Chronic postoperative endophthalmitis: a review of clinical characteristics, microbiology, treatment strategies, and outcomes

Primary Vitrectomy versus Tap and Inject for Fungal Endophthalmitis: Meta-Analysis and Comparison with Data from a Reference Centre

PURPOSE

We aimed to compare the visual outcomes after pars plana vitrectomy (PPV) versus tap and inject (T&I) in fungal endophthalmitis (FE) reported in the literature and to compare the findings from the literature with data from a reference centre.

METHODS

We performed a systematic review and meta-analysis of studies reporting the use of PPV versus T&I in FE. We also performed a retrospective review of the clinical records of patients with endophthalmitis from a reference centre in Colombia.

RESULTS

We included 13 studies with 334 eyes; 53.59% received PPV and 46.4% received T&I. The overall relative risk of improving ≥ 2 lines in PPV versus T&I was 0.98 (95% confidence interval [CI] 0.80-1.22; p = 0.88) with a mean difference of final visual acuity of 0.26 (95% CI 0.12-0.63; p = 0.18). There were no significant differences in subgroup analysis. Data from the reference centre included 32 endophthalmitis cases, 15.6% of which had a fungal aetiology (80% received PPV and 20% T&I). There were no significant differences in the subgroup analysis.

CONCLUSIONS

Based on the findings from the literature and the reference centre, T&I is noninferior to PPV. This is the first meta-analysis in the literature evaluating these effects in FE. It is necessary to execute new prospective randomised controlled studies in patients with endophthalmitis.

Outcomes of Post-Cataract Surgery Endophthalmitis Managed Without Microbial Cultures

PURPOSE

To evaluate outcomes of eyes with post-cataract surgery endophthalmitis that were managed without microbial cultures.

DESIGN

This retrospective, single-center comparative cohort study identified all cases of endophthalmitis after cataract surgery presenting between February 1, 2014, and November 1, 2022.

SUBJECTS

All eyes presenting with presumed endophthalmitis requiring in-office treatment with intravitreal antibiotics and either a vitreous or aqueous tap were included.

METHODS

Endophthalmitis cases were divided into the "culture group" if the vitreous or aqueous specimens were sent for microbiologic sampling or into the "no culture group" if an aqueous or vitreous tap was performed but not sent for microbiologic sampling.

MAIN OUTCOME MEASURES

Best corrected visual acuity (VA) 12 months following endophthalmitis presentation, incidence of retinal detachment, and need for subsequent procedures.

RESULTS

Of the 232 endophthalmitis cases identified, 196 (85%) were in the "culture group" and 36 (15%) were in the "no culture group". At endophthalmitis presentation, eyes in the "culture group" had a mean (SD) logMAR VA [Snellen Equivalent] of 2.14 (0.8) [20/2760] and mean (SD) logMAR VA in the "no culture group" was 1.93 (0.8) [20/1702] (p=0.185). At 12-month follow up, mean (SD) logMAR VA for the "culture group" was 0.80 (1.0) [20/126] and 0.41 (0.5) [20/50] in the "no culture group" (adjusted difference = 0.41, 95% CI = -0.043 - 0.857, p=0.076). Twenty of 196 (10%) eyes in the "culture group" developed secondary retinal detachments within 12 months of presentation compared to 0 in the "no culture group" (p=0.045).

CONCLUSIONS

Eyes with endophthalmitis following cataract surgery managed without microbiologic cultures have similar visual outcomes to eyes managed with microbiologic cultures and may be less likely to develop secondary retinal detachments. This may be an acceptable strategy to manage endophthalmitis after cataract surgery when prompt access to a microbiologic facility is unavailable.

Uveitis masquerade syndromes: An approach to diagnosis

Uveitis masquerade syndromes are a diverse group of clinical entities which mimic conventional immune-mediated uveitis due to the presence of inflammatory signs but are resistant to anti-inflammatory therapy. Misdiagnosis hinders appropriate management in these conditions and may result in poor outcomes. This review discusses commonly encountered neoplastic and non-neoplastic disease processes that masquerade as intraocular inflammation with a focus on relevant clinical features and adjunctive investigations that are helpful in reaching a correct diagnosis.

