CLINICAL CHARACTERISTICS AND VISUAL OUTCOMES IN ENDOPHTHALMITIS AFTER KERATOPROSTHESIS IMPLANTATION

PURPOSE

To describe the presentation, microbiology, management, and prognosis of eyes with endophthalmitis after Boston keratoprosthesis implantation.

METHODS

Retrospective case series with history, diagnostics, management, and outcomes data in endophthalmitis after keratoprosthesis implantation presenting to a tertiary center between 2009 and 2020.

RESULTS

Of 137 keratoprosthesis-implanted eyes, 7 eyes of 7 patients (5%) developed endophthalmitis. On presentation, 6 (86%) reported decreased visual acuity, and only 1 (14%) reported pain. Peripheral corneal ulcers were present in 2 eyes (29%). Seidel testing was negative in all cases. Six eyes (86%) had retroprosthetic membranes. One (14%) underwent initial pars plana vitrectomy with mechanical vitreous biopsy, whereas 6 (86%) received a needle vitreous tap-half of which were dry. Organisms were isolated after vitreous tap in two eyes: Streptococcus intermedius and Mycobacterium abscessus. The mean visual acuity preendophthalmitis, at presentation, and at 6 months were 20/267, 20/5,944, and 20/734, respectively. The visual acuity improved 9.08 ± 11.78 Early Treatment Diabetic Retinopathy Study lines from presentation to 6 months. Six-month visual acuity was correlated with preendophthalmitis visual acuity (r = 0.92, P = 0.003) but not presenting visual acuity (P = 0.838).

CONCLUSION

Visual acuity at 6 months is correlated with preendophthalmitis visual acuity, not presenting visual acuity. Endophthalmitis should be considered in the differential diagnosis of painless intraocular inflammation any time after keratoprosthesis implantation, even if Seidel negative.

Visual function deficits in eyes with resolved endophthalmitis

To evaluate the changes in functional vision in patients with resolved endophthalmitis. This was a cross-sectional study. The study included 20 patients with resolved endophthalmitis and best-corrected visual acuity of 20/100 or better. Visual acuity (VA), contrast threshold (CT), red/green (RG) and yellow/blue (YB) colour vision and 15 Hz flicker modulation threshold (FMT) were assessed using standard psychophysical techniques. The median age was 54 years. The median visual acuity was 0.27 (~ 20/40-Snellen Equivalent) ((interquartile range [IQR]), 0.30) logMAR). The median log contrast threshold (CT) was - 1.13 (IQR, 0.36) log units (normative value for age-matched CT: - 1.61 log units). The median red/green (RG) and yellow/blue (YB) thresholds were 11.52 (IQR, 26.19) and 9.45 (IQR, 16.20) CAD units respectively, which were at least 5 times higher than age-matched normative RG and YB thresholds. The median central cone- mediated FMT was 17.64% (IQR, 23.40%), which was much higher compared to age-matched FMT (5.48% [IQR, 3.47]). Linear regression revealed significant relationship between contrast thresholds and foveal thickness (y = 0.001x-1.47, R2 = 0.20, p = 0.048). Though endophthalmitis may resolve with a good visual acuity, deficits in visual functions like chromatic discrimination, cone-mediated flicker and contrast sensitivity persist.

Age-related differences in the clinical features of ocular sarcoidosis

The distribution of age at diagnosis in ocular sarcoidosis has shifted towards the older age groups in developed countries. In systemic sarcoidosis, age-related differences in the clinical presentation, which reflect the therapeutic strategies, was reported. We retrospectively compared 100 consecutive patients from April 2010 to March 2016 who were initially diagnosed with ocular sarcoidosis by International Workshop on Ocular Sarcoidosis criteria. They were classified into elder (>65 years: 50 patients) and younger (≤65 years: 50 patients) groups by the age at diagnosis of uveitis associated with sarcoidosis. All patients received ophthalmic examination to assess the presence of seven intraocular signs and 4 laboratory parameters. Significantly fewer ocular signs (2.8 ± 1.5 and 3.6 ± 1.5; P = 0.0034) and abnormal laboratory results (1.5 ± 1.2 and 2.0 ± 1.2; P = 0.023) were detected in the elder group than in the younger group; statistical differences were found between the groups regarding the frequencies of mutton-fat keratic precipitates (40% and 64%; P = 0.012), vitreous opacities (60% and 78%; P = 0.0059), bilateral inflammation (64% and 80%; P = 0.012), and bilateral hilar lymphadenopathy between the groups (52% and 78%; P < 0.001). Multiple linear regression analysis showed negative correlations between age and number of detected ocular signs (r = −0.36, P < 0.001) and laboratory results (r = −0.20, P = 0.023). The characteristic ocular signs and abnormal laboratory results had a lower frequency in the elder patients compared with the younger patients. Probable or possible ocular sarcoidosis by the international criteria should increase with increased life expectancy in developed countries.

