Burkholderia cepacia, a cause of post pars plana vitrectomy silicone oil related endophthalmitis: clinico-pathological presentation and outcome of management

Endophthalmitis caused by Burkholderia cepacia complex (BCC): clinical characteristics, antibiotic susceptibilities, and treatment outcomes

PURPOSE

To report the clinical characteristics, antibiotic susceptibilities, and review the literature of Burkholderia cepacia complex (BCC) associated endophthalmitis.

STUDY DESIGN

Retrospective, observational case series.

METHODS

Clinical and microbiology records were reviewed for patients evaluated at the Bascom Palmer Eye Institute and diagnosed wisth culture-confirmed endophthalmitis due to BCC. Antibiotic susceptibility profiles were generated using standard microbiologic protocols via an automated VITEK system.

RESULTS

Endophthalmitis associated with BCC was diagnosed in three patients. Infection occurred in the setting of post-penetrating keratoplasty (PKP), glaucoma filtering surgery, and suspected trauma. All isolates demonstrated in vitro susceptibility to ceftazidime and meropenem. Presenting visual acuity (VA) ranged from hand motion to light perception. Initial treatment strategies included intravitreal ceftazidime (2.25 mg/0.1 mL) and vancomycin (1.0 mg/0.1 mL) injections with fortified topical antibiotics in 2 patients, and surgical debridement of a corneoscleral melt with patch graft along with both topical fortified antibiotics oral antibiotics in the third patient. In all 3 patients, there was no VA improvement at last follow-up, as 2 eyes ultimately underwent enucleation and 1 eye exhibited phthisis bulbi at last follow-up. BCC related endophthalmitis was reviewed among 13 reports. Treatment outcomes were generally poor and antibiotic resistance was common. These BCC isolates cases demonstrated broad resistance patterns, with susceptibilities to ceftazidime (58%), ciprofloxacin (53%), and gentamicin (33%).

CONCLUSIONS

Endophthalmitis caused by B. cepacia is a rare clinical entity with generally poor visual outcomes despite prompt treatment with appropriate antibiotics.

Endophthalmitis caused by Burkholderia cepacia complex (BCC): Clinical characteristics, antibiotic susceptibilities, and treatment outcomes

Purpose

To report the clinical characteristics, antibiotic susceptibilities, and review the literature of Burkholderia cepacia complex (BCC) associated endophthalmitis.

Study design

Retrospective, observational case series.

Methods

Clinical and microbiology records were reviewed for patients evaluated at the Bascom Palmer Eye Institute and diagnosed with culture-confirmed endophthalmitis due to BCC. Antibiotic susceptibility profiles were generated using standard microbiologic protocols via an automated VITEK system.

Results

Endophthalmitis associated with BCC was diagnosed in three patients. Infection occurred in the setting of post-penetrating keratoplasty (PKP), glaucoma filtering surgery, and suspected trauma. All isolates demonstrated in vitro susceptibility to ceftazidime and meropenem. Presenting visual acuity (VA) ranged from hand motion to light perception. Initial treatment strategies included intravitreal ceftazidime (2.25 mg/0.1 mL) and vancomycin (1.0 mg/0.1mL) injections with fortified topical antibiotics in 2 patients, and surgical debridement of a corneoscleral melt with patch graft along with both topical fortified antibiotics oral antibiotics in the third patient. In all 3 patients, there was no VA improvement at last follow-up, as 2 eyes ultimately underwent enucleation and 1 eye exhibited phthisis bulbi at last follow-up. BCC related endophthalmitis was reviewed among 13 reports. Treatment outcomes were generally poor and antibiotic resistance was common. These BCC isolates cases demonstrated broad resistance patterns, with susceptibilities to ceftazidime (58%), ciprofloxacin (53%), and gentamicin (33%).

Conclusions

Endophthalmitis caused by B. cepacia is a rare clinical entity with generally poor visual outcomes despite prompt treatment with appropriate antibiotics.