Delayed-onset micrococcus luteus-induced postoperative endophthalmitis several months after cataract surgery: A case report

BACKGROUND

Micrococcus luteus (M. luteus)-induced endophthalmitis is very rare and and may present as either acute or chronic postoperative endophthalmitis. The aim of this study was to report a case of delayed-onset M. luteus-induced endophthalmitis that occurred several months after cataract surgery.

CASE SUMMARY

A 78-year-old man presented with decreased vision, pain and redness in the right eye that had begun 3 days prior. He had undergone cataract surgery 4 mo prior. Visual acuity was counting fingers; slit-lamp examination revealed conjunctival injection, posterior corneal precipitates, anterior chamber inflammation (cell 4+), and hypopyon. Fundus examination revealed moderate vitreous haze. Urgent vitrectomy was performed for suspected infectious endophthalmitis, followed by vitreous irrigation with injections of antibiotics. On the postoperative day 1, anterior chamber cell decreased to 2+ and hypopyon was not observed on slit lamp examination. Six days postoperatively, the patient had recurrent eye pain, and the anterior chamber cell grade increased to 4+; hypopyon recurred in the anterior chamber, and whitish plaque was observed in the lens capsule. Therefore, the patient underwent intraocular lens (IOL) and lens capsule removal, followed by vitreous irrigation, antibiotics injection, and vitrectomy. M. luteus was identified from a lens capsule culture.

CONCLUSION

In cases of delayed-onset M. luteus-induced endophthalmitis, early vitrectomy and removal of the IOL and lens capsule may be necessary.

Semi-Autologous Corneal Transplantation with Simultaneous Bilateral Surgery: A Case Report

The present report describes a case of semi-autologous corneal transplantation with bilateral surgery using two operating microscopes simultaneously. An 86-year-old man with history of six prior failed penetrating keratoplasties in his right eye presented with decreased vision. His other eye was deeply amblyopic but had a clear 30-year-old Castroviejo-square graft with an endothelial cell count of 803 cells/mm2. A semi-autologous graft was performed from the left eye to the right. Surgery was performed simultaneously on both eyes by two different surgeons using a standard ophthalmic operating microscope as well as a second ENT microscope. Upon trephination of the right failed corneal graft, vitreous opacities were noted and sent for culture. The semi-autologous tissue was directly transferred from the left eye to the right without any storage in preservation media to avoid endothelial cell loss. The semi-autologous graft remained clear in the immediate postoperative period. However, the vitreous cultures grew coagulase-negative Staphylococcus. Despite all efforts, the patient eventually developed a retinal detachment and vision in the right eye decreased to light perception. Autologous penetrating keratoplasty is an option for patients with loss of corneal function in a potentially seeing eye and a clear cornea in a contralateral eye with poor visual potential due to non-corneal disease. This case is unique in that part of the autologous penetrating keratoplasty had an old square graft in the center and corneal transplant surgery was done simultaneously in both eyes. It also highlights chronic indolent endophthalmitis as a potential cause of multiple graft failures.

Factors associated with recurrence of bleb-related infections

PURPOSE

To identify the risk factors for a recurrence of a bleb-related infection (BRI).

STUDY DESIGN

Retrospective cohort study.

METHODS

The medical records of all patients diagnosed with BRI at Gifu University Hospital between January 1989 and December 2020 were reviewed. The time when conjunctival hyperemia could not be detected and when the anterior chamber was quiet were defined as the resolution time of the BRI. The primary endpoint was a recurrence of a BRI. Kaplan-Meier estimation and the Cox proportional hazards model were used to determine the risk of a recurrence from the initial onset data of each eye. Bacteriological studies were performed to determine the pathogen causing the BRI.

