Endophthalmitis following pars plana vitrectomy: a literature review of incidence, causative organisms, and treatment outcomes

In vivo evaluation of a Nano-enabled therapeutic vitreous substitute for the precise delivery of triamcinolone to the posterior segment of the eye

This study focused on the design of a thermoresponsive, nano-enabled vitreous substitute for the treatment of retinal diseases. Synthesis of a hydrogel composed of hyaluronic acid and a poloxamer blend was undertaken. Poly(D,L-lactide-co-glycolide) acid nanoparticles encapsulating triamcinolone acetonide (TA) were synthesised with a spherical morphology and mean diameter of ~ 153 nm. Hydrogel fabrication and nanoparticle loading within the hydrogel was confirmed via physicochemical analysis. Gelation studies indicated that hydrogels formed in nine minutes and 10 min for the unloaded and nanoparticle-loaded hydrogels, respectively. The hydrogels displayed in situ gel formation properties, and rheometric viscoelastic studies indicated the unloaded and loaded hydrogels to have modulus values similar to those of the natural vitreous at 37 °C. Administration of the hydrogels was possible via 26G needles allowing for clinical application and drug release of triamcinolone acetonide from the nanoparticle-loaded hydrogel, which provided sustained in vitro drug release over nine weeks. The hydrogels displayed minimal swelling, reaching equilibrium swelling within 12 h for the unloaded hydrogel, and eight hours for the nanoparticle-loaded hydrogel. Biodegradation in simulated vitreous humour with lysozyme showed < 20% degradation within nine weeks. Biocompatibility of both unloaded and loaded hydrogels was shown with mouse fibroblast and human retinal pigment epithelium cell lines. Lastly, a pilot in vivo study in a New Zealand White rabbit model displayed minimal toxicity with precise, localised drug release behaviour, and ocular TA levels maintained within the therapeutic window for the 28-day investigation period, which supports the potential applicability of the unloaded and nanoparticle-loaded hydrogels as vitreous substitutes that function as drug delivery systems following vitrectomy surgery.

Endophthalmitis in Eyes Treated with the Port Delivery System with Ranibizumab: Summary of Cases during Clinical Trial Development

PURPOSE

The Port Delivery System with ranibizumab (PDS) is approved in the United States for neovascular age-related macular degeneration. The United States Prescribing Information has a Boxed Warning for endophthalmitis and reports the incidence rate in patients developing endophthalmitis after receiving the PDS compared with monthly intravitreal ranibizumab. Endophthalmitis cases noted in the Boxed Warning, treatment outcomes, potential contributing factors, and potential mitigations are summarized.

DESIGN

Retrospective review of endophthalmitis cases in PDS-treated patients in the phase II Ladder (NCT02510794) and phase III Archway (NCT03677934) and Portal (NCT03683251) trials.

PARTICIPANTS

Endophthalmitis cases in the pooled all-PDS safety population (N = 555) including PDS patients in Ladder, Archway, or Portal.

METHODS

Ladder patients received PDS (10, 40, or 100 mg/ml) with pro re nata refill-exchanges. Archway patients received PDS 100 mg/ml with fixed refill-exchanges every 24 weeks (PDS Q24W). Portal patients received PDS Q24W from day 1.

MAIN OUTCOME MEASURES

Clinical features, management, and visual outcomes were summarized. Cases were summarized by date of PDS implant and/or refill, other prior invasive procedures/refills, and preceding/concurrent conjunctival complications.

RESULTS

Twelve endophthalmitis events were reported in 11 patients (11/555 [2.0%]) through March 12, 2021. All were cultured (3 were culture positive) and treated with intravitreal antibiotics. Two cases (2/555 [0.4%]) occurred in the immediate postoperative period (days 5 and 6). Nine cases occurred later (day range: 57-853), including 4 before the first refill-exchange (day range: 57-161). Five patients received between 1 and 11 refill-exchanges before the event (onset: 6-168 days after last refill-exchange). Seven cases (7/11 [63.6%]) had preceding/concurrent conjunctival complications. At last follow-up, 7 patients recovered vision to study baseline levels or ≥20/40; 4 patients experienced vision loss of ≥15 ETDRS letters.