Endophthalmitis in Silicone Oil-Filled Eyes

Incidences of post pars plana vitrectomy (PPV) endophthalmitis vary between 0.02% and 0.13%, and infectious endophthalmitis in silicone oil-filled eyes is even rarer. We performed a literature review to describe the incidence, protective and predisposing factors, causative pathogens, management options, and prognosis of infectious endophthalmitis in silicone oil-filled eyes. Various studies have elucidated different aspects of this condition. Causative pathogens commonly include commensals. Traditional management involves the removal of silicone oil (SO), intravitreal antibiotics and then SO re-injection. Alternatively, injecting intravitreal antibiotics into silicone oil-filled eyes has also been reported. Visual prognoses are uniformly guarded. Due to the uncommon nature of this condition, studies are limited either by their retrospective design or by small sample sizes. However, observational studies, case series, and case reports can play an important role in rare conditions until larger studies are conducted. This comprehensive review aims to summarise the information available in the literature, to act as a good source for ophthalmologists looking for answers on this topic, and to suggest areas for future development.

Citrobacter koseri: A Cause of Silicone Oil Related Endophthalmitis after Post Pars Plana Vitrectomy

Purpose. We present a rare case of Citrobacter koseri culture-positive endophthalmitis in a postvitrectomy silicone oil-filled eye. Case report. A 64-year-old male patient presented to our ophthalmology emergency room with representative symptoms of acute endophthalmitis. He underwent a plana vitrectomy oil-filled tamponade previously. Preoperative and postoperative findings of the case were reported. Results. Culture tests of aqueous, silicone oil, and vitreous taps were positive for Citrobacter koseri. Conclusions. Culture-positive endophthalmitis in a silicone oil-filled eye has very rarely been in the literature. The described cases were caused by acute inflammatory reactions to silicone oil and were culture-negative. The postvitrectomy culture-positive endophthalmitis caused by Citrobacter is a very rare condition, and its management is not so smooth. Approaching with silicone oil removal, intraoperative intravitreal antibiotic injection, and silicone oil reinjection was performed in our case with good outcomes.

The Role of Silicone Oil in the Surgical Management of Endophthalmitis: A Systematic Review

(1) Background: We aimed to systematically review the current literature to evaluate if in patients with postoperative endophthalmitis treated with pars plana vitrectomy, silicone oil tamponade could provide a useful contribution to the control and eradication of infection and if it could influence anatomical recovery and functional outcome. (2) Randomized controlled trials, cross-sectional studies, case series, and case reports published in the English language in peer-reviewed journals were included. No restriction was placed based on the study location. We used medical subject headings (MeSH) and text words. We searched MEDLINE (OVID and PubMed), Google Scholar, ISI Web of Science (Thom-on-Reuters), and the Cochrane Library (Wiley) from January 1995 to the present. To ensure literature saturation, we scanned the reference lists of included studies or relevant reviews identified through the search. Risk of Bias was assessed using the Newcastle-Ottawa scale for longitudinal studies and Cochrane risk-of-bias tool for randomized trials. (3) Results: abstracts of 75 articles were selected for full-text reading; after full-text reading, 44 articles were taken into consideration in the systematic review. 5 out of 7 in vitro experimental studies demonstrated antimicrobial activity against different species of bacteria and fungi. The use of SO as endotamponade associated with PPV led to better visual acuity and a lower rate of retinal detachment and the need for additional surgery. (4) Conclusions: Silicone oil reduces the risk of postoperative retinal detachment, especially in case of undetected retinal breaks, produces compartmentalization of the eye, may lead to early visual recovery, allows laser photocoagulation, prevents severe postoperative hypotony and has antimicrobic activity due to an inhibitory effect for several species of pathogens. Concerns regarding possible toxic effects on the retina and optic disc, compartmentalization and impaired washout of pathogen toxins have been reported. It may also influence intravitreal antibiotic distribution and clearance.

CULTURE-POSITIVE ACUTE POSTVITRECTOMY ENDOPHTHALMITIS IN A SILICONE OIL-FILLED EYE

BACKGROUND/PURPOSE

The aim of this report was to present the details of a case of culture-positive endophthalmitis in a silicone oil-filled eye.

