Neonatal endogenous endophthalmitis: a report of six cases

Gram-Negative Endogenous Endophthalmitis: A Systematic Review

Background: Gram-negative bacteria are causative agents of endogenous endophthalmitis (EBE). We aim to systematically review the current literature to assess the aetiologies, risk factors, and early ocular lesions in cases of Gram-negative EBE. Methods: All peer-reviewed articles between January 2002 and August 2022 regarding Gram-negative EBE were included. We conducted a literature search on PubMed and Cochrane Controlled Trials. Results: A total of 115 studies and 591 patients were included, prevalently Asian (98; 81.7%) and male (302; 62.9%). The most common comorbidity was diabetes (231; 55%). The main aetiologies were Klebsiella pneumoniae (510; 66.1%), Pseudomonas aeruginosa (111; 14.4%), and Escherichia coli (60; 7.8%). Liver abscesses (266; 54.5%) were the predominant source of infection. The most frequent ocular lesions were vitreal opacity (134; 49.6%) and hypopyon (95; 35.2%). Ceftriaxone (76; 30.9%), fluoroquinolones (14; 14.4%), and ceftazidime (213; 78.0%) were the most widely used as systemic, topical, and intravitreal anti-Gram-negative agents, respectively. The most reported surgical approaches were vitrectomy (130; 24.1%) and evisceration/exenteration (60; 11.1%). Frequently, visual acuity at discharge was no light perception (301; 55.2%). Conclusions: Gram-negative EBEs are associated with poor outcomes. Our systematic review is mainly based on case reports and case series with significant heterogeneity. The main strength is the large sample spanning over 20 years. Our findings underscore the importance of considering ocular involvement in Gram-negative infections.

Ophthalmic findings in a septic calf with the concurrent exhibition of meningitis and endophthalmitis

The aim of this study was to evaluate the impacts of ophthalmic findings obtained from both macroscopic examination and ocular ultrasonography when diagnosing bovine endophthalmitis. A newborn crossbreed (Japanese black and Holstein breeds) calf was suspected of visual impairment and central nervous system (CNS) symptoms, such as decreased activity and weak drinking performance. This calf was found to display macroscopic signs, such as clouded lens, convergent strabismus, and horizontal nystagmus, in both eyes. On ocular ultrasonography of both eyes, a V-shaped, thickened, hyperechoic structure was present in the anechoic vitreous humors, indicating retinal detachment. The animal died 4 days after the examination. Sepsis was evident in this case, as Escherichia coli was isolated from multiple organs. The autopsy and histological examination revealed meningitis, encephalitis, and secondary hydrocephalus in the CNS, and endophthalmitis and retinal detachment in both eyes. In this case, the ophthalmic findings did not provide definitive evidence for a diagnosis of endophthalmitis. However, this study indicated that retinal detachment might be an ultrasonographic finding that is suggestive of bovine endophthalmitis.

Endogenous endophthalmitis and multifocal brain abscess-An interesting case

We present an unusual case that staphylococcal brain abscess can present in an immunocompetent with endogenous endophthalmitis secondary to a septic foci and early prevention of dissemination with appropriate management to prevent its complications.

Clinical presentations, microbiology and management outcomes of culture-proven endogenous endophthalmitis in India

Purpose:

To report the clinical presentation, microbiology, and management outcome of endogenous endophthalmitis in Indian patients.

Methods:

Retrospective chart review of culture-positive (vitreous/urine/blood) endogenous endophthalmitis cases treated in tertiary eye care facility in India was done.