CONCLUSIONS

Endophthalmitis is a serious complication that can endanger vision after any ocular procedure, including PDS implantation. Most, but not all, of this limited series of endophthalmitis cases were late onset, associated with conjunctival breach, and recovered vision with treatment. Meticulous attention to PDS surgical techniques with vigilant monitoring of conjunctiva during follow-up may minimize risk of endophthalmitis. Prompt treatment is critical for optimizing patient outcomes.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Oral administration of S-nitroso-L-glutathione (GSNO) provides anti-inflammatory and cytoprotective effects during ocular bacterial infections

Bacterial endophthalmitis is a severe complication of eye surgeries that can lead to vision loss. Current treatment involves intravitreal antibiotic injections that control bacterial growth but not inflammation. To identify newer therapeutic targets to promote inflammation resolution in endophthalmitis, we recently employed an untargeted metabolomics approach. This led to the discovery that the levels of S-nitroso-L-glutathione (GSNO) were significantly reduced in an experimental murine Staphylococcus aureus (SA) endophthalmitis model. In this study, we tested the hypothesis whether GSNO supplementation via different routes (oral, intravitreal) provides protection during bacterial endophthalmitis. Our results show that prophylactic administration of GSNO via intravitreal injections ameliorated SA endophthalmitis. Therapeutically, oral administration of GSNO was found to be most effective in reducing intraocular inflammation and bacterial burden. Moreover, oral GSNO treatment synergized with intravitreal antibiotic injections in reducing the severity of endophthalmitis. Furthermore, in vitro experiments using cultured human retinal Muller glia and retinal pigment epithelial (RPE) cells showed that GSNO treatment reduced SA-induced inflammatory mediators and cell death. Notably, both in-vivo and ex-vivo data showed that GSNO strengthened the outer blood-retinal barrier during endophthalmitis. Collectively, our study demonstrates GSNO as a potential therapeutic agent for the treatment of intraocular infections due to its dual anti-inflammatory and cytoprotective properties.

Incidence rate and clinical characteristics of acute endophthalmitis following 23-gauge pars plana vitrectomy

PURPOSE

In this study, we evaluated the incidence and clinical characteristics of post-vitrectomy acute endophthalmitis in a tertiary eye center.

METHODS

Data were obtained by reviewing the patients' medical records who underwent primary pars plana vitrectomy (PPvitx) from September 2011 to March 2017. We excluded patients who had any ocular surgery in the past 6 months, immunocompromised patients, and patients with a pre-operative diagnosis of endophthalmitis. The primary outcome was the incidence of acute post-pars plana vitrectomy endophthalmitis.

RESULTS

Out of 6474 cases who underwent PPvitx, 12 cases of endophthalmitis (incidence rate of 0.18%) were identified. We found two positive cultures for staphylococcus epidermidis and one positive culture for staphylococcus aureus. Underlying causes of primary vitrectomy in patients who got endophthalmitis were diabetic retinopathy (8 cases), rhegmatogenous retinal detachment (2 cases), and the epiretinal membrane (1 case), and non-clearing vitreous hemorrhage secondary to central retinal vein occlusion (1 case).

CONCLUSION

In the present study, the rate of post-vitrectomy acute endophthalmitis was higher than in other reported studies.

Toxic Anterior Segment Syndrome After an Uncomplicated Vitrectomy With Epiretinal Membrane Peeling

Infectious endophthalmitis is the most devastating complication of eye surgery and is associated with severe inflammation of ocular tissues. This study aimed to present a similar condition, a case of toxic anterior segment syndrome (TASS) after an uncomplicated vitrectomy. A 69-year-old woman presented with epiretinal membrane and underwent 25-gauge pars plana vitrectomy with membrane peeling in her left eye. Thirty hours after the procedure, the patient complained of increasing loss of visual acuity and a red left eye. The ophthalmic examination revealed moderate hyperemia, hypopyon and snowbanks in the anterior vitreous. Subconjunctival and topical steroids were administered, and the inflammatory symptoms resolved within 30 days. The visual acuity improved to 20/32, however, cystoid changes were noted in the macula by optical coherence tomography.  TASS should be considered a potential complication after vitrectomy. This report presents a case of TASS and discusses the differential diagnosis between TASS, infectious and non-infectious endophthalmitis.

Ten-year trends in the incidence, clinical profile and outcomes of acute-onset endophthalmitis following combined pars plana vitrectomy and sutureless, glueless and flapless scleral fixation of intraocular lenses

PURPOSE

To evaluate the frequency and outcomes of acute-onset endophthalmitis following combined pars plana vitrectomy and scleral fixation of intraocular lens.

METHODS

We evaluated patients undergoing a sutureless, glueless, flapless technique of scleral fixation of intraocular lenses (SFIOL) implantation for various causes of aphakia and documented the clinico-demographic data, microbiological profile and final outcome after acute endophthalmitis in this cohort of eyes.

