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

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.

Endogenous fungal endophthalmitis caused by Cladophialophora devriesii: report of a case and literature review

PURPOSE

To report a case of endogenous endophthalmitis caused by the dematiaceous fungus Cladophialophora devriesii.

METHODS

Observational case report and literature review.

CASE PRESENTATION

A 73-year-old female with a history of chronic obstructive pulmonary disease presented with a red and painful left eye. Examination revealed anterior segment inflammation and vitritis, indicative of endophthalmitis. She underwent core vitrectomy and intravitreal injection of vancomycin and amphotericin B. The vitreous sample showed inflammatory cells and fungal hyphae, and systemic amphotericin B and itraconazole were commenced for fungal endophthalmitis. Targeted amplification of the sample for bacterial DNA (V2-V3 region of 16 S rDNA) was negative, but fungal DNA targets (ITS1 and ITS2) were present, and their sequences were consistent with Cladophialophora devriesii. Phenotypic characterisation and sequencing of ITS1 and ITS2, carried out on cultured fungus from the sample, also revealed Cladophialophora devriesii. She received repeated intravitreal injections of voriconazole, and based on the antifungal susceptibility results, her systemic medication was changed to posaconazole. After 12 months, the eye showed no signs of inflammation, and posaconazole therapy was discontinued. After 3 months without antifungal medication, the inflammation recurred, and she was restarted on antifungal therapy for an additional 20 months. Another recurrence occurred 3 months after discontinuation of treatment, and a repeat vitreous sample confirmed the presence of Cladophialophora devriesii. She was started on isavuconazole, but developed seclusio pupillae and painful secondary glaucoma. Due to the duration and severity of the infection, the eye was enucleated. Histopathology revealed persistent fungal elements at the ciliary processes and the posterior lens surface.

CONCLUSIONS

This second reported case of endogenous endophthalmitis caused by Cladophialophora devriesii illustrates the role of vitreous sampling and molecular methods in diagnosis and treatment of fungal endophthalmitis. Despite early diagnosis and prolonged local and systemic antifungal therapy, it was not possible to achieve long-term control of the fungal infection.

Cladosporium spp. endogenous endophthalmitis simulating the classic "headlight-in-the-fog" appearance of active toxoplasmosis

Endogenous fungal endophthalmitis caused by an unusual fungus poses both diagnostic and therapeutic challenges. We report a case of endogenous endophthalmitis caused by a rare mold, namely Cladosporium spp., which presented with a foveal abscess. A 52-year-old male patient who was diagnosed with rectal carcinoma presented with pain, redness, and a loss of vision in the right eye. He had been experiencing the symptoms for 1 week. The patient had undergone gastrointestinal surgery 2 weeks before experiencing the eye complaint. His best-corrected visual acuity was hand movements. Fundus examination revealed a foveal abscess of around a half-disc diameter in size that simulated retinochoroiditis with vitritis. Optical coherence tomography of the macula revealed a hyperreflective lesion in the fovea, which breached the full thickness of the fovea and extended into the preretinal space. Ocular toxoplasmosis was considered. On that basis, oral trimethoprim/sulfamethoxazole was given for 1 week, although the patient's condition worsened. A vitreous tap and an intravitreal combination of vancomycin, ceftazidime, and amphotericin B were administered twice but did not improve the patient's condition. Pars plana vitrectomy was performed and the vitreous biopsy results revealed the presence of Cladosporium spp. Intravitreal voriconazole was given three times and the foveal abscess resolved into a scar. Endophthalmitis caused by Cladosporium spp. is uncommon and published case reports are extremely limited. The present case may provide insight into the variable presentation of fungal endophthalmitis and, therefore, assist with the early diagnosis and appropriate management of the condition.

Combined Therapeutic Penetrating Keratoplasty and Pars Plana Vitrectomy for the Treatment of Infectious Keratitis Endophthalmitis: Mexican Endophthalmitis Study Group Protocol 4

PURPOSE

The purpose of this study was to assess the role of combined surgical treatment of therapeutic penetrating keratoplasty and pars plana vitrectomy in the anatomical and functional outcome of infectious keratitis endophthalmitis.

METHODS

This study reviewed the medical records of 4 participating centers in the United States and Mexico. This study included patients with a clinical diagnosis of infectious keratitis endophthalmitis who had been treated with an early therapeutic penetrating keratoplasty and pars plana vitrectomy as the main treatment for endophthalmitis. From each medical record, the study retrieved demographic data, relevant medical and drug history, baseline clinical manifestation of endophthalmitis, best-corrected visual acuity, and the need for enucleation/evisceration for the control of the infection or any other reason through the follow-up.

RESULTS

The study included 48 patients (50.15 ± 20.6 years). The mean follow-up time was 13 ± 0.5 months. The mean best-corrected visual acuity at baseline was 2.1 ± 0.25 logarithm of the minimum angle of resolution. At month 12 was 2.09 ± 0.61 logarithm of the minimum angle of resolution ( P = 0.9). The overall prevalence of enucleation/evisceration was 8.3% (95% confidence interval: 2.32%-19.98%). The prevalence of a vision of no-light perception was 20.8% (95% confidence interval: 2.32%-19.98%).

CONCLUSIONS

Combined surgery for severe cases of infectious keratitis endophthalmitis eradicates the infection in most cases, while significantly improving the overall outcomes.

A Review on Pathogens and Necessary Diagnostic Work for Bleb-Related Infections (BRIs)

At the present time, as newer techniques and minimally invasive procedures gain popularity among anterior segment surgeons for regulating intraocular pressure, trabeculectomy still has a leading role in glaucoma surgery. Trabeculectomy retains a highly successful and safe profile; however, one of the major complications includes bleb-related infections (BRIs). To date, the most common pathogens remain Gram-positive cocci, but the list of pathogens that have been identified in the literature includes more than 100 microorganisms. Because antibiotic use is more widespread than ever before and our ability to identify pathogens has improved, the pathogen spectrum will broaden in the future and more pathogens causing BRIs will be described as atypical presentations. The scope of this review was to identify all pathogens that have been described to cause bleb-related infections to date, as well as focus on the risk factors, clinical presentation, and various available diagnostic tools used for an appropriate diagnostic workup.

The Diagnosis and Treatment of Fungal Endophthalmitis: An Update

In recent, large case series of fungal endophthalmitis (FE) that were published by Asian authors, the most frequent etiologic agents for all types of FE are molds (usually Aspergillus species, while Fusarium is the prevalent etiology in keratitis-related FE). Candida was the organism found in most cases of endogenous FE. However, we must keep in mind that prevalence of fungal species varies with the geographical area. Lately, polymerase chain reaction (PCR) was increasingly used for the diagnosis of FE, allowing for very high diagnostic sensitivity, while the costs become more affordable with time. The most important shortcoming of PCR—the limited number of pathogens that can be simultaneously searched for—may be overcome by newer techniques, such as next-generation sequencing. There are even hopes of searching for genetic sequences that codify resistance to antifungals. We must not forget the potential of simpler tests (such as galactomannan and β-d-glucan) in orienting towards a diagnosis of FE. There are few reports about the use of newer antifungals in FE. Echinocandins have low penetration in the vitreous cavity, and may be of use in cases of fungal chorioretinitis (without vitritis), or injected intravitreally as an off-label, salvage therapy.