Sturge-Weber syndrome-associated glaucoma and intraocular osseous metaplasia: a unique complicated case

A 30-year-old European man was admitted to our centre complaining about severe pain of the right eye (OD) and right part of the face, redness and no vision of the OD. He had an 18-year history of secondary to Sturge-Weber syndrome glaucoma, 6-month history of red eye and 1-week history of pain in OD. The best-corrected visual acuity was no light perception OD and 20/20 OS. Intraocular pressure was 36 mm Hg OD. Examination revealed endophthalmitis, Sturge-Weber syndrome-associated glaucoma and complicated cataract of OD.Unfortunately, no prescribed treatment helped this patient, so evisceration of OD was performed. During the evisceration, a subretinal 20 mm in width and 22 mm in length osseous tissue, partially vascularised, was removed surgically and was sent to the histological laboratory. Histopathologically, there were data of active inflammatory process, retinal detachment due to huge subretinal osseous metaplasia, gliosis and retinal pigment epithelial hyperplasia, and druses with ossification.

Posttraumatic Endophthalmitis

In a group of 615 cases of perforating trauma, 25 cases (4%) of proven endophthalmitis were seen. The percentage of Bacillus infections was unusually high compared to other types of endophthalmitis (3.8% for the whole group, 31% for the group with intraocular foreign bodies). Bacillus cases have a very poor outcome and in fact the overall functional results in the posttraumatic endophthalmitis group were poorer than in other categories.

Predictors of Visual Outcomes and Microbial Profile in Endophthalmitis

BACKGROUND AND OBJECTIVE

To evaluate predictors of visual outcomes and microbial profile in endophthalmitis.

PATIENTS AND METHODS

This was a prospective, interventional case series at a tertiary eye care center. Of the 207 patients included, 83 had post-cataract surgery endophthalmitis (PCE), 84 had post-traumatic endophthalmitis (PTE), and 16 had endogenous endophthalmitis. Vitreous samples were evaluated for microbial profile, and all patients received similar empirical antibiotic therapy. Main outcome measures were good visual acuity, defined as better than 20/400, and microbial profile with drug resistance.

RESULTS

Final visual acuity better than 20/400 was seen in 88% patients previously treated with intravitreal antibiotics (P < .001), 89% with presenting vision of less than 3.3 LogMAR units (P < .001), 61% without retinal detachment (RD) (P < .001), 58% without retained intraocular foreign body (RIOFB) (P = .007), 88% without extensive media haze (P = .007), 71% of culture-negative patients (P = .007), and 65% with gram-positive bacteria (P = .03). On multivariate analysis, presenting visual acuity of less than 3.3 LogMAR units was found to have the highest adjusted odds ratio, 26.28 (95% CI, 9.13-75.6), for better visual outcome. Culture positivity was nearly 37%. Gram-positive bacteria were the most common in both PCE (90%) and PTE (55%) groups, whereas hyphae form fungus was the most common organism grown in endogenous endophthalmitis (50%) (P < .001). In patients without extensive media haze, hyphae form fungus was the most common grown organism (42%) (P = .03). PTE was predominant (60%) in the patients with antibiotic resistance.

CONCLUSIONS

Presenting visual acuity better than hand motions close to face is the single most common indicator of good visual prognoses. Fungal infections are associated with RD, RIOFB, trauma, and absence of extensive media haze. Microbial resistance may be an important concern in PTE patients. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:991-998.].

Ocular Emergencies: Red Eye

"Red eye" is used as a general term to describe irritated or bloodshot eyes. It is a recognizable sign of an acute/chronic, localized/systemic underlying inflammatory condition. Conjunctival injection is most commonly caused by dryness, allergy, visual fatigue, contact lens overwear, and local infections. In some instances, red eye can represent a true ocular emergency that should be treated by an ophthalmologist. A comprehensive assessment of red eye conditions is required to preserve the patients visual function. Severe ocular pain, significant photophobia, decreased vision, and history of ocular trauma are warning signs demanding immediate ophthalmological consultation.

