESULTS

In this study posttraumatic endophthalmitis was observed in 8 out of 149 cases (5.4 %) after perforating ocular injuries. Severe injuries had a higher risk of this complication. In comparison to the clinical courses of non-postraumatic endophthalmitis, the visual outcome showed a tendency to be worse after an average of 18 ± 6 months (1.25 vs 1.0 logMAR). In all of the cases the posttraumatic endophthalmitis could be successfully treated with antibiotics and surgery and the already severely limited visual function due to the injury could at least be maintained in most cases.

DISCUSSION

Due to the low case numbers statistical evidence of a clear benefit of treatment by a rapidly initiated and intensive individualized surgery following trauma and a pathogen-specific and operative therapy is not possible: nevertheless, such a comprehensive therapeutic approach to posttraumatic endophthalmitis is recommended.

Pediatric Infectious Endophthalmitis: A 271-case Retrospective Study at a Single Center in China

Background:

Pediatric infectious endophthalmitis is a serious sight-threatening disease for children. The purpose of this study was to investigate the etiology, microbiological spectrum, and visual outcomes of infectious endophthalmitis in children at a single institution in China.

Methods:

It is a retrospective study of the medical records of all patients under 14 years of age with histories of infectious endophthalmitis, treated at a single institution from January 1, 2009 to January 1, 2015. The clinical characteristics, etiology, microbiological spectrum, and management, as well as the visual outcomes, were analyzed. The Kappa test and Chi-square test were used in the statistical evaluation.

Results:

A total of 271 children were identified, with a mean age of 5.61 ± 2.93 years (range 5 months to 14 years). Ocular trauma (94.8%) and previous ocular surgery (3.0%) were the most common etiologies. Overall, 147 (54.2%) cases had positive cultures, and 176 organisms were isolated from these patients. A single species was isolated in 120 (81.6%) cases, with multiple organisms in 27 (18.4%) cases, and the most commonly identified organisms were coagulase-negative Staphylococcus and Streptococcus species, comprising 29.5% and 26.8% of the isolates, respectively. Moreover, of 176 isolates, 142 (80.8%) were Gram-positive organisms, 23 (13.0%) were Gram-negative organisms, and 11 (6.2%) were fungi. The final visual outcomes were 20/200 or better in 66 (24.4%) eyes, counting fingers to 20/200 in 34 (12.5%), hand motions in 30 (11.1%), light perception in 33 (12.2%), no light perception in 32 (11.8%), and 9 (3.3%) eyes were enucleated or eviscerated. The visual outcomes were not available in 67 (24.7%) patients.

Conclusions:

Penetrating ocular trauma is the most frequent cause of pediatric endophthalmitis in China. Streptococcus and Staphylococcus species are the most commonly identified organisms in exogenous pediatric endophthalmitis whereas Fusarium species are commonly seen in endogenous endophthalmitis. In this research, in spite of aggressive management with antibiotics and vitrectomy, the visual prognosis was found to be generally poor.

Pediatric Posttraumatic Endophthalmitis in China for Twenty Years

Pediatric posttraumatic endophthalmitis (PTE) is a rare but serious disease that frequently has a poor visual prognosis. To date, only a few English studies have focused on this disease. We perform a systematic review of the Chinese literature on pediatric PTE and describe the epidemiology, management, causative organisms, and visual acuity outcomes of reported cases in twenty years. We found that Staphylococcus epidermidis was the most common isolated organism and the use of a disposable syringe needle was the most common cause of ocular injuries in pediatric PTE in China. In the last ten years, the time from injury to first presentation for treatment has shortened, the proportion of cases resulting from a disposable syringe needle has decreased, the use of intravitreal antibiotics as the initial treatment has increased, and the use of palliative treatment has decreased. Although these favorable changes have occurred in the last ten years, the visual prognosis of pediatric PTE is still poor.