METHODS

This report includes the description of the preoperative, intraoperative, and postoperative findings of the case.

PATIENT

A 73-year-old male patient presented to our emergency department with complaints and symptoms indicative of acute postvitrectomy endophthalmitis.

RESULTS

Aqueous, silicone oil, and vitreous washout samples tested positive for Streptococcus pneumoniae after a culture test.

CONCLUSION

Culture-positive endophthalmitis in a silicone oil-filled eye has rarely been described in literature. The reported cases were culture-negative cases, possibly because they were cases of acute inflammatory reactions to silicone oil. In the present case, an otherwise healthy patient developed acute endophthalmitis after pars plana vitrectomy plus silicone oil tamponade. The case was successfully managed with conventional silicone oil removal, antibiotic injection, and silicone oil reinjection.

Clinical profile, visual outcome and root cause analysis of post-operative cluster endophthalmitis due to Burkholderia cepacia complex

Purpose:

To present varied clinical presentations, surveillance reports, and final visual outcomes of a rare outbreak of cluster endophthalmitis caused by gram-negative, opportunistic bacilli, Burkholderia cepacia complex (Bcc).

Methods:

Details of five patients who developed postoperative cluster endophthalmitis were collected. For each patient, an undiluted vitreous sample was collected during vitreous tap. Bacterial culture from the vitreous sample in each case had grown Bcc. Surveillance investigations for root cause analysis (RCA) were performed in the operating room (OR), admission, and day-care wards to localize the source.

Results:

Four patients had undergone phacoemulsification surgery, and one patient had undergone penetrating keratoplasty. Each patient received an initial dose of empiric intravitreal ceftazidime and vancomycin. The organism isolated in each case was sensitive to ceftazidime, cotrimoxazole, and meropenem and resistant to other antibiotics. Core vitrectomy was done after 48–60 hours in four patients along with intravitreal imipenem injection. One patient did not provide consent for core vitrectomy and subsequently developed phthisis bulbi. Three patients had subsequent recurrences. Two patients had a final BCVA of 20/60, two had BCVA better than 20/200, while one patient had no perception of light. None of the surveillance samples from the OR complex could isolate Burkholderia.

Conclusion:

Extensive OR surveillance should be done to identify the potential source of infection. However, the source may not be identifiable in few instances like in our case. Longer follow-up is recommended in cases of Bcc endophthalmitis due to the persistent nature of the infection.

Clinical course, treatment and visual outcome of an outbreak of Burkholderia contaminans endophthalmitis following cataract surgery

Background

Postoperative endophthalmitis is a rare but dreaded complication of intraocular surgery and often results in severe visual impairment or blindness. The present study describes the clinical course, treatment and visual outcome of an outbreak of Burkholderia contaminans endophthalmitis following cataract surgery.

Methods

Among 290 patients who underwent uneventful phacoemulsification cataract surgery at one outpatient clinic between January 4th and 28th 2019, 6 cases developed Burkholderia contaminans endophthalmitis. Clinical data were collected by retrospective review of patient records. Microbiological samples from vitreous aspirates, intraocular lenses (IOL) and lens capsules were cultured, and recA and draft whole genome sequences analysed.

Results

The recA sequences of all Burkholderia contaminans isolates and the allelic profile of the isolates were identical. All cases had a similar clinical presentation with rapid development of endophthalmitis symptoms with variable time to onset. The mean time to admission was 34 days (12–112 days). All cases had a seemingly favourable response to intravitreal antibiotics. However, acute recurrences occurred after long time periods (12–71 days). The cases experienced between 0 and 3 recurrences. Due to persistent infection, the cases received between 5 and 15 treatments (mean 7.8) including IOL and lens capsule explantation in 5 of 6 cases. Burkholderia contaminans was detected in all explanted lens capsules. The final corrected distance visual acuity (CDVA, Snellen chart) was between 0.8 and 1.2 and all cases had final CDVA ≥0.8.

Conclusions

A persistent and intensive treatment approach including total lens capsule and IOL explantation is recommended for Burkholderia contaminans endophthalmitis following cataract surgery and may lead to a favourable visual result.

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.