RESULTS

There were 108 eyes of 103 patients followed for at least 3 months after the initial BRI. A recurrent bleb infection developed in 21 (19.4%) eyes of 21 patients (13 men, 8 women). Log-rank test at the 10-year follow-up examination revealed that hypotony at the onset of the BRI (P=0.004), the prophylactic use of topical antibiotics at the onset of the BRI (P=0.046), and bleb leakage after the resolution of the BRI (P=0.021) were significantly associated with a BRI recurrence. Cox proportional hazards model showed that ocular hypotony at the onset of the BRI (unadjusted, P=0.007; adjusted for bleb leakage, P=0.015) and bleb leakage after the resolution of the BRI (unadjusted, P=0.027; adjusted for hypotony, P=0.024) were significantly associated with a BRI recurrence. Other factors were not significantly associated with the recurrence of a BRI.

CONCLUSION

We recommend close observations when a bleb leakage is detected after the BRI has resolved.

Delayed-onset endophthalmitis associated with Achromobacter species developed in acute form several months after cataract surgery: Three case reports

BACKGROUND

Achromobacter species-associated endophthalmitis is rare and may present as either acute or chronic postoperative endophthalmitis. Delayed-onset Achromobacter species endophthalmitis appearing in acute presentation that develops more than several months after cataract surgery is very rare. Intraocular lens (IOL) removal is commonly recommended to treat Achromobacter species endophthalmitis, which is based on previous studies. Here, we report the results of surgery without IOL removal when treating patients with delayed-onset postoperative Achromobacter species endophthalmitis that developed in an acute form.

CASE SUMMARY

Three patients visited our ophthalmology clinic due to visual impairment that began 2-3 d earlier. They had undergone cataract surgery 5-18 mo prior. Best-corrected visual acuity of the diseased eye was between counting fingers at 30 cm to non-light perception. They showed conjunctival injection, inflammation in the anterior chamber (cell reaction 4+) and hypopyon formation. The patients were diagnosed with infectious endophthalmitis and immediately underwent pars plana vitrectomy, anterior chamber irrigation and intravitreal injection of ceftazidime and vancomycin. Before fluid infusion, a vitreous specimen was obtained. In all cases, the IOLs were not removed. Achromobacter species was detected on vitreous specimen culture. After surgery, the vitreous opacity decreased gradually and there was little retinal damage. At 1 mo after treatment, the best-corrected visual acuity had improved to 20/50 and 20/40.

CONCLUSION

Delayed onset postoperative endophthalmitis caused by Achromobacter species can appear in an acute form. All patients responded well to early vitrectomy and administration of empirical antibiotics including ceftazidime. There was no need for IOL removal during surgery.

Chronic postoperative Cutibacterium acnes endophthalmitis with implantable collamer lens

Purpose

We report a case of chronic post-operative endophthalmitis secondary to Cutibacterium acnes (C. acnes) in a patient with an implantable collamer lens (ICL).

Observations

A 45-year-old male presented three months after ICL implantation of the right eye with blurry vision, redness, and ocular pain in the setting of prolonged post-operative anterior chamber (AC) cell. Reduced visual acuity (VA) at 20/30-1, keratic precipitates, 1+ AC cell, and white ICL precipitates were concerning for chronic post-operative endophthalmitis. Anaerobic cultures from a vitreous tap grew C. acnes. Multiple intravitreal and intracameral injections with topical steroids were required to maintain a stable VA at 20/30; however, inflammation persisted and removal of the ICL and his native lens was ultimately required.

Conclusions and importance

Chronic post-operative inflammation and white plaque after ICL implantation should raise high suspicion for endophthalmitis secondary to C. acnes. Anaerobic vitreous cultures can confirm the diagnosis. Removal of the ICL implant is often necessary for treatment. More research is needed to best manage this vision threatening condition.

Decisive role of histopathology of lens capsule in the diagnosis of chronic fungal postoperative endophthalmitis

We report three cases of refractory chronic endophthalmitis after cataract surgery presenting to a referral center, and with repeated negative cultures. Initial treatment consisted of intravitreal and systemic antibiotics, with partial improvement. After subsequent worsening, pars plana vitrectomy, intraocular lens explantation and en bloc capsulectomy were performed. Histopathological examination revealed multiple filamentous fungal structures, sequestered between anterior/posterior lens capsule in all cases. Chronic postoperative fungal endophthalmitis may manifest with negative cultures possibly associated with sequestration of the microorganism into the capsular bag. Careful histopathological examination of lens capsule in these cases may be essential for a definite diagnosis.