Posttraumatic Endophthalmitis in children: Epidemiology, Diagnosis, Management, and Prognosis

Pediatric posttraumatic endophthalmitis presents with great complexities and challenges arising due to delayed presentation, difficulty in eliciting an accurate history, or trauma with unusual and highly contaminated objects. The possibility of initial misdiagnosis as panuveitis, metastatic endophthalmitis, and masquerade syndrome is also very high, which results not only in several unwarranted investigations being performed, but also a delay in the initiation of treatment. The standard treatment remains primary repair of the wound, intravitreal therapy with broad spectrum antibiotics, and parsplana vitrectomy. Despite appropriate intervention, visual outcome in children with posttraumatic endophthalmitis is dampened by additional factors like poor compliance with postoperative instructions and high risk of amblyopia. Hence, it is important to recognize that posttraumatic endophthalmitis in children differs from that in adults in several ways. We made a very tailored effort to review the published literature pertaining to posttraumatic endophthalmitis in children and herein present the results of our search.

Post-traumatic endophthalmitis in 143 eyes of children and adolescents from India

PURPOSE

The purpose of this study was to describe clinical features, risk factors, causative organisms, treatment options, and outcomes of post-traumatic endophthalmitis in children and adolescents.

METHODS

Retrospective interventional case series. Case records of 143 consecutive eyes presenting with post-traumatic endophthalmitis between 1997 and 2007 were reviewed. Univariate and multivariate analysis were done to analyze factors associated with adverse outcomes.

RESULTS

Mean age at presentation was 9.2 years (median 8 years, range: 2 months to 18 years). Broomstick and hypodermic needle were most common causes for injuries. Common presenting features were cataract (n=51), hypopyon (n=45) and retinal detachment (n=29). Corneal abscess (n=21; OR: 5, CI: 1.4-18.7) and retinal detachment (n=29, OR: 5, CI: 1.6-11.3) were independent risk factors for poor outcome (P=0.04 and 0.012, respectively). Gram-positive bacteria were isolated in 54% (n=31) of culture-positive cases. Forty-nine (34%) patients had ambulatory vision at final visit. Patients who received treatment within 24 h were 3.6 and 9 times more likely to have better anatomical outcome than those treated at 2-7 days, or >7 days, respectively (P=0.0001). Patients undergoing early vitrectomy were 27 times more likely to have better outcome (P=0.0001).

CONCLUSION

Post-traumatic endophthalmitis in children is more common in boys <10 years of age and most often caused by injury with organic matter. Corneal abscess and retinal detachment are associated with poor outcome. E. fecalis is the most common causative organism. Early vitrectomy results in better outcomes.

Pediatric open globe injury: A review of the literature

Open globe injury (OGI) is a severe form of eye trauma estimated at 2-3.8/100,000 in the United States. Most pediatric cases occur at home and are the result of sharp object penetration. The aim of this article is to review the epidemiology, diagnosis, management, and prognosis of this condition by conducting a systematic literature search with inclusion of all case series on pediatric OGI published between 1996 and 2015. Diagnosis of OGI is based on patient history and clinical examination supplemented with imaging, especially computed tomography when indicated. Few prospective studies exist for the management of OGI in pediatric patients, but adult recommendations are often followed with success. The main goals of surgical management are to repair the open globe and remove intraocular foreign bodies. Systemic antibiotics are recommended as medical prophylaxis against globe infection, or endophthalmitis. Other complications are similar to those seen in adults, with the added focus of amblyopia therapy in children. Severe vision decline is most likely due to traumatic cataracts. The ocular trauma score, a system devised to predict final visual acuity (VA) in adults, has proven to be of prognostic value in pediatric OGI as well. Factors indicating poor visual prognosis are young age, poor initial VA, posterior eye involvement, long wound length, globe rupture, lens involvement, vitreous hemorrhage, retinal detachment, and endophthalmitis. A thorough understanding of OGI and the key differences in epidemiology, diagnosis, management, and prognosis between adults and children is critical to timely prevention of posttraumatic vision loss early in life.