Results:

The study included 173 eyes of 117 patients. Mean patient age was 25.41 ± 20.46 years (median 24 years). Pre-disposing systemic illness could not be elicited in 79 (67.63%) patients. Commonest predisposing systemic condition in patients where it could be detected (n = 79) was pyrexia of unknown origin (25/79 = 32.0%). Following treatment, 45 out of 173 (26.0%) eyes regained vision of ≥20/400. Commonest isolated organism from vitreous was Streptococcus pneumoniae (36 eyes, 20.8%) and fungi were isolated in 24 (13.8%) eyes, the commonest being Candida spp. (8/24, 33.33%). Favorable functional outcome was seen in 26% eyes and favorable anatomic outcome in 43% eyes. Those with an underlying systemic illness were older (P = 0.02), had greater urine culture positivity (P = 0.003), lesser vitreous culture positivity (0.001), greater gram negative etiology (P = 0.0006), and greater fungal etiology (P = 0.01) as compared to those cases without underlying systemic illness.

Conclusion:

Endogenous endophthalmitis in India often presents in young immunocompetent individuals without any underlying systemic illness and with negative blood or urine microbiologic work up. Underlying systemic illness leads to greater gram-negative and fungal etiology. Overall visual outcome is poor inspite of prompt management.

Endophthalmitis in Retinopathy of Prematurity after Intravitreal Aflibercept Injection

We report the case of a male infant who had an intravitreal anti-VEGF (aflibercept) injection for the treatment of retinopathy of prematurity at 35-week postmenstrual age. Four days following the injection, retinal imaging demonstrated a yellowish gray blurred mass that extended into the vitreous in the right eye, and the vitreous body was blurred. After two days, despite starting endophthalmitis treatment, there was still no improvement in the retinal lesion. Due to the worsening of the clinical signs, we decided to perform 25-gauge lens-sparing pars plana vitrectomy.

Trends in Infantile Endogenous Endophthalmitis Hospitalizations in the United States: An Analysis from 2007 through 2014 Using the National Inpatient Sample

PURPOSE

To determine the annual change in incidence of neonatal and infantile endogenous endophthalmitis in the United States between 2007 and 2014 and identify associated risk factors for development of endophthalmitis and mortality.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Neonates (<28 days; n = 1650) hospitalized for endogenous endophthalmitis between 2003 and 2014 and infants (age range, 28 days-1 year; n = 1850) hospitalized between 2007 and 2014 across United States community hospitals were analyzed.

METHODS

The Nationwide Inpatient Sample database was queried to identify neonates hospitalized for endogenous endophthalmitis between 2003 and 2014 and infants hospitalized between 2007 and 2014 across the United States. National and regional incidence of neonatal and infantile endogenous endophthalmitis and comorbidities as well as risk factors in the development of the disease and predictive factors for mortality from the years 2007 through 2014 were calculated.

MAIN OUTCOMES AND MEASURES

National incidence, regional incidence, and risk factors for development of neonatal and infantile endogenous endophthalmitis.

RESULTS

The rate of decline in incidence of neonatal endogenous endophthalmitis was 4% from 2003 through 2014. The rate of decline in the infantile population was 7% from 2007 through 2014. In 2007, an estimated 291 total cases of infantile endophthalmitis were identified, in comparison with 140 cases in 2014. Comorbidities prevalent in the endophthalmitis population included prematurity, respiratory disorders, perinatal infections, and retinopathy of prematurity (ROP). Significant positive predictors for the development of endogenous endophthalmitis based on multivariate logistic regression were perinatal infections, candidemia, bacteremia, very low birth weight, prematurity, respiratory disorders, and ROP. Descriptive analyses showed that the in-hospital mortality rate for patients identified with endophthalmitis was 1.55% in comparison with infants without endophthalmitis.

CONCLUSIONS

The incidence of endogenous endophthalmitis declined in both the neonatal and infantile population from 2007 through 2014. Odds of endogenous endophthalmitis were higher for premature and low-birthweight infants and those identified with perinatal infections, candidemia, bacteremia, respiratory disorders, or ROP. These findings are consistent with the decline observed in pediatric infectious disease-related hospitalizations in general.