Endophthalmitis panorama in the Jerusalem area

PURPOSE

The spectrum of microbial infections and the pattern of their susceptibility are variable among communities. Researching these data will lead to the establishment of the most appropriate national management strategies. The purpose of this study was to analyze the epidemiological, clinical, microbial spectrum and antibiotic susceptibility of endophthalmitis cases in a tertiary referral center in Jerusalem.

METHODS

Retrospective review of medical charts of patients presenting with endophthalmitis over a 12-year period.

RESULTS

A total of 74 eyes of 70 patients (males 56%) were included. Mean age ± SD at presentation was 60 ± 19.5 years. Exogenous endophthalmitis accounted for 78% of cases, of which 62% followed an intraocular surgery, 21% occurred after intravitreal injections, 10% followed infectious keratitis and 7% were posttraumatic. Endogenous cases were predominantly observed in diabetic patients. Microbial isolates were identified in 44 samples. Of them, gram-positive bacteria were the predominant microorganisms detected in 33 samples (75%); Staphylococcus epidermidis and Enterococcus faecalis were the most commonly detected pathogens. Mean presenting ± SD LogMAR visual acuity (VA) was 2.38 ± 1.21 and it improved at last follow-up to 1.7 ± 1.37 (p = 0.004, paired t test). Cases secondary to gram-positive microbes were associated with improved VA during the follow-up while cases secondary to gram-negative microbes was correlated with poor final VA (p = 0.046, r² = 0.4). There was no evidence of bacterial resistance in the antibiograms for either vancomycin, ceftazidime, ceftriaxone or amikacin.

CONCLUSIONS

Intraocular surgery remains the most common event preceding endophthalmitis with coagulase-negative staphylococci being the most frequently detected microorganisms. The microbial spectrum of endophthalmitis is similar to that in the western world.

[Postoperative endophthalmitis-a review of literature]

Postoperative endophthalmitis is one of the most feared complications for ophthalmologists, and the number of infections after intraocular procedures have been increasing. Nonetheless, a prompt intervention can result in the recovery of vision. In the past, endophthalmitis after cataract surgery was accountable for the majority of cases but is becoming less frequent due to the progress of surgical techniques and demographic developments with a steadily increasing number of intravitreal injections. In this article, the different forms of postoperative endophthalmitis are assessed in terms of pathophysiology and their specific characteristics depending on their etiology.

[Treatment of postoperative endophthalmitis : Operate or only inject?]

BACKGROUND

Postoperative endophthalmitis is among the most feared complications encountered after intraocular surgery. A prompt diagnosis and initiation of treatment are crucial for the visual prognosis, which also depends on the causative microorganism. Despite advances in prevention and the availability of more epidemiological data, most of the evidence for treatment dates back to a single study, the early vitrectomy study (EVS) carried out in the early 1990s. The EVS showed that vitrectomy with intravitreal antibiotics was superior to intravitreal antibiotics alone, only when visual acuity was light perception or below. The addition of systemic antibiotics did not have any benefits. Over the last 30 years, however, surgical techniques have continued to evolve and the medicinal options have also been expanded. Moreover, the EVS examined only endophthalmitis after cataract surgery and strictly speaking the results cannot be transferred to endophthalmitis from other causes.

OBJECTIVE

This review discusses the current evidence for the different treatment modalities of the most important types of postoperative endophthalmitis.

CONCLUSION

The EVS provided important guidelines for the initial management of endophthalmitis and these guidelines remain relevant to this day; however, in view of the refinement of surgical techniques, novel treatment options, especially the nowadays continuously growing number of intravitreal injections and even some new antibiotics, it would be desirable if new controlled trials addressing the treatment of endophthalmitis would be performed.

Post intravitreal bevacizumab recurrent Burkholderia cepacia endophthalmitis treated with clear lens extraction in an African

Purpose

To report the successful treatment of post intravitreal bevacizumab recurrent Burkholderia cepacia endophthalmitis managed with a clear lens extraction and posterior capsulectomy.