Pediatric infectious endophthalmitis: a review

Infectious endophthalmitis is a rare but severe complication of septecemia, intraocular surgeries, or penetrating eye trauma. The etiology, prognosis, and management of pediatric endophthalmitis resulting from exogenous and endogenous infections are reviewed. Open-globe trauma and glaucoma surgery are the most frequent causes of endophthalmitis in children, whereas endogenous infection is the least common cause. Streptococcus and Staphylococcus species are common bacterial agents in both posttraumatic and postoperative pediatric endophthalmitis, whereas Candida albicans is a commonly reported organism in endogenous endophthalmitis. Additionally, Streptococcus pneumoniae and Haemophilus influenzae appear more likely as pathogens in children than in adults. The clinical manifestations and outcome usually correlate with the virulence of the infecting organism. The visual prognosis of endophthalmitis is generally poor.

Endophthalmitis

Endophthalmitis means bacterial or fungal infection inside the eye involving the vitreous and/or aqueous humors. Most cases are exogenous and occur after eye surgery, after penetrating ocular trauma, or as an extension of corneal infection. An increasing number of cases are occurring after intravitreal injections of anti-vascular endothelial growth factor (VEGF) medications. Endophthalmitis may also be endogenous, arising from bacteraemic or fungaemic seeding of the eye. The infected eye never serves as a source of bacteraemia or fungaemia, however. The most common pathogens in endophthalmitis vary by category. Coagulase-negative staphylococci are the most common causes of post-cataract endophthalmitis, and these bacteria and viridans streptococci cause most cases of post-intravitreal anti-VEGF injection endophthalmitis, Bacillus cereus is a major cause of post-traumatic endophthalmitis, and Staphylococcus aureus and streptococci are important causes of endogenous endophthalmitis associated with endocarditis. In Taiwan and other East Asian nations, Klebsiella pneumoniae causes most cases of endogenous endophthalmitis, in association with liver abscess. Endogenous fungal endophthalmitis in hospitalized patients is usually caused by Candida species, particularly Candida albicans. Acute endophthalmitis is a medical emergency. The most important component of treatment is the intravitreal injection of antibiotics, along with vitrectomy in severe cases. Systemic antibiotics should be used in cases of endogenous endophthalmitis and exogenous fungal endophthalmitis, but their role in exogenous bacterial endophthalmitis is uncertain. Repeated intravitreal injections of antibiotics may be necessary if there is no response to the initial therapy. Many eyes that receive prompt and appropriate treatment will recover useful vision.

Endophthalmitis: A review of recent trends

Endophthalmitis is a feared complication of trauma, surgical procedures and septicemia. Although uncommon, its potential for significant visual loss is well recognized. Especially over the past decade, complicated surgeries and medical techniques have increased and seriously ill patients are being sustained in ever increasing numbers. New pathogens are being recognized and known ones reclassified thanks to advances in molecular analysis. Continuously evolving PCR methodologies also add a new dimension to the diagnosis of infectious endophthalmitis. As well, medical literature is now truly international, encompassing studies from around the world that expand our understanding of ocular infectious disease. This report reviews some of these changes as they relate to endophthalmitis and particularly to the spectrum of organisms involved.

Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives

Endophthalmitis is a rare but sight-threatening complication that can occur after ocular surgery or trauma or as a consequence of systemic infection. To optimize visual outcome, early diagnosis and treatment are essential. Over recent decades, advances in hygienic standards, improved microbiologic and surgical techniques, development of powerful antimicrobial drugs, and the introduction of intravitreal antibiotic therapy have led to a decreased incidence and improved management of endophthalmitis. However, endophthalmitis still represents a serious clinical problem. This review focuses on current principles and techniques for evaluation and treatment of endophthalmitis. In addition, it addresses recent developments regarding antimicrobial treatment and prophylaxis of infectious endophthalmitis.

Exogenous Endophthalmitis in Pediatric Age Group

PURPOSE

To identify the microbiological spectrum and visual outcome of exogenous infectious endophthalmitis in the pediatric age group.

METHODS

We reviewed the medical records of all children 14 years and younger with culture-positive endophthalmitis treated at King Khaled Eye Specialist Hospital and King Abdulaziz University Hospital between January 1, 1980, and December 31, 2004.