Chronic candida endophthalmitis as a cause of intermediate uveitis

Intermediate uveitis is a subset of intraocular inflammation where vitritis is the most consistent sign, with or without snowball opacities or snow banks over the pars plana. Some patients will have an associated underlying systemic disease such as sarcoidosis, multiple sclerosis, ocular tuberculosis, inflammatory bowel disease, possibly Behçet's disease and intraocular lymphoma, whereas some will be classified as pars planitis in case of the lack of an identifiable systemic disease association. Our patient, a 47-year-old woman, developed intermediate uveitis after cataract surgery in her right eye, was misdiagnosed as pars planitis, and received steroid monotherapy for 8 months. Her inflammation only fully resolved after vitrectomy with removal of the intraocular lens (IOL) and capsular bag. Oral fluconazole and intravitreal amphotericin B injection had failed to resolve her inflammation when Candida albicans was identified as the cause of her persistent intermediate uveitis.

Changes in visual acuity and intra-ocular pressure following bleb-related infection: the Japan Glaucoma Society Survey of Bleb-related Infection Report 2

PURPOSE

To identify changes in visual acuity and intra-ocular pressure (IOP) 12 months after the development of bleb-related infection.

METHODS

Data obtained from 146 eyes of 146 patients with bleb-related infection were analyzed as a part of the Japan Glaucoma Society Survey of Bleb-related Infection. Multiple logistic regression analysis was conducted to identify factors associated with poor prognosis in visual acuity and increased IOP and for being stage III.

RESULTS

The logMAR increased by a mean of 0.140, 0.440, 1.099 and 1.122 at 12 months postinfection for stage I, II, IIIa and IIIb infections, respectively. The logMAR was significantly worse at 6 and 12 months postinfection in stage IIIb (p = 0.002 and p = 0.003, respectively; Wilcoxon signed-rank test) and at 6 months postinfection in stage IIIa (p = 0.036). The IOP was significantly elevated following infection in both stage IIIa and stage IIIb (p = 0.028 and p = 0.008 at 6 and 12 months, respectively, for stage IIIa; p = 0.002 and p = 0.005 for stage IIIb). The multiple logistic regression analysis revealed that being stage III and positive culture were significant risk factors for poor outcome for visual acuity (Odds ratio: 9.26 and 6.29, respectively) and that being stage III was a prognostic factor for increased IOP (Odds ratio: 8.33). Pseudophakia or aphakia was significantly associated with stage III and stage IIIb infections (Odds ratio: 2.85 and 6.30).

CONCLUSIONS

Stage III bleb-related infection causes significant visual loss and IOP elevation within 12 months after development. Therefore, preventative measures should be taken, especially in cases that are pseudophakic or aphakic.

[Bilateral blindness in endogenous endophthalmitis with fulminant course -- a clinical case]

We present the case of man with endogenous endophtalmitis AO, with Insulin-dependent Diabetes Mellitus type 2 and Viral hepatitis type C. The prognosis was reserved in the context of the underlying disease, with loss of his visual acuity OD and evisceration OS. Despite the correct treatment and many clinical, laboratory, imaging and interclinical examinations, etiologic diagnosis was established with great difficulty and very late.

[Treatment option for intralamellar corneo-scleral abscesses in the zone of tunnel incision after phacoemulsification]

The article provides data on clinical diagnosis (4 patients, 4 eyes) and early surgical treatment of corneal intralamellar abscesses (ICA) in the zone of corneo-scleral tunnel incision after phacoemulsification (PE). ICA developed via corneo-scleral incision was a relatively reliable biomicroscopic sign of the beginning chronic endophthalmitis. Despite of massive nonsurgical treatment (antibiotics, glucocorticoids, non-steroid anti-inflammatory agents etc.) inflammation was not arrested completely, it recurred within 2,5-6 months after PE. Reconstructive conjunctivo-sclerokeratoplasty resulted in arrest of inflammation and visual function recovery in 3 patients. In one patient this procedure was not possible to perform because of total loss of visual functions due to chronic endophthalmitis.

[Clinical and functional considerations in some cases of postoperative endophthalmitis]

We present 3 cases of postsurgery endophthalmitis, with good initial operatory technique, which were admitted in our hospital within variable time, to which a second surgery was performed, with good postoperative evolution, without any inflamatory signs and preserving the eye. We analyse the pre and post-operative treatment of endophthalmitis, but also the ways to prevent the appearance of this post-operative complication.