Endogenous endophthalmitis as a severe complication following a Streptococcus pyogenes infection

The diagnosis of endogenous endophthalmitis is challenging. We report a pediatric case of endogenous endophthalmitis due to Streptococcus pyogenes angina. A previously healthy 33-month-old child presented to the emergency department with a history of fever and fatigue related to bacterial angina. On physical examination, an opalescent cornea was noticed and the diagnosis of endogenous endophthalmitis was confirmed by the pediatric ophthalmologist. Streptococcus pyogenes was found in blood culture and in the anterior chamber fluid. There was an adverse outcome with posterior vitrectomy and eye atrophy. Since endogenous endophthalmitis can lead to a poor visual outcome, urgent therapeutic management is necessary.

Endogenous endophthalmitis in children and adolescents: Case series and literature review

Purpose:

To study the clinical and microbiological profile, treatment modalities, and anatomical and functional outcomes among children and adolescents with endogenous endophthalmitis (EE) at a tertiary eye care centre in India.

Methods:

Medical records of subjects <18 years, presenting with EE from 1997 to 2007 were reviewed. Cases where the causative organism was identified were included. Treatment regimen included systemic antibiotics, vitrectomy, intravitreal antibiotics, and enucleation. Systemic evaluation to identify the source of infection was done by an internist. Microbiological analysis of blood, urine, and ocular specimens was done. The favorable anatomical outcome was defined as the attached retina, with controlled intraocular pressure and clear media at the last follow up. The favorable functional outcome was defined as vision >3/60 on the final follow up. Univariate regression analysis was done to identify factors predicting functional outcome.

Results:

Thirty eyes of 30 subjects (23 (77%) males) were studied. The mean age at presentation was 6.8 years (range=1–16 years). Fever was evident in four (13%) and blood culture was negative in all cases. Gram-positive organisms were identified in 11 (37%) eyes, fungi in 3 (10%), and toxocara in 8 (27%) eyes. Twenty-three (77%) eyes underwent vitrectomy. Favorable functional and anatomical outcomes were achieved in 9 (30%) and 12 (40%) eyes, respectively. Eyes undergoing vitrectomy showed significant correlation with good functional outcome (P = 0.05).

Conclusion:

EE is under-reported and not well studied in children. The absence of systemic features may be evident in a developing country with over the counter availability of antibiotics. Gram-positive infections are common and vitrectomy is a beneficial modality of treatment.

Post-Ranibizumab injection endophthalmitis in aggressive posterior retinopathy of prematurity

A preterm infant with zone 1 aggressive posterior retinopathy of prematurity developed infectious endophthalmitis after intravitreal injection of ranibizumab. Urgent empirical intravitreal therapy with vancomycin, ceftazidime, and dexamethasone along with intravenous therapy with amikacin and meropenem helped in early resolution. Vascularization/activity of disease subsided on follow-up, media cleared, and laser photocoagulation was completed. Later the disease reactivated, developed vitreous membranes and central retinal traction, for which 25-gauge lens-sparing vitrectomy was performed. Emergent treatment helped in salvaging the eye from both aggressive ROP disease and devastating endophthalmitis. Rationale approach to such a case is being discussed.

Targets of immunomodulation in bacterial endophthalmitis

Bacterial infection of the posterior segment of the eye (endophthalmitis) leads to a robust host response that often results in irreversible damage to the layers of the retina, significant vision loss, and in some patients, enucleation of the globe. While a great deal of effort has gone into understanding the role of bacterial virulence factors in disease initiation and propagation, it is becoming increasingly clear that the host response to infection plays a major role in causing the damage associated with endophthalmitis. Researchers have identified the host receptors which detect infecting organisms and initiate the cascade of events that result in inflammation. This inflammation may damage nonregenerative tissues of the eye while attempting to clear the infection. Both Gram-positive and Gram-negative bacteria can cause endophthalmitis. These organisms initiate an immune response by activating toll-like receptor (TLR) pathways. Once an inflammatory response is initiated, the expression of immunomodulators, such as proinflammatory chemokines and cytokines, affect the recruitment of PMNs and other inflammatory cells into the eye. We and others have reported that knockout mice that do not express specific inflammatory pathways and molecules have an attenuated response to infection and retain significant retinal function. These findings suggest that host immune mediators are important components of the response to infections in the posterior segment of the eye, and the timing and level of their production may be related to the severity of the damage and the ultimate visual outcome. If that is the case, a better understanding of the complex and often redundant role of these pathways and inflammatory mediators may identify host molecules as potential anti-inflammatory therapeutic targets. This review highlights potential anti-inflammatory targets during acute inflammation in endophthalmitis, compares and contrasts those with findings in other models of ocular inflammation, and translates current immunomodulatory strategies for other types of infection and inflammation to this blinding disease. Given the poor visual outcomes seen in patients treated with antibiotics alone or in combination with corticosteroids, immunomodulation in addition to antibiotic therapy might be more effective in preserving vision than current regimens.