Observation

A 34-year-old female African, known SC hemoglobinopathy patient, presented with bilateral blur in vision and floaters of a week duration; worse in her right eye. Her visual acuity was right eye 6/9 (20/30) and left eye 6/6 (20/20). Her anterior segment examination was normal in both eyes. On fundus examination, she had a right eye vitreous hemorrhage and bilateral active Sea-fan neovascular proliferation in the retina periphery. Following the administration of bilateral simultaneous intravitreal bevacizumab, she presented 4 days later with a right eye infective endophthalmitis. She suffered multiple recurrences despite adequate treatment, including a vitrectomy with silicone oil injection. Multiple microbiological assessment of intraocular extracts confirmed persistent Burkholderia cepacia infection. A wide ring-shaped opaque plaque was noticed on the posterior capsule of her clear lens. A decision was taken to perform a lensectomy and posterior capsulectomy. This resulted in immediate resolution of hypopyon and all intraocular inflammation. Vision improved from Hand Motion to 6/18 (20/60).

Conclusion and importance

This report suggests than in some cases of recurrent, difficult to treat, Burkholderia cepacia endophthalmitis, since the organism may have colonized the posterior lens capsule, the eye and vision can be salvaged by timely removal of a clear lens and capsulectomy. Clear lens removal has not been previously reported for treating recurrent Burkholderia cepacia endophthalmitis.

Infectious endophthalmitis at a Philippine tertiary hospital: a ten-year retrospective study

Background

Endophthalmitis is a sight-threatening disease characterized by marked progressive inflammation of the vitreous and/or aqueous humors. Limited information is currently available regarding endophthalmitis in the Philippines. This study aimed to provide long-term summary data on endophthalmitis cases seen at the largest tertiary referral hospital in the Philippines.

Methods

All endophthalmitis cases diagnosed at the Philippine General Hospital from January 1, 2007 to December 31, 2016 were retrieved and classified by etiology. Data pertaining to history, associated risk factors, isolated microorganisms, management, and final visual outcomes for each patient were reviewed.

Results

A total of 202 cases diagnosed within the audit period were included in the study. These were classified as post-traumatic (55.94%), endogenous (14.36%), acute post-operative (10.40%), keratitis-induced (6.93%), chronic post-operative (5.44%), bleb-associated (3.96%), and suture-associated (2.97%) endophthalmitis. Males comprised 71.29% of the population, while the largest age group affected was 0–10 years (24.75%). The culture-positive rate was 57.89%. The predominant etiology was Gram-positive bacteria (38.18%), followed by Gram-negative bacteria and mixed pathogens (21.82% each), and fungi (18.18%). The most common organisms were Streptococcus, Staphylococcus, Pseudomonas, Aspergillus, and Candida, accounting for 56.45% of isolates. Pars plana vitrectomy was done for 62.87% of patients, intravitreal and other antibiotic therapy in 23.27%, and primary enucleation/evisceration in 10.89%. The final outcomes and best corrected visual acuities were: anophthalmia 11.86%, no light perception/no dazzle 27.84%, light perception 8.76%, hand motions 24.23%, counting fingers 5.15%, 3/200 to 20/50 12.89%, and 20/40 to 20/20 9.28%.

Conclusions

There was a higher proportion of post-traumatic endophthalmitis cases compared to traditional estimates but consistent with studies from China and Thailand. The majority of these cases involved younger children as well as young to middle-aged males engaged in carpentry and construction work, implying a need for increased public health awareness and strengthening of childcare and workplace safety policies. Our microbiologic profile showed a lower proportion of Gram-positive infections and a higher proportion of mixed pathogen infections compared to other studies. There was also a higher proportion of fungi associated with post-operative and keratitis-induced endophthalmitis. The best outcomes were seen in acute post-operative and bleb-associated endophthalmitis, and the worst outcomes in endogenous and keratitis-induced endophthalmitis. Visual outcomes were poorer compared to other Western and Asian countries, with only 21.7% of patients improving from presentation.