[Case of retinal ischemia and retinal arteritis secondary to intravitreal nuclear drop]

BACKGROUND

A rare case of retinal arteritis and retinal ischemia as an incomplete branch retinal artery occlusion is reported following dropped lens fragments into the vitreous body.

CASE

A 69 year-old-woman had a cataract OD with corrected visual acuity of 0.4. When she underwent phacoemulsification on March 11, the posterior capsule was damaged and nucleus fragments dropped into a vitreous body. A few days later, the vitreous opacity increased. The corrected visual acuity OD dropped to 0.06 due to anterior chamber inflammation and the intraocular pressure increased to 26 mmHg. During a pars plana vitrectomy on May 7, some retinal whitening were observed and incomplete branch retinal artery occlusion was confirmed by fluorescence fundus angiography. The corrected visual acuity finally improved to 0.3, but the right visual field defect remained.

CONCLUSION

Incomplete branch retinal artery occlusion caused by phacoanaphylactic endophthalmitis secondary to lens fragments in the vitreous cavity seems to be a rare condition related to retinal whitening. The timing of pars plana vitrectomy should be considered before retinal arterial sheathing or retinal whitening can be noted.

Outcomes and risk factors associated with endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents

OBJECTIVE

To describe outcomes of and risk factors for endophthalmitis after intravitreal anti-vascular endothelial growth factor (VEGF) injection.

DESIGN

Single-center, consecutive, case series and retrospective case-control study.

PARTICIPANTS

Between January 1, 2009, and May 31, 2010, 16 vitreoretinal surgeons administered a total of 27 736 injections. During this period, 23 cases of presumed infectious endophthalmitis occurred. Each surgeon used his own preferred injection technique.

INTERVENTION

Vitreous or aqueous tap, or both, with intravitreal antibiotic injection and subsequent topical antibiotic and steroid drops.

MAIN OUTCOME MEASURES

Visual acuity, bladed lid speculum use, conjunctival displacement, hemisphere of injection, bevacizumab versus ranibizumab, and infectious organism.

RESULTS

Seven of 23 cases had positive culture results; 3 grew coagulase-negative Staphylococcus. All cases had pain and vitritis on average 3.4 days (range, 1-6 days) after injection, with no difference between culture-positive and culture-negative groups. Eighteen (78%) of 23 cases had a hypopyon. Fifteen of 23 cases returned to baseline vision (±2 lines) within 3 months. Neither lid speculum use (0.10% vs. 0.066% in the no-use group; P = 0.27), conjunctival displacement (0.11% vs. 0.076% in the no-displacement group; P = 0.43), hemisphere of injection (0.11% superior vs. 0.079% inferior; P = 0.56), or bevacizumab versus ranibizumab (0.11% vs. 0.066%; P = 0.21) affected risk. Analysis of only culture-positive results yielded similar results. There was no statistically significant difference between the proportion of culture-negative cases after bevacizumab injection (83%) versus ranibizumab injection (55%; P = 0.13).

CONCLUSIONS

Most patients in whom presumed infectious endophthalmitis develop after anti-VEGF injection regained baseline vision after treatment. Bladed lid speculum use, conjunctival displacement, hemisphere of injection, and type of anti-VEGF agent did not affect risk. No difference in culture-negative endophthalmitis rates was detected after bevacizumab versus ranibizumab injection. Neither the presence of pain, vitritis, decreased vision, hypopyon, nor the interval between injection and development of symptoms differentiate culture-positive from culture-negative cases. Because a subgroup of patients had poor outcomes, a low threshold for vitreous tap with intravitreal antibiotic injection may be warranted.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Endophthalmitis in paediatric penetrating ocular injuries in Hyderabad

OBJECTIVE

To determine the frequency, risk factors, and visual outcome of post traumatic endophthalmitis in children.

METHODS

The study was conducted on patients less than fifteen years age, presenting with penetrating ocular injuries and associated with endophthalmitis. Anterior segment slit lamp examination and if possible posterior segment slit lamp examination with 90 D fundoscopes was performed. After completing necessary investigations, urgent surgical intervention was carried out.

RESULTS

There were 43 registered patients with 29 (67.4%) males and 14 (32.6%) females. Twenty three (53.4%) children presented on the day of injury. Remaining 20 (46.6%) reported after first 24 hours. Twenty seven (62.7%) children presented with corneal wound, 11 (25.6%) had scleral entrance, and 5 (11.7%) patients had corneo scleral extension. Nineteen (44.1%) patients developed clinical evidence of endophthalmitis. Fifteen subjects with endophthalmitis completed six weeks follow up. Two (13.3%) subjects achieved final visual acuity (FVA) of 3/60. Four (26.7%) had only hand movements, 5 (33.4%) subjects were restricted to perception of light, and 2 (13.3%) patients developed phthisis bulbi.