Clinical profile and outcomes of pediatric endogenous endophthalmitis: A report of 11 cases from South India

AIM

To study the clinical profile and outcomes of pediatric endogenous endophthalmitis from a tertiary eye hospital in South India.

METHODS

A total of 13 eyes of 11 children presented to us with varied symptoms and presentations of endogenous endophthalmitis, over a five-year period from January 2010 to December 2015 were studied. Except for two eyes of a patient, vitreous aspirates were cultured from all 11 eyes to isolate the causative organism. These eleven eyes also received intravitreal injections. All patients were treated with systemic antibiotics.

RESULTS

Two cases had bilateral endophthalmitis. Ages ranged from 4 d to 11 years. Five cases were undiagnosed and treated, before being referred to our center. Ten of the 13 eyes underwent a core vitrectomy. The vitrectomy was done at an average on the second day after presenting (range 0-20 d). Five of the 11 vitreous aspirates showed isolates. The incriminating organisms were bacteria in three and fungus in two. An underlying predisposing factor was found in seven patients. At a mean follow-up 21.5 mo, outcome was good in 7 eyes of 6 cases (54%), five eyes of four cases (38%) ended up with phthisis bulbi while one child died of systemic complications.

CONCLUSION

Endogenous endophthalmitis is a challenge for ophthalmologists. Early diagnosis and intervention is the key for a better outcome.

Endogenous endophthalmitis: diagnosis, management, and prognosis

Endogenous endophthalmitis is an ophthalmic emergency that can have severe sight-threatening complications. It is often a diagnostic challenge because it can manifest at any age and is associated with a number of underlying predisposing factors. Microorganisms associated with this condition vary along a broad spectrum. Depending upon the severity of the disease, both medical and surgical interventions may be employed. Due to rarity of the disease, there are no guidelines in literature for optimal management of these patients. In this review, treatment guidelines based on clinical data and microorganism profile have been proposed.

Intraocular myofibroblastoma in an infant: a case report

BACKGROUND

Myofibroblastoma is a benign tumor composed of spindle cells and bands of hyalinized collagen. Intraocular myofibroblastoma in infancy is rarely encountered.

CASE PRESENTATION

The present study reports the case of a 4-month-old female baby with intraocular myofibroblastoma. She was suspected as corneal perforation due to the rupture of a corneal neoplasm in the right eye. The anterior segment was also involved according to the Color Doppler ultrasonography. A surgical exploration was performed and the protuberant part of the mass was resected. Conventional HE staining showed numerous spindle-shaped cells with bands of collagen beneath multilayers of well-differentiated corneal epithelia. Immunohistochemical staining demonstrated the tumor cells were strong positive for vimentin and smooth muscle actin, while negative for S-100 protein. The mass was confirmed as myofibroblastoma. After 12 month follow-up, there was no apparent growth of the tumor.

CONCLUSIONS

Myofibroblastoma is a very rare type of intraocular neoplasm, which may have complicated manifestation and could be misdiagnosed as dermoid or Peter's anomaly. Histopathological and immunohistochemical staining is crucial to form a precise diagnosis.

Endogenous methicillin-resistant Staphylococcus aureus endophthalmitis after leg trauma

We present a case of endogenous endophthalmitis in a 13-year-old boy with methicillin-resistant Staphylococcus aureus sepsis. The patient underwent magnetic resonance imaging of the brain after intermittent anisocoria was noted on examination, leading to a diagnosis of endophthalmitis with a chorodial abscess.