Uveitis-glaucoma-hyphema syndrome associated with an in-the-bag square-edge intraocular lens

A 54-year-old woman presented with recurrent redness and blurred vision of the left eye with elevated intraocular pressure (IOP) for one year. She was treated as “iridocyclitis” and ``Posner-Schlossman syndrome'' at the local hospitals. However, the patient developed intermittent ocular inflammation and hyphema. Patient had a cataract surgery and intraocular lens (IOL) implantation in the left eye one year before at the local hospital. A diagnostic procedure was performed and the possible pathogenesis was discussed.

HW. Post-Traumatic Endophthalmitis Caused by <b><i>Oerskovia turbata</i></b>

Purpose

To present a previously unreported cause of bacterial endophthalmitis manifesting as delayed post-traumatic endophthalmitis ultimately responsive to total capsulectomy.

Case Report

A patient presented with chronic endophthalmitis that occurred after ocular trauma with organic material and Oerskovia turbata was eventually isolated. After a prolonged treatment course, including two pars plana vitrectomies and total capsulectomy, the patient achieved 20/80 visual acuity at 1-year follow-up.

Conclusion

This is the first reported patient with endophthalmitis due to O. turbata, a Gram-positive bacillus found in soil that rarely causes human infection. The infection had a delayed presentation despite early prophylactic antibiotics and was ultimately eliminated with total capsulectomy. Removal of lens and lens capsule may be necessary in the management of post-traumatic endophthalmitis unresponsive to more conservative therapy, particularly in cases involving atypical organisms and lens capsule violation.

Incidence and characteristics of acute-onset postoperative bacterial and sterile endophthalmitis in dogs following elective phacoemulsification: 1,447 cases (1995-2015)

OBJECTIVE To characterize and determine the incidence of acute-onset (ie, developing ≤ 6 weeks after surgery) postoperative infectious and sterile endophthalmitis in dogs following elective cataract surgery. DESIGN Retrospective case series. ANIMALS 2,630 eyes of 1,447 dogs that underwent elective unilateral or bilateral cataract surgery by phacoemulsification at Cornell University from 1995 through 2015. PROCEDURES Medical records were reviewed to collect and summarize data regarding dog signalment, clinical findings, diagnostic test results, surgery characteristics, eye or eyes affected, concurrent major systemic diseases, treatments, and clinical outcome. RESULTS Infectious endophthalmitis developed in 4 eyes of 4 dogs during the follow-up period, representing 0.15% of eyes and 0.28% of dogs that underwent surgery. Unilateral sterile endophthalmitis developed in 3 (0.11%) eyes of 3 (0.21%) dogs. All cases of infectious endophthalmitis were unilateral and in pseudophakic eyes and followed bilateral cataract surgeries. Clinical signs consistent with infectious endophthalmitis developed a median of 18 days after surgery and included marked and progressive hypopyon; Staphylococcus or Streptococcus spp were recovered from aqueous and vitreous humor samples. All eyes with infectious endophthalmitis responded poorly to medical treatment and were enucleated. In 2 eyes with infectious endophthalmitis, corneal incision nonunion with epithelial downgrowth was identified histologically and postulated as the route of bacterial entry into the globe. CONCLUSIONS AND CLINICAL RELEVANCE Bacterial endophthalmitis following elective phacoemulsification was uncommon in the dogs of this study. Introduction of bacteria into the eye may occur during surgery or in the postoperative period from corneal incisions that fail to heal normally.

A diagnostic dilemma in a patient with delayed onset endophthalmitis

We report a case of nonpainful uveitis nine months after an uncomplicated phacoemulsification cataract surgery. Chronic postoperative endophthalmitis was suspected. Diagnostic vitrectomy and partial capsular bag removal was performed, but the specimens cultured in microbiology laboratory showed no pathogens. Systemic workup came positive for skin Tuberculosis test, and presumed intraocular tuberculosis treatment was started accordingly. Inflammation persisted, so a repeat vitrectomy was performed with removal of the lens implant with the capsule, and this time bedside culture inoculation was performed in operating room, revealing Pseudomonas infection. Delayed-onset postoperative endophthalmitis typically progresses slowly and therefore can be confused with uveitis and treated with steroid and immunosuppressant treatment regimes. Our case confirms both the value of immediate bacterial inoculation and the necessity of aggressive surgical treatment in chronic postoperative endophthalmitis cases.