RESULTS

The frequency of suspected acute endophthalmitis diagnosed post-surgery was 0.112% (4/3541 eyes), with culture-positive endophthalmitis frequency being 0.028% (1 eye), showing growth of Pseudomonas aeruginosa. Mean age of patients with endophthalmitis was 51.75 ± 9.28 years, and mean interval between surgery and acute endophthalmitis presentation was 10.25 ± 9.6 days. Patients were managed with intravitreal antibiotics with or without core vitrectomy. Visual acuity of patients increased from baseline 1.43 ± 0.32 logMAR (Snellen equivalent = 6/150) to 0.79 ± 0.16 logMAR (Snellen equivalent = 6/36) after an average follow-up of 11 ± 2 weeks.

CONCLUSION

Endophthalmitis is a rare complication following SFIOL surgery, and all ophthalmic surgeons must be aware of this inadvertent possibility, since SFIOLs are gaining wider acceptability recently. Moreover, these cases of endophthalmitis may show a different pattern of microorganisms than post-cataract surgery endophthalmitis; however, with prompt diagnosis and effective timely management, favorable outcomes can be achieved.

Endophthalmitis after pars plana vitrectomy with reused single-use devices: a 13-year retrospective study

BACKGROUND

To describe the incidence, clinical characteristics, and treatment outcomes of endophthalmitis after pars plana vitrectomy (PPV) with recycled single-use devices. The recommended sterilization process as well as safety measures are discussed.

METHODS

Medical charts of patients who developed endophthalmitis after PPV were retrospectively reviewed and reported in a descriptive manner. Cases undergoing PPV for preexisting endophthalmitis or open globe injury were excluded. Data collection included patient demographics, operative details, ocular findings, microbiological profiles, treatment modalities, and visual outcomes.

RESULTS

Over the past thirteen years, a total of 12,989 pars plana vitrectomy operations were included. In total, 13 eyes of 13 cases (0.10%) experienced endophthalmitis after vitrectomy. These occurred in 3 cases (0.11%) using 20-gauge vitrectomy compared to 8 cases (0.09%) using 23-gauge vitrectomy and 2 cases (0.18%) using 25-gauge vitrectomy. There were no statistically significant differences between the 20-gauge and microincisional vitrectomy surgery (MIVS) group (P = 0.64), and the 23- and 25-gauge approach (P = 0.34). Causative pathogens were positive by culture in 5 cases (45%): 3 g-positive cases, 1 g-negative case, and 1 fungus case.

CONCLUSIONS

The rate of endophthalmitis in patients who underwent 23-gauge PPV was comparable to those who underwent 25-gauge PPV. With our standardized protocol for instrument sterilization, endophthalmitis rates in those undergoing PPV using recycled single-use instruments were within the range of previously published results in which vitrectomy tools were disposed of after one use.

Exogenous Fungal Endophthalmitis: Clues to Aspergillus Aetiology with a Pharmacological Perspective

Exogenous fungal endophthalmitis (EXFE) represents a rare complication after penetrating ocular trauma of previously unresolved keratitis or iatrogenic infections, following intraocular surgery such as cataract surgery. The usual latency period between intraocular inoculation and presentation of symptoms from fungal endophthalmitis is several weeks to months as delayed-onset endophthalmitis. Aspergillus spp., is the most common causative mould pathogen implicated in this ocular infection and early diagnosis and prompt antimicrobial treatment, concomitantly in most cases with expert surgical attention, reduce unfavorable complications and increase the possibility of eye function preservation. Topical, intravitreal and systemic antifungal molecules are the mainstay of a medical approach to the disease and azoles, polyenes and in particular cases echinocandins are the pharmacological classes most commonly used in clinical practice. This review discusses pharmacokinetics and pharmacodynamic of antifungal agents in their principal modes of administration with a focus on their ability to achieve high drug concentration in the vitreous and ocular tissues.

Research Trends and Hotspot Analysis of Conjunctival Bacteria Based on CiteSpace Software

OBJECTIVE

To sort out the literature related to conjunctival bacteria and summarize research hotspots and trends of this field.

MATERIALS AND METHODS

The relevant literature data from 1900 to 2019 was retrieved from the Web of Science Core Collection database. After manual selection, each document record includes title, author, keywords, abstract, year, organization, and citation. We imported the downloaded data into CiteSpace V (version 5.5R2) to draw the knowledge map and conduct cooperative network analysis, discipline and journal analysis, cluster analysis, and burst keyword analysis.