RESULTS

Forty-nine children were identified. There were 32 males and 17 females with a mean age of 5.7 +/- 2.8 years (range 1-13 years). Thirty-five (71.4 %) cases occurred after penetrating open globe injuries and the remaining 14 (28.6%) followed ocular surgery. Primary vitrectomy was performed on 29 (59.2%) eyes. The mean follow-up was 28.4 +/- 28.4 months (range 1.2-98.5 months). A single species was isolated in 42 (85.7%) eyes, and multiple organisms in seven (14.3%) with a total of 56 infecting organisms. The most common isolates were Streptococcus species and coagulase-negative Staphylococci comprising 44.6% and 21.4% of the isolates, respectively. Final visual acuity was 20/200 or better in 15 (34.1%), counting fingers in 8 (18.2%), light perception to hand motions in 8 (18.2%), no light perception in 13 (29.5%) eyes, including 3 that have been enucleated or eviscerated, and not available in 5 patients. None of the children who had nonvirulent organisms had a final visual acuity of no light perception compared with 39.4% of children who had virulent organisms (p = 0.011). Visual outcome of counting fingers was attained in 26% of children who were treated with primary vitrectomy compared with 5.9% of children treated with antibiotics alone on presentation (p = 0.0484). Visual outcome was no light perception in 18.5% of children who underwent primary vitrectomy compared with 47.1% of children treated with antibiotics alone.

CONCLUSIONS

The most common organisms identified were Streptococcus species and coagulase-negative Staphylococci. Culture of a nonvirulent organism, and treatment with primary vitrectomy were associated with better visual outcomes. Visual outcomes were generally poor.

Anesthetic management of preschool children with penetrating eye injuries: postal survey of pediatric anesthetists and review of the available evidence

BACKGROUND

Pediatric anesthetists were surveyed regarding their anesthesia management of a screaming child with a penetrating eye injury. The results are reviewed in relation to the available evidence in the literature.

METHODS

A postal survey was sent to all the members of the APA living in the UK. Seven clinical questions were asked regarding the management of penetrating eye injury and two questions regarding seniority and the number of cases seen.

RESULTS

Of the 318 questionnaires sent out 238 were evaluated. Of the responders indicating the number of cases seen, 21.2% had never seen a single case, 55.1% had seen <5, 17.8% had seen 5-10, and 5.9% had seen >10 cases. Suxamethonium was used more often by respondents who had handled more cases; 42.9% of those doing >10 compared with 10% of those doing less than five cases. Senior anesthetists preferred the use of techniques without relaxants and to extubate children under deep anesthesia.

CONCLUSIONS

Few people have extensive experience managing a penetrating eye injury in a child. A variety of anesthesia techniques are used for induction with anesthetists avoiding suxamethonium, despite there being little evidence in the literature that the use of suxamethonium is harmful to the open globe.

Post traumatic polymicrobial endophthalmitis, including Neisseria subflava

DESIGN

To report the second known case of post-traumatic endophthalmitis caused by Neisseria subflava.

DESIGN

Interventional case report.

METHODS

A two-year-old child with post-traumatic corneal laceration and uveal prolapse required medical and surgical therapy for endophthalmitis caused by multiple organisms including N. subflava.

RESULTS

After aggressive therapy, patient had a favorable outcome without vision compromise.

CONCLUSIONS

As there is still not a standard protocol for therapy for post-traumatic endopthalmitis, we recommend the use of broad-spectrum antibiotics via intravitreal, intravenous, and topical routes. Consideration of typical and unusual bacteria that have been reported to cause endopthalmitis, as well as the source of injury, should guide antibiotic choice.

Open globe injuries with positive intraocular cultures: factors influencing final visual acuity outcomes

PURPOSE

To investigate the clinical features influencing final visual acuity outcomes of eyes with positive intraocular cultures after open globe injuries.

DESIGN

Retrospective, consecutive, interventional case series.

PARTICIPANTS

Thirty-seven patients.

METHODS

The medical records were reviewed of all patients with positive intraocular cultures after open globe injuries treated at Bascom Palmer Eye Institute between January 1, 1995, and December 31, 2001.