Candida albicans enhances initial biofilm growth of Cutibacterium acnes under aerobic conditions

Candida albicans and Cutibacterium acnes are opportunistic pathogens that co-colonize the human body. They are involved in biofilm-related infections of implanted medical devices. The objective of this study was to evaluate the ability of these species to interact and form polymicrobial biofilms. SEM imaging and adhesion assays showed that C. acnes adhesion to C. albicans did not have a preference for a specific morphological state of C. albicans; bacteria adhered to both hyphal and yeast forms of C. albicans. C. albicans did not influence growth of C. acnes under anaerobic growth conditions, however under aerobic growth condition, C. albicans enhanced early C. acnes biofilm formation. This favorable impact of C. albicans was not mediated by secreted compounds accumulating in the medium, but required the presence of metabolically active C. albicans. The ability of these microorganisms to interact together could modulate the physiopathology of infections.

Cataracts

An estimated 95 million people worldwide are affected by cataract. Cataract still remains the leading cause of blindness in middle-income and low-income countries. With the advancement of surgical technology and techniques, cataract surgery has evolved to small-incisional surgery with rapid visual recovery, good visual outcomes, and minimal complications in most patients. With the development of advanced technology in intraocular lenses, the combined treatment of cataract and astigmatism or presbyopia, or both, is possible. Paediatric cataracts have a different pathogenesis, surgical concerns, and postoperative clinical course from those of age-related cataracts, and the visual outcome is multifactorial and dependent on postoperative visual rehabilitation. New developments in cataract surgery will continue to improve the visual, anatomical, and patient-reported outcomes. Future work should focus on promoting the accessibility and quality of cataract surgery in developing countries.

Chronic post-operative iris prosthesis endophthalmitis in a patient with traumatic aniridia: a case report

Background

Post-operative endophthalmitis is a serious complication of intraocular surgery which may present acutely or chronically. Chronic post-operative endophthalmitis is characterized by decreased visual acuity, mild pain, and low-grade uveitis several weeks or months after intraocular surgery which may be responsive to corticosteroids, but recur upon tapering. Low virulence organisms such as Propionibacterium acnes are the most common culprit organisms, and treatment most often consists of both intravitreal antibiotic injections and surgery.

Aniridia is a condition defined by total or partial loss of the iris and leads to decreased visual quality marked by glare and photophobia. Treatment of complex or severe cases of traumatic aniridia in which surgical repair is difficult may consist of implantation of iris prostheses, devices designed to reduce symptoms of aniridia.

Though chronic, post-operative endophthalmitis has been associated with most intraocular surgeries including intraocular lens implantation after cataract removal, it has never been described in a patient with an iris prosthesis.

Case Presentation

In this case report, we describe the case of a 49 year old, male construction worker with traumatic aniridia who experienced chronic, recurrent low-grade intraocular inflammation and irritation for months after implantation of the Ophtec 311 prosthetic iris. Symptoms and signs of inflammation improved temporarily with sub-Tenon’s capsule triamcinolone injections. Ultimately after more than 2 post-operative years, the iris prosthesis was explanted, and intravitreal cultures showed P. acnes growth after 5 days. Intravitreal antibiotics treated the infection successfully.

Conclusions

To our knowledge, this is the first reported case of chronic, post-operative endophthalmitis in a patient with an iris prosthesis. Chronic, post-operative endophthalmitis may be a difficult to identify in the context of traumatic aniridia and iris prosthesis implantation due to other potential etiologies of chronic intraocular inflammation such as implant-induced chafing. Clinicians should suspect chronic, post-operative endophthalmitis in any case of recurrent, low-grade intraocular inflammation.

[Low grade endophthalmitis caused by P. acnes : Case report]

Low grade endophthalmitis is usually a chronic indolent inflammation that may be misdiagnosed as noninfectious uveitis. Therefore, this form of endophthalmitis is often unsuccessfully treated with corticosteroids. We describe the case of a patient with low grade endophthalmitis caused by Propionibacterium acnes after cataract surgery. This case report presents the difficulties in establishing the diagnosis of this form of endophthalmitis as well as the benefits of a combined operative therapy with pars plana vitrectomy, intravitreal antibiotics and posterior capsulectomy for successful treatment in such cases.