Klebsiella pneumoniae induces an inflammatory response in an in vitro model of blood-retinal barrier

Klebsiella pneumoniae has become an important pathogen in recent years. Although most cases of K. pneumoniae endogenous endophthalmitis occur via hematogenous spread, it is not yet clear which microbial and host factors are responsible for the ability of K. pneumoniae to cross the blood-retinal barrier (BRB). In the present study, we show that in an in vitro model of BRB based on coculturing primary bovine retinal endothelial cells (BREC) and primary bovine retinal pericytes (BRPC), K. pneumoniae infection determines changes of transendothelial electrical resistance (TEER) and permeability to sodium fluorescein. In the coculture model, bacteria are able to stimulate the enzyme activities of endothelial cytosolic and Ca(2+)-independent phospholipase A2s (cPLA2 and iPLA2). These results were confirmed by the incremental expression of cPLA2, iPLA2, cyclo-oxygenase-1 (COX1), and COX2 in BREC, as well as by cPLA2 phosphorylation. In supernatants of K. pneumoniae-stimulated cocultures, increases in prostaglandin E2 (PGE2), interleukin-6 (IL-6), IL-8, and vascular endothelial growth factor (VEGF) production were found. Incubation with K. pneumoniae in the presence of arachidonoyl trifluoromethyl ketone (AACOCF3) or bromoenol lactone (BEL) caused decreased PGE2 and VEGF release. Scanning electron microscopy and transmission electron microscopy images of BREC and BRPC showed adhesion of K. pneumoniae to the cells, but no invasion occurred. K. pneumoniae infection also produced reductions in pericyte numbers; transfection of BREC cocultured with BRPC and of human retinal endothelial cells (HREC) cocultured with human retinal pericytes (HRPC) with small interfering RNAs (siRNAs) targeted to cPLA2 and iPLA2 restored the pericyte numbers and the TEER and permeability values. Our results show the proinflammatory effect of K. pneumoniae on BREC, suggest a possible mechanism by which BREC and BRPC react to the K. pneumoniae infection, and may provide physicians and patients with new ways of fighting blinding diseases.

Treatment outcomes and clinicomicrobiological characteristics of a protocol-based approach for neonatal endogenous endophthalmitis

PURPOSE

To describe the outcomes and clinicomicrobiological profile of 11 years of a protocol-based management in neonatal endogenous endophthalmitis.

METHODS

This was a retrospective interventional study of endogenous endophthalmitis in 31 eyes of 26 neonates. The protocol for active infection included systemic antimicrobials, vitreous and/or aqueous tap, and intravitreal antimicrobials under topical or general anesthesia along with core vitrectomy in selected cases. Blood, urine, umbilicus, aqueous, and vitreous samples underwent microbiological evaluation. Retinopathy of prematurity screening and treatment were done when indicated. Primary outcome was anatomic status assessed by comprehensive eye examination and by fundus photography whenever possible.

RESULTS

Twenty-one of 26 babies (81%) were preterm. Two types of presentations included those with a fulminant appearance (24 eyes) and those with focal retinitis detected during routine screening (7 eyes). Vitreous culture was positive in 12/20 eyes (60%). Pseudomonas aeruginosa (8) was the most common isolate. Incorrect initial diagnosis was common. Treatment included intravitreal injections in 26 eyes, 10 of which also underwent vitrectomy. Twenty-four of the 26 patients (92%) received parenteral antimicrobials and 17 had evidence of systemic infection. All eyes with a fulminant presentation developed phthisis, while all focal fungal cases were salvaged.

CONCLUSIONS

Neonatal endogenous endophthalmitis has 2 distinct presentations. Focal retinal infections have good visual and anatomical outcomes while fulminant nosocomial cases do poorly. Management under topical anesthesia can be an alternative strategy for sick babies that cannot undergo surgery under general anesthesia due to systemic morbidity. Awareness about early diagnostic signs may help early referral.