RESULTS

After manual screening, there were 285 relevant papers published in the last 28 years (from 1991 to 2019), and the number is increasing year by year. The publications of conjunctival bacteria were dedicated by 1381 authors of 451 institutions in 56 countries/regions. The United States dominates this field (82 literatures), followed by Germany (23 literatures) and Japan (23 literatures). Overall, most cited papers were published with a focus on molecular biology, genetics, nursing, and toxicology. Most papers fall into the category of ophthalmology, veterinary sciences, and pharmacology and pharmacy. The only organized cluster is the "postantibiotic effect," and the top 5 keywords with the strongest citation bursts include "postoperative endophthalmiti(s)," "infectious keratoconjunctiviti(s)," "conjunctiviti(s)," "resistance," and "diversity".

CONCLUSION

The global field of conjunctival bacteria has expanded in the last 28 years. The United States contributes most. However, there are little cooperation among authors and institutions. Overall, this bibliometric study organized one cluster, "postantibiotic effect", and identified the top 5 hotspots in conjunctival bacteria research: "postoperative endophthalmiti(s)," "infectious keratoconjunctiviti(s)," "conjunctiviti(s)," "resistance," and "diversity". Thus, further research focuses on these topics that may be more helpful to prevent ocular infection and improve prophylaxis strategies to bring a benefit to patients in the near future.

The Role of Systemic Antimicrobials in the Treatment of Endophthalmitis: A Review and an International Perspective

Background

The optimal management of patients with endophthalmitis is challenging and includes both intravitreal and, in some cases, systemic antimicrobials. Systemic antimicrobials may be administered either intravenously or orally. In this article we review systemic antimicrobial options currently available for the treatment of types of endophthalmitis and the role of systemic antimicrobials (antibiotics and antifungals) in these treatments.

Review

While systemic antimicrobials are not universally utilized in the management of endophthalmitis, they may be helpful in some circumstances. The blood–retinal barrier affects the penetration of systemic medications into the posterior segment of the eye differently; for example, moxifloxacin and imipenem cross the blood–retinal barrier relatively easily while vancomycin and amikacin do not. However, inflammation, including endophthalmitis, may disrupt the blood–retinal barrier, enhancing the penetration of systemic agents into the eye.

Conclusion

Systemic antimicrobials may be particularly beneficial in patients with certain types of endophthalmitis; as such, they are standard treatment in the management of endogenous endophthalmitis (fungal and bacterial) and also widely used for prophylaxis and treatment of open-globe injuries. Although systemic antimicrobials are used in some patients with acute-onset postoperative endophthalmitis following cataract surgery, the literature generally does not support this practice. It is noted that there are currently no randomized clinical trials demonstrating a benefit of systemic antibiotics for any category of endophthalmitis.

Is it necessary to use tobramycin-dexamethasone eye ointment prophylactically in eyes at the end of intraocular surgery?

BACKGROUND

There are no data available regarding the complications associated with using antibiotic ointment at the end of intraocular surgery. This study aimed to explore the necessity of using ocular tobramycin-dexamethasone prophylactically at the end of intraocular surgery.

METHODS

This was a retrospective cohort study of patients who received intraocular surgery at Tianjin Medical University General Hospital from January 2015 to December 2017. The patients were grouped according to whether they received tobramycin-dexamethasone eye ointment or not after surgery. The Tobramycin dexamethasone eye ointment was sampled to observe bacterial contamination pathogens at 0.5, 1, 1.5, 2, 2.5, 3, 6, 8, 24, 36, 48, 72, and 168 h after being opened.

RESULTS

A total of 3811 eyes in 3811 patients (mean age of 63 ± 12 years) were included: 2397 eyes that received prophylactic tobramycin-dexamethasone eye ointment and 1414 eyes that did not. The overall rate of endophthalmitis was 0.08% (3/3811) in our study, all in the eye ointment group (0.12%, 3/2397); no patients developed endophthalmitis in the non-ointment group (0%, 0/1414)(P = 0.184). The anterior chamber reactions 1 day after surgery were more serious in the eye ointment group compared with the non-ointment group (all P < 0.05), but there were no statistically significant differences at 1 month postoperatively (all P > 0.05). The contamination rate was 0% at all time points over 7 days.

CONCLUSION

We did not observe a statistically significant difference in the incidence of endophthalmitis in patients with or without prophylactic tobramycin-dexamethasone eye ointment. And tobramycin-dexamethasone eye ointment seemed to increase some side effects such as eye secretions increasing and foreign body feeling.