CONCLUSION

Delayed arrival of patients in eye hospital with open globe injury may result in endophthalmitis

Visual Recovery FollowingMycobacterium chelonaeEndophthalmitis

Following uncomplicated cataract surgery, a patient receiving etanercept for psoriatic arthritis developed Mycobacterium chelonae endophthalmitis. Vitrectomy, capsulectomy, and intraocular lens removal was followed by intravitreal amikacin, topical gatifloxacin, intravenous imipenem, and oral clarithromycin for six months. The patient achieved a final corrected visual acuity of 20/20. Etanercept has been implicated in the development of numerous, severe granulomatous infections, though not previously with M. chelonae. This represents the first reported case of visual recovery following M. chelonae endophthalmitis.

Somatostatin actions via somatostatin receptors on the ocular surface are modulated by inflammatory processes

Recent investigations support the presence of human somatostatin (SS) in the excretory system of the human lacrimal gland. To get deeper insights into a possible role of SS at the ocular surface and in the lacrimal apparatus, we investigated the distribution pattern of SS and its receptors 1-5 (SSTR1-5) by means of RT-PCR, real-time RT-PCR, Western blot and immunodot blot analysis as well as immunohistochemistry in lacrimal gland, tear fluid, conjunctiva, cornea, nasolacrimal duct epithelium, and conjunctival (HCjE) and corneal (HCE) epithelial cell lines. Cell culture experiments with HCjE and HCE were performed to analyze a possible impact of SS and inflammatory mediators on the regulation of SSTR. The results confirmed the presence of SS in lacrimal gland and tear fluid, whereas it was absent at the protein level in all other tissues and cell lines investigated. Expression of SSTR1, -2, and -5 was detectable in lacrimal gland, conjunctiva, cornea, and nasolacrimal ducts. HCjE expressed only hSSTR1 and -2, and HCE revealed only SSTR2. SSTR3 and -4 were not detected in any of the analyzed samples or cell lines. In vitro on cultured immortalized HCjE cells SS leads to a concentration-dependent down-regulation of SSTR1 mRNA but does not affect SSTR2 mRNA expression. Relative expression of SSTR1 and -2 is differentially modulated by proinflammatory cytokines and bacterial components, suggesting that the expression of both receptors is immunomodulated. Our data support an autocrine and paracrine role of SS in the lacrimal system and at the ocular surface and implicate a role of SS in corneal immunology.

[Clinical features of endophthalmitis after cataract surgery evaluated by the presence of background factors]

PURPOSE

The clinical features and visual prognosis after vitrectomy for endophthalmitis which had developed after cataract surgery were compared in two groups with or without background factors, including malignant tumor, diabetes, oral steroid administration, collagen disease, dacryocystitis, and lid closure disturbance.

METHOD

Fifty-two patients (53 eyes) who underwent a vitrectomy for the treatment of endophthalmitis which had developed within 6 weeks after cataract surgery. They were divided into two groups according to the presence (21 eyes, group A) or absence (32 eyes, group B) of background factors, and were retrospectively compared based on their medical records.

RESULTS

The culture-positive rate was 62% in group A and 69% in group B. The incidence of a final visual acuity of more than 20/20 was significantly lower in group A (14%) than in group B (47%, p < 0.05). Methicillin-resistant Staphylococcus aureus, alpha-hemolytic Streptococcus and Enterococcus were frequently identified in group A. Leakage from the cataract wound was found in about 80% of the patients with corneal incisions, and a wound that had not been covered by the conjunctiva was significantly more frequent as a factor in group A (group A, 13 eyes; group B, 10 eyes; p < 0.05).

CONCLUSION

Postoperative endophthalmitis may have a less favorable visual prognosis in patients with background factors, so precise wound construction during cataract surgery is important in these patients.

Presumed Candida endogenous fungal endophthalmitis: a case report and literature review

BACKGROUND

Endogenous fungal endophthalmitis (EFE) is a rare intraocular infection that has recently increased in incidence over the last few decades. The most common causative organism of endogenous endophthalmitis is Candida albicans. Treatment generally is initiated with an antifungal drug systemically and, depending on the ocular findings, may also include a vitrectomy with the injection of an intraocular antifungal agent. Specific predisposing factors may make a patient more at risk for development of an ocular infection.