MAIN OUTCOME MEASURES

Final visual acuity. Clinical features investigated included the following: (1). presence or absence of clinical endophthalmitis; (2). virulence of the cultured organism (coagulase-negative Staphylococci, Corynebacterium, and Propionibacterium acnes were classified as nonvirulent organisms, whereas all other organisms were classified as virulent organisms); (3). presence of intraocular foreign body (IOFB); (4). presence of retinal detachment; (5). interval between ocular injury and surgical repair; (6). severity of vision loss at presentation; (7). zone of injury; (8). wound length; and (9). presence of vitreous hemorrhage.

RESULTS

The study included 37 eyes of 37 patients with a mean age of 30 years (range, 18 months-85 years) and a median follow-up of 13 months (range, 1-71 months). Study eyes were stratified into two groups: group 1 eyes (n = 16) were those in which clinical endophthalmitis did not develop, whereas group 2 eyes (n = 21) were those in which clinically diagnosed endophthalmitis developed at some point during their clinical course. Presenting visual acuity was similar in the two groups (mean logarithm of the minimum angle of resolution [logMAR] acuity, 1.91 and 2.22 [Snellen equivalents, 2/162 and 2/331] respectively; P = 0.33). Final acuities in the two groups were different, but not to a statistically significant level (mean logMAR acuity, 1.14 and 2.05 [Snellen equivalents, 20/276 and 2/224], respectively; P = 0.069). In group 1, final visual acuity ranged from 20/20 to no light perception (median acuity, 20/186); 12 eyes (75.0%) achieved a final visual acuity of 20/400 or better. In group 2, final visual acuity ranged from 20/25 to no light perception (median acuity, 7/200); of 20 eyes with known final visual acuity, 10 (50.0%) retained 20/400 or better vision. In group 1, three eyes (19%) eyes had virulent organisms, and 13 eyes (81%) had nonvirulent organisms. In group 2, 12 eyes (57%) had virulent organisms, and nine eyes (43%) had nonvirulent organisms. A final acuity of 20/60 or better was achieved in 14 eyes (41%), and a final acuity of 20/400 or better was achieved in 22 eyes (59%). Better presenting visual acuity (P = 0.038), culture of a nonvirulent organism (P = 0.011), lack of a retinal detachment (P = 0.002), absence of clinical endophthalmitis (P = 0.069), and shorter wound length (P = 0.024) were associated with better visual acuity outcome. In four of six eyes (67%) with both an IOFB and clinical endophthalmitis (group 2), the final visual acuity was no light perception (IOFB was not itself significantly associated with final visual acuity; P = 0.11).

CONCLUSIONS

Among eyes with positive intraocular cultures after open globe injury, the visual prognosis is guarded. Clinical features associated with better visual acuity outcomes include better presenting visual acuity, culture of a nonvirulent organism, lack of a retinal detachment, absence of clinical endophthalmitis, and shorter wound length.

Clostridium beijerinckii endophthalmitis secondary to penetrating ocular injury

Endophthalmitis occurs in five to 10% of injuries involving intraocular foreign bodies. A 52 year old abattoir worker sustained such penetrating ocular trauma and developed fulminant endophthalmitis. Clostridium beijerinckii was isolated from the vitreous humor. Intravitreal vancomycin and amikacin and intravenous penicillin and clindamycin were given. Despite therapeutic vancomycin and amikacin levels in the vitreous, vision was lost and enucleation was ultimately required.

Characterization of Bacillus thuringiensis isolated from infections in burn wounds

Four strains of Bacillus thuringiensis were isolated from infections in burn wounds and from water used in the treatment of burn wounds. The strains produced large parasporal inclusion bodies composed of 141, 83, and 81 kDa protoxins. The four strains were tested for insecticidal activity against larvae of Pieris brassicae and Aedes aegypti but showed no activity; Vero cell assays for the production of enterotoxins were also negative. Attempts to classify the strains according to flagellar H-serotype showed them all to be non-flagellated. Apart from two occupational health accidents that occurred during the handling of highly concentrated B. thuringiensis fluids, this is the first report of B. thuringiensis causing non-gastrointestinal clinical infection in immunosuppressed patients.