Bacillus S-Layer-Mediated Innate Interactions During Endophthalmitis

Bacillus endophthalmitis is a severe intraocular infection. Hallmarks of Bacillus endophthalmitis include robust inflammation and rapid loss of vision. We reported that the absence of Bacillus surface layer protein (SLP) significantly blunted endophthalmitis severity. Here, we further investigated SLP in the context of Bacillus-retinal cell interactions and innate immune pathways to explore the mechanisms by which SLP contributes to intraocular inflammation. We compared phenotypes of Wild-type (WT) and SLP deficient (ΔslpA) Bacillus thuringiensis by analyzing bacterial adherence to and phagocytosis by human retinal Muller cells and phagocytosis by mouse neutrophils. Innate immune receptor activation by the Bacillus envelope and purified SLP was analyzed using TLR2/4 reporter cell lines. A synthetic TLR2/4 inhibitor was used as a control for this receptor activation. To induce endophthalmitis, mouse eyes were injected intravitreally with 100 CFU WT or ΔslpA B. thuringiensis. A group of WT infected mice was treated intravitreally with a TLR2/4 inhibitor at 4 h postinfection. At 10 h postinfection, infected eyes were analyzed for viable bacteria, inflammation, and retinal function. We observed that B. thuringiensis SLPs contributed to retinal Muller cell adherence, and protected this pathogen from Muller cell- and neutrophil-mediated phagocytosis. We found that B. thuringiensis envelope activated TLR2 and, surprisingly, TLR4, suggesting the presence of a surface-associated TLR4 agonist in Bacillus. Further investigation showed that purified SLP from B. thuringiensis activated TLR4, as well as TLR2 in vitro. Growth of WT B. thuringiensis was significantly higher and caused greater inflammation in untreated eyes than in eyes treated with the TLR2/4 inhibitor. Retinal function analysis also showed greater retention of A-wave and B-wave function in infected eyes treated with the TLR2/4 inhibitor. The TLR2/4 inhibitor was not antibacterial in vitro, and did not cause inflammation when injected into uninfected eyes. Taken together, these results suggest a potential role for Bacillus SLP in host-bacterial interactions, as well as in endophthalmitis pathogenesis via TLR2- and TLR4-mediated pathways.

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

Aim

To report the long-term outcome of the management of a series of culture proven post pars plana vitrectomy endophthalmitis in which the infective agent was in the silicone oil used as an endotamponade. The isolates were Burkholderia cepacia and Pseudomonas aeruginosa.

Method

A retrospective interventional reporting of a series consisting of a cluster of five cases.

Cases

Five consecutive patients received the same batch of 5000-centistoke silicone oil as endotamponade at the conclusion of vitreoretinal surgery and presented with features of acute intraocular inflammation, which was due to an infective cause. The infective organism isolated from the mixture of silicone oil and fluid was B. cepacia in three out of the initial cluster of four eyes and P. aeruginosa in the fifth eye.

Outcome of management

The initial 4 eyes evolved into eyes with poor vision (hand motion, perception of light and no perception of light), advanced proliferative vitreoretinopathy, hypotony, phthisis bulbi and cornea opacity. The poor visual outcome was deemed to be consequent to delay in removal of the silicone oil, despite use of intravitreal, systemic and topical antibiotics. The fifth case, because of the heightened index of suspicion gained from the preceding four cases, had a prompt removal of the silicone oil, vitreal lavage with antibiotics, and intravitreal injection of antibiotics and steroid. He regained a 6/9 vision.

Conclusion

Gram-negative bacilli can colonize silicone oil resulting in post pars plana vitrectomy endophthalmitis. The index of suspicion for this should be high and can be managed successfully with prompt removal of the silicone oil, microbial sensitive antibiotic lavage of the vitreous cavity, followed by a repeat tamponade.

The rate of endophthalmitis after pars plana vitrectomy and its risk factors

PURPOSE

To study the incidence of endophthalmitis after pars plana vitrectomy, its causative organisms, and visual acuity outcomes.

PATIENTS AND METHODS

In this retrospective, comparative study, the medical records of patients with acute-onset postoperative endophthalmitis after pars plana vitrectomy at Farabi Eye Hospital, Tehran, Iran, during a 12-year period between January 2004 and November 2015 were reviewed. To compare the endophthalmitis patients with other cases who underwent pars plana vitrectomy at the same day and also the same operating room, a control group was developed by gathering the data from surgical records.