Endophthalmitis: state of the art

Endophthalmitis is an uncommon diagnosis but can have devastating visual outcomes. Endophthalmitis may be endogenous or exogenous. Exogenous endophthalmitis is caused by introduction of pathogens through mechanisms such as ocular surgery, open-globe trauma, and intravitreal injections. Endogenous endophthalmitis occurs as a result of hematogenous spread of bacteria or fungi into the eye. These categories of endophthalmitis have different risk factors and causative pathogens, and thus require different diagnostic, prevention, and treatment strategies. Novel diagnostic techniques such as real-time polymerase chain reaction (RT-PCR) have been reported to provide improved diagnostic results over traditional culture techniques and may have a more expanded role in the future. While the role of povidone-iodine in prophylaxis of postoperative endophthalmitis is established, there remains controversy with regard to the effectiveness of other measures, including prophylactic antibiotics. The Endophthalmitis Vitrectomy Study (EVS) has provided us with valuable treatment guidelines. However, these guidelines cannot be directly applied to all categories of endophthalmitis, highlighting the need for continued research into attaining improved treatment outcomes.

Recovery of visual function after administration of dabigatran etexilate

A 46-year-old Caucasian female underwent pars plana vitrectomy (ppv) for retinal detachment. After the procedure, the patient could only distinguish hand movements; the condition was tentatively diagnosed as nonarteritic anterior ischemic optic neuropathy. Conventional treatment with systemic corticosteroids and acetylsalicylic acid was ineffective and yielded substantial steroid-related side effects. Additional administration of 2 × 110 mg dabigatran etexilate (Pradaxa(®)), a novel direct thrombin inhibitor, resulted in a prompt and marked improvement of visual acuity, which indicated improved blood flow in the central vessels of the optic nerve. Dabigatran etexilate may provide a promising alternative for the treatment of postprocedural vision loss after ppv.

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.

Recurrent endophthalmitis after trabeculectomy for glaucoma: importance of timely filtering bleb coverage for the conjunctiva

Purpose

To report the occurrence of endophthalmitis after trabeculectomy for glaucoma that was treated by vitrectomy without bleb closure and recurred 3 times after an initial clinically inapparent period of about 2 years.

Methods

Interventional case report and short review of the pertinent literature.

Results

A 73-year-old Caucasian female underwent trabeculectomy (without mitomycin) for glaucoma. Four years after the trabeculectomy, an endophthalmitis with Staphylococcus epidermidis as the causative organism occurred and was treated with a pars plana vitrectomy (20-gauge) and a combined antibiotic and anti-inflammatory drug regimen. The bleb was not covered during the emergency procedure because the filtering bleb was heavily infected and filled with pus. As the filtering bleb healed nicely and the filtering function was restored, the filtering bleb was left as it was, and best-corrected visual acuity initially recovered to 0.8. After 22 months, the endophthalmitis recurred, this time with Enterococcus faecalis as the causative organism. Its treatment required a total of four further vitrectomies (23-gauge), each accompanied by the same antibiotic and anti-inflammatory drug regimen that had been applied previously. However, the visual acuity could not be preserved, and the eye is blind with defective light projection.

Conclusions

The literature suggests an aggressive surgical approach to endophthalmitis, and the present case report confirms this. Since the visual prognosis of eyes after endophthalmitis is poor, the course of treatment for endophthalmitis after trabeculectomy should emphasize recurrence prophylaxis rather than address glaucoma symptoms and therefore include safe bleb leak coverage.

Exogenous group G Streptococcus endophthalmitis following intravitreal ranibizumab injection

We report a case of group G Streptococcus endophthalmitis following an intravitreal ranibizumab injection for a choroidal neovascular membrane. Pars plana vitrectomy was applied for endophthalmitis and group G Streptococcus cultures were isolated in the vitreous samples taken from the patient. Twenty-four hours following pars plana vitrectomy the patient underwent myocardial infarction and cardiac arrest. To our knowledge this is the first reported case of group G Streptococcus endophthalmitis following an intravitreal injection.