CASE REPORT

We present a case of presumed Candida endogenous endophthalmitis in an 83-year-old white man with a Candida albicans urinary tract infection and describe the general characteristics, treatment, and management of this condition.

CONCLUSION

Endogenous fungal endophthalmitis is a potentially blinding condition that can signal an underlying systemic infection. Without a dilated fundus examination in the presence of ocular inflammation, the condition easily can be misdiagnosed. Fungal infection may lead to retinal and vitreal lesions that can be visually debilitating if left untreated. Prognosis for visual outcome is dependent on timely diagnosis and initiation of treatment.

Incidence and visual outcome of endophthalmitis associated with intraocular foreign bodies

PURPOSE

To determine the risk factors and visual outcome of endophthalmitis associated with traumatic intraocular foreign body (IOFB) removal and its allied management.

METHODS

A retrospective review was conducted of patients with penetrating eye trauma and retained IOFB with associated endophthalmitis managed at King Khaled Eye Specialist Hospital over a 22 year period (1983 to 2004).

RESULTS

There were 589 eyes of 565 patients (90.3% male; 9.7% female) which sustained ocular trauma and had retained IOFB that required management. Forty-four eyes (7.5%) developed clinical evidence of endophthalmitis at some point after trauma. From these 44 eyes, initial presenting visual acuity (VA) of 20/200 or better was recorded in 8 eyes (18.1%) and the remaining 36 eyes (81.9%) had VA ranging from 20/400 to light perception. Eleven eyes (25%) underwent IOFB removal and repair within 24 hours after trauma while 33 eyes (75%) had similar procedures done 24 hours or more after trauma. Thirty-one eyes (70%) underwent primary pars plana vitrectomy (PPV) at the time of removal of posteriorly located IOFBs. Definite positive cultures were obtained from 17 eyes (38.6%). Over a mean follow-up of 24.8 months, 21 eyes (47.7%) had improved VA, 6 eyes (13.6%) maintained presenting VA while 17 eyes (38.7%) had deterioration of their VA, including 10 eyes (22.7%) that were left with no light perception (NLP) vision. After the treatment of endophthalmitis, 20 eyes (45.4%) had VA of 20/200 or better at their last follow-up. Four eyes (12.9%) from the vitrectomy group (31 eyes) and 5 eyes (45.4%) from non-vitrectomy (11 eyes) group had final VA of NLP. Predictive factors for the good visual outcome included good initial presenting VA, early surgical intervention to remove IOFB (within 24 hours), and PPV. Predictors of poor visual outcome included IOFB removal 48 hours or later, posterior location and no PPV for the posteriorly located IOFB.

CONCLUSIONS

Delayed removal of IOFB following trauma may result in a significant increase in the development of clinical endophthalmitis. Other risk factors for poor visual outcome may include poor initial presenting VA, posterior location of IOFB and no vitrectomy at the time of IOFB removal.

Functional and anatomical outcomes of vitreoretinal surgery for posterior segment complications after elective cataract surgery

PURPOSE

To assess the outcomes in patients who required 1 or more vitreoretinal interventions for posterior segment complications arising from elective uneventful cataract surgery.

SETTING

Tertiary referral center, single-center study.

METHODS

A retrospective interventional case series included 56 consecutive patients who were referred for surgical correction of posterior segment complications within 6 months of cataract surgery. The study period was between 1996 and 2003, and the minimum follow-up was 5 months.

RESULTS

Posterior segment complications were resolved with a single surgical intervention in 40 cases (71.4%). Within 5 months of primary surgical correction, persisting or newly arising posterior segment complications were noted in 16 cases (28.6%). After a mean of 2.1 +/- 1.4 (SD) additional surgeries, the number of eyes with posterior segment problems decreased to 7 (12.5%) (P = .035). Posterior segment complications requiring more than 1 vitreoretinal intervention included retinal detachment, endophthalmitis, and choroidal hemorrhages. After primary correction surgery, the mean best corrected visual acuity increased from 0.15 +/- 0.24 to 0.37 +/- 0.33 (P = .001) after a single intervention and to 0.39 +/- 0.32 (P>.05) after additional interventions. Although the intraocular pressure (IOP) decreased from 21.8 +/- 16.6 mm Hg to 14.9 +/- 3.4 mm Hg (P = .008), 4 (7.1%) consecutive vascular optic atrophies occurred. A reduction in corneal transparency was observed in 46.4% of patients before primary surgical correction and 12.5% after primary surgical correction (P<.001).