RESULTS

In the present study, the incidence rate of pos- vitrectomy endophthalmitis was 0.04% (16/39783). The organisms identified in aqueous or vitreous cultures (culture positive 44%) included Streptococcus pneumoniae (two patients, 12.5%), Pseudomonas aeruginosa (two patients, 12.5%), fungi (two patients, 12.5%), and Streptococcus viridans (one patient, 6.25%). Visual acuity after treatment for endophthalmitis ranged from light perception (7 eyes) to hand motion (1 eye), and evisceration was performed in 8 eyes (50%). When comparing the cases (patients developing endophthalmitis) and controls (patients with no complications operated in the same day and place of operation with the case group), only not using tamponade showed a statistically significant relation with the occurrence of endophthalmitis (p = 0.034).

CONCLUSION

Our results indicated low incidence of endophthalmitis after pars plana vitrectomy comparable to previous studies which resulted in poor visual acuity. It seems that not using tamponade might increase the risk of endophthalmitis among these patients.

Bacterial and Fungal Endophthalmitis

Endophthalmitis is a severe eye infection that may result in permanent loss of useful vision in the affected eye. Most cases are exogenous and occur as a complication of cataract surgery, an intravitreal injection, or penetrating ocular trauma. Endogenous endophthalmitis results from hematogenous seeding of the eye by bacteria or fungi, but bacteremia or fungemia may be transient and patients may present without symptoms of systemic infection. Nearly all endophthalmitis patients present with decreased vision, and some also have eye pain. Eye examination usually reveals a hypopyon and intraocular inflammation. Diagnosis is clinical, supported by cultures of the vitreous and/or aqueous or by blood cultures in some endogenous cases. Molecular diagnostic techniques have been used in research laboratories for pathogen identification in endophthalmitis and offer the possibility of rapid diagnosis, including in culture-negative cases. Intravitreal injection of antibiotics is the most important component of treatment; some cases also benefit from surgical debridement of the vitreous by a vitrectomy. The visual outcome depends partly on the pathogen: coagulase-negative staphylococcal endophthalmitis has a better prognosis than does streptococcal endophthalmitis, for example. Endophthalmitis is a medical emergency, and prompt diagnosis and treatment are essential for saving vision.

Occurrence rate of retinal detachment after small gauge vitrectomy for idiopathic epiretinal membrane

PurposeTo assess the occurrence rate of retinal detachment (RD) after small gauge vitrectomy for idiopathic epiretinal membrane (ERM).Patients and methodsRetrospective observational case series. The records of consecutive patients operated on for idiopathic ERM using small gauge pars plana vitrectomy between August 2012 and December 2014 with at least a 1-year follow-up were reviewed. All patients were contacted by phone to assess the occurrence of RD during the post-operative follow-up. The main outcome was the occurrence of RD. Patients who underwent surgery for senile cataract over the same period with at least a 1-year follow-up were also contacted by phone for comparison.ResultsTwo hundred and sixteen eyes of 212 patients who had undergone ERM surgery were included, with a mean follow-up of 892±211 days (216-1238). RD occurred in two eyes (0.92%). Over the same period, two RD occurred in the 203 eyes (0.98%) of 157 patients operated on for senile cataract in our department.ConclusionsThe occurrence of RD after 25-gauge vitrectomy for idiopathic ERM was <1%. Using small gauge sutureless vitrectomy systems has improved the safety of ERM surgery, with a RD rate similar to that observed after cataract surgery.

Perioperative Antibiotics to Prevent Acute Endophthalmitis after Ophthalmic Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Post-operative endophthalmitis is a rare and dreaded complication in ophthalmic operations because it often induces irreparable vision loss. Although many ophthalmological studies aimed at reducing the rate of endophthalmitis have been performed around the world, controversy continues to surround some issues, including the choice of antimicrobials and their route of administration, duration and timing. The aim of this study is to investigate some of these unresolved issues.

METHODS

A systematic review and meta-analysis of randomized controlled trials and observational studies was performed. The PubMed, EMBASE, Cochrane Library and Clinical Trials databases were searched to identify studies published until Feb. 2016. The relative risk (RR) for each clinical outcome data is presented with 95% confidence intervals (CIs). Pooled estimates of effects were calculated using random-effect models.

RESULTS

Thirty-four studies from twenty-four reports involving 1264797 eyes were included in this analysis. Endophthalmitis occurred, on average, in one out of 6177 eyes when intracameral vancomycin/moxifloxacin were used and in one out of 1517 eyes when intracameral vancomycin/moxifloxacin were not used. The relative risk (95% CI) of endophthalmitis was reduced to 0.20 (0.10, 0.42) when intracameral antibiotics were used (p<0.0001). The subconjunctival injection of antibiotics was not superior to other administration routes included in this study (RR = 1.67, 95% CI (0.55, 5.05), p = 0.36). A statistically significant difference was found in the rate of endophthalmitis between the use and lack of use of topical antibiotics (RR = 0.65, 95% CI (0.43, 0.99), p = 0.04). However, no statistically significant difference was found in microbial isolation rates between these groups (RR = 0.77, 95% CI (0.34, 1.75), p = 0.53). When long-term and short-term use of topical antibiotics before surgery were compared, a statistically significant difference was found in microbial isolation rates (RR = 0.57, 95% CI (0.44, 0.74), p<0.0001).

CONCLUSIONS

This meta-analysis concluded intracameral antibiotics are effective at preventing endophthalmitis in ocular surgery. A randomized controlled trial confirms the efficacy of cefuroxime but recent large cohort studies support the efficacy of vancomycin/moxifloxacin intracamerally. Intracameral antibitoics are superior to subconjunctival injections but that irrigation antibitoic data are not of enough quality to make a comparison. Different results were found in two clinical outcomes between the use or lack of use of topical antibiotic therapy, we did not find sufficient evidence to conclude that its use prevents endophthalmitis.

Long-term outcomes of sutureless 25-G+ pars-plana vitrectomy for the management of diabetic tractional retinal detachment

PURPOSE

To evaluate the short- and long-term surgical and clinical outcomes in eyes with diabetic tractional retinal detachment (TRD) undergoing 25-G+ pars-plana vitrectomy (PPV).

METHODS

A total of 238 patients were reviewed for inclusion in this study. A retrospective cohort study of 109 eyes of 73 patients operated on for diabetic TRD were included. All eyes received intraocular tamponade of air, sulfur hexafluoride, octofluropropane or silicone oil. All patients were followed up for a minimum period of one year.

RESULTS

The mean age of all patients at surgery was 53.9 years ± 9.2, while the mean duration of diabetes was 18.7 ± 10.4 years. The mean length of follow-up was 923 ± 87 days after surgery (range, 432-1792 days). Thirty-two cases (29.3 %) had an associated rhegmatogenous component. Mean BCVA improved from logarithm minimum angle of resolution (logMAR) 1.17 (20/300) to 0.812 (20/130) (p < 0.05). All eyes underwent intraoperative laser photocoagulation. Primary, single-surgery anatomic reattachment was achieved in 99 eyes (91 %). Final anatomic attachment was achieved in 107 eyes (98 %). There was no statistically significant difference in primary or secondary re-attachment rate in terms of type of tamponade agent used. There were five cases of post-operative hypotony (≤5 mmHg) on postoperative day 1, while 11 eyes had IOP ≥ 30 mmHg. There were no cases of endophthalmitis in our cohort.

CONCLUSIONS

25G+ PPV provides for safe and effective repair of diabetic TRDs. Patients experienced positive functional and anatomic outcomes, with no significant intraoperative complications and minimal postoperative sequelae.

Persistently Vitreous Culture-Positive Exogenous Bacterial Endophthalmitis

PURPOSE

To report the clinical settings, bacterial isolates, antibiotic sensitivities, and visual acuity outcomes of patients with persistently positive vitreous cultures after intravitreal antibiotics.

DESIGN

Consecutive, noncomparative case series.

METHODS

setting: Tertiary care center.

PATIENT POPULATION

Thirty-six eyes of 36 patients with exogenous endophthalmitis with the same bacterial organism identified on at least 2 consecutive vitreous cultures from 1981 to 2015.

OBSERVATION PROCEDURES

Vitreous cultures with intravitreal injections of antibiotics and pars plana vitrectomies with intravitreal antibiotics.

MAIN OUTCOME MEASURES

Bacterial isolates, antibiotic sensitivities, visual outcomes.

RESULTS

Thirty-six eyes of 36 patients met the study criteria. The mean follow-up was 26.5 months. The most common clinical settings were after cataract extraction (18/36, 50%) and glaucoma surgery (11/36, 31%). The mean initial visual acuity was 2.16 ± 0.77 logMAR (Snellen equivalent ≈20/2900), and there was no statistically significant change at the final evaluation (2.08 ± 0.97 logMAR, ≈20/1900, P = .72). The most common bacteria were Staphylococcus (11/36, 31%) and Streptococcus (9/36, 25%). Gram-positive bacteria were sensitive to vancomycin (27/27, 100%); gram-negative bacteria were sensitive to amikacin (5/5, 100%). The antibiotic sensitivities were the same on repeat cultures in 34 of 36 patients (94%). The initial treatment was a vitreous culture and intravitreal injection of antibiotics in 28 of 36 patients (78%). The vision at the last follow-up was 20/200 or better in 12 patients (33%) and no light perception in 11 of 36 patients (31%).