CONCLUSIONS

In many cases, posterior segment complications arising from cataract surgery could be repaired with favorable functional and anatomical outcomes by a single vitreoretinal intervention. Additional surgery, if requested, provided stabilization of the anatomical and functional outcomes.

Evaluation of outcome of various treatment methods for endogenous endophthalmitis

AIM

To evaluate the role of different treatment methods (intravitreal antibiotics and vitrectomy) for endogenous endophthalmitis and assess the outcome. Materials and0

METHODS

This is a retrospective observational case study. Sixteen cases of endogenous endophthalmitis noted in 14 patients between October 2000 and April 2004 were reviewed. Two patients had bilateral disease. Patients were followed up for a mean of 3 months (range, 1-12 months).

RESULTS

Vitreous and aqueous cultures were positive in 8 (66%) cases and 3 (75%) cases respectively. Fungal isolates occurred in 4 (33%) cases, out of which 3 were due to candida, gram-positive isolates occurred in 2 (16%) and gram-negative isolates in 2 (16%) of the cases. Initial treatment included vitreous tap and injection of intravitreal medication in 12 (75%) cases and pars plana vitrectomy with injection of intravitreal medication in 3 (19%) cases. Final visual outcomes were obtainable for13 cases (1 patient died and 1 patient was lost to follow-up and 1 eye was eviscerated). Five (43%) of these cases achieved visual acuity of 6/60 or better and 8 (56%) eyes achieved a visual acuity less than 6/60. Risk factors mainly associated with the disease were uncontrolled diabetes mellitus, chronic renal failure, renal transplant, abdominal surgeries and septicemia.

CONCLUSION

Our experience suggests that endogenous endophthalmitis is generally associated with poor visual outcome. Prompt treatment with intravitreal antibiotics and vitrectomy can result in improvement in ocular signs and visual acuity in majority of the patients. The patients with culture-positive endogenous endophthalmitis are more likely to have fungal isolates with a predominance of candida. Fungal endopthalmitis has a poor visual outcome as compared to bacterial endophthalmitis.

Atopic ocular surface disease: implications on tear function and ocular surface mucins

PURPOSE

To describe tear function, mucin alterations, and ocular surface disorder in patients with atopic diseases.

METHODS

Subjects underwent corneal sensitivity measurements, Schirmer test, tear film break-up time (BUT) assay, and fluorescein and rose Bengal staining of the ocular surface. Conjunctival impression cytology and brush cytology were also conducted. Impression cytology samples underwent PAS and immunohistochemical staining for MUC5AC. Brush cytology specimens underwent evaluation for inflammatory cell expression and RT-PCR for MUC5AC mRNA expression. Differences related to tear function and ocular surface examination parameters among patients with and without corneal ulceration and healthy control subjects were studied.

RESULTS

Mean corneal sensitivity and BUT values were significantly lower in atopic patients with corneal ulcers compared with patients without ulcers and controls (P<0.001). Brush cytology specimens from patients with corneal ulcers revealed significantly higher expression of inflammatory cells compared with patients without ulcers and controls (P<0.001). Impression cytology samples from eyes with corneal ulcers showed significant squamous metaplasia and reduction of goblet cell density compared with eyes without ulcers and control subjects. Specimens from eyes with corneal ulcers showed PAS (+) mucin pick up and did not stain positive for MUC5AC. MUC5AC mRNA expression was significantly lower in eyes with corneal ulcers compared with in eyes without ulcers and control subjects.

CONCLUSIONS

Ocular surface inflammation, tear film instability, and decreased conjunctival MUC5AC mRNA expression are important in the pathogenesis of noninfectious corneal shield ulcers in atopic ocular surface disease.

Hypopyon and Pseudoendophthalmitis Associated With Chronic Vitreous Hemorrhage

Infectious endophthalmitis is an uncommon but potentially devastating eye disease. Although the presence of a hypopyon is considered one of the hallmark clinical signs of infectious endophthalmitis, hypopyon associated with non-infectious causes may occur. Two patients with hypopyon and pseudoendophthalmitis secondary to chronic vitreous hemorrhage are described. In both cases, the hypopyon improved without the use of intravitreal antibiotics.