CONCLUSIONS

The most commonly identified organisms were gram-positive bacteria. There was good concordance in the antibiotic sensitivities between initial and subsequent cultures. Patients with persistently vitreous culture-positive endophthalmitis had poor visual outcomes.

Temporal retinal transcriptome and systems biology analysis identifies key pathways and hub genes in Staphylococcus aureus endophthalmitis

Bacterial endophthalmitis remains a devastating inflammatory condition associated with permanent vision loss. Hence, assessing the host response in this disease may provide new targets for intervention. Using a mouse model of Staphylococcus aureus (SA) endophthalmitis and performing retinal transcriptome analysis, we discovered progressive changes in the expression of 1,234 genes. Gene ontology (GO) and pathway analyses revealed the major pathways impacted in endophthalmitis includes: metabolism, inflammatory/immune, antimicrobial, cell trafficking, and lipid biosynthesis. Among the immune/inflammation pathways, JAK/Stat and IL-17A signaling were the most significantly affected. Interactive network-based analyses identified 13 focus hub genes (IL-6, IL-1β, CXCL2, STAT3, NUPR1, Jun, CSF1, CYR61, CEBPB, IGF-1, EGFR1, SPP1, and TGM2) within these important pathways. The expression of hub genes confirmed by qRT-PCR, ELISA (IL-6, IL-1β, and CXCL2), and Western blot or immunostaining (CEBP, STAT3, NUPR1, and IGF1) showed strong correlation with transcriptome data. Since TLR2 plays an important role in SA endophthalmitis, counter regulation analysis of TLR2 ligand pretreated retina or the use of retinas from TLR2 knockout mice showed the down-regulation of inflammatory regulatory genes. Collectively, our study provides, for the first time, a comprehensive analysis of the transcriptomic response and identifies key pathways regulating retinal innate responses in staphylococcal endophthalmitis.

Complications of Macular Peeling

Macular peeling refers to the surgical technique for the removal of preretinal tissue or the internal limiting membrane (ILM) in the macula for several retinal disorders, ranging from epiretinal membranes (primary or secondary to diabetic retinopathy, retinal detachment…) to full-thickness macular holes, macular edema, foveal retinoschisis, and others. The technique has evolved in the last two decades, and the different instrumentations and adjuncts have progressively advanced turning into a safer, easier, and more useful tool for the vitreoretinal surgeon. Here, we describe the main milestones of macular peeling, drawing attention to its associated complications.

Unexpected Roles for Toll-Like Receptor 4 and TRIF in Intraocular Infection with Gram-Positive Bacteria

Inflammation caused by infection with Gram-positive bacteria is typically initiated by interactions with Toll-like receptor 2 (TLR2). Endophthalmitis, an infection and inflammation of the posterior segment of the eye, can lead to vision loss when initiated by a virulent microbial pathogen. Endophthalmitis caused by Bacillus cereus develops as acute inflammation with infiltrating neutrophils, and vision loss is potentially catastrophic. Residual inflammation observed during B. cereus endophthalmitis in TLR2(-/-) mice led us to investigate additional innate pathways that may trigger intraocular inflammation. We first hypothesized that intraocular inflammation during B. cereus endophthalmitis would be controlled by MyD88- and TRIF-mediated signaling, since MyD88 and TRIF are the major adaptor molecules for all bacterial TLRs. In MyD88(-/-) and TRIF(-/-) mice, we observed significantly less intraocular inflammation than in eyes from infected C57BL/6J mice, suggesting an important role for these TLR adaptors in B. cereus endophthalmitis. These results led to a second hypothesis, that TLR4, the only TLR that signals through both MyD88 and TRIF signaling pathways, contributed to inflammation during B. cereus endophthalmitis. Surprisingly, B. cereus-infected TLR4(-/-) eyes also had significantly less intraocular inflammation than infected C57BL/6J eyes, indicating an important role for TLR4 in B. cereus endophthalmitis. Taken together, our results suggest that TLR4, TRIF, and MyD88 are important components of the intraocular inflammatory response observed in experimental B. cereus endophthalmitis, identifying a novel innate immune interaction for B. cereus and for this disease.