A five-year review of patients admitted with the diagnosis of bacterial endophthalmitis

We conducted a retrospective, hospital-based study of patients who were diagnosed with bacterial endophthalmitis on admission to the Department of Ophthalmology, Hiroshima University Hospital, between January 1999 and December 2003. Thirty eyes of 30 patients were identified. Of these patients, 19 eyes had postoperative endophthalmitis, 8 eyes had penetrating trauma and 3 eyes were infected from an endogenous source. All of the patients underwent immediate three-port pars plana vitrectomy. Vitreous specimens of diabetic patients demonstrated a significantly higher incidence of positive bacterial culture. Diabetic vitreous appeared to be a good medium for culture. Visual acuity of hand motion or less at the latest follow-up visit was associated with the presence of diabetes. Prompt treatment with vitrectomy and intra-vitreal antibiotics is crucial for patients with bacterial endophthalmitis, especially if they are diabetic.

[Postoperative acute endophthalmitis: a prospective study. Clinical presentation, management and prognostic factors]

AIMS

To assess the characteristics and visual outcome of patients with acute postoperative endophthalmitis hospitalized in a referral center.

MATERIALS AND METHODS

All patients suspected of having infectious endophthalmitis were included in this study. All patients were treated with the same protocol including at least intravitreal injection of antibiotics and instillation of fortified antibiotics. Symptoms, visual acuity, and slit lamp examination were recorded before treatment, at the end of hospitalization and during clinical follow-up. Treatments and biological results were also reported. For patients developing infectious endophthalmitis after cataract surgery, intraoperative management such as location of the incision, suture or sutureless incision, and material of the intraocular lens were also noted.

RESULTS

Forty-one patients were included in the study over 32 months (33 patients after cataract surgery). Intraocular inflammation and a decrease in subjective visual acuity were the most frequently reported findings (90% and 94%, respectively). Ocular pain and conjunctiva injection were less frequently reported (47% and 48%, respectively). Symptoms occurred 5 days after the surgery (median); 56% of patients needed a second intravitreal injection of antibiotics. There was a significant increase in visual acuity during and after hospitalization; median final visual acuity was 4.6/10 (0.34 log MAR = 20/43); 30% of patients had less than 20/200, but 44% more than 20/40. In endophthalmitis following cataract surgery, incisions were corneal in all cases and sutured in 62% of cases. Incisions were temporal in 55% of patients.

DISCUSSION

Our results are similar to those previously published for acute endophthalmitis following ocular surgery. Intravitreal antibiotic injection remains the gold standard on the management of acute postoperative endophthalmitis.

Relationship between clinical presentation and visual outcome in postoperative and posttraumatic endophthalmitis in South Central India

PURPOSE

To determine risk factors for poor visual outcome in postoperative and posttraumatic endophthalmitis in a large referral center in south central India.

METHODS

In this prospective observational series the authors examined 388 patients of postoperative (n= 206) and posttraumatic (n= 182) endophthalmitis at the L V Prasad Eye Institute in Hyderabad, India between 1991 and 1997. The analysis was confined to 236 patients-128 (62.1%) postoperative and 108 (59.3%) posttraumatic patients who were followed for a minimum period of 3 months. A detailed protocol was followed. Chi-square and logistic regression analysis were used to determine risk factors for visual outcome worse than 6/18 and worse than 6/120.

RESULTS

Postoperative endophthalmitis: In univariate analysis the features associated with poor visual acuity (grouped as < 6/18 and < 6/120) included intracapsular cataract surgery, poor presenting visual acuity, presence of vitreous cells, inability to visualise the optic disc on indirect ophthalmoscopy, presence of vitreous membranes on ultrasonography, and a culture-positive vitreous biopsy. In the multivariate analysis, visual acuity of less or equal light perception (LP) at presentation was associated with a 3-month postoperative visual acuity of < 6/18, with an odds ratio of 5.85 [1.25 - 27.42, 95% CI], and vitreous membranes seen on ultrasonography was associated with a final visual acuity of < 6/120, with an odds ratio of 2.47 [1.05 - 5.83, 95% CI]. Posttraumatic endophthalmitis: In univariate analysis the features associated with poor visual acuity (grouped as < 6/18 and < 6/120) included a retained intraocular foreign body (IOFB), trauma by needle (hypodermic or sewing), poor presenting visual acuity, inability to visualise the optic disc on indirect ophthalmoscopy, presence of vitreous membranes on ultrasonography, and a culture-positive vitreous biopsy. In multivariate analysis, IOFB was associated with a 3-month follow-up visual acuity of < 6/18, with an odds ratio of 5.90 [1.85 - 18.78, 95% CI], and trauma by a needle (hypodermic or sewing) and retained IOFB was associated with a final visual acuity of < 6/120, with an odds ratio of 4.47 [1.22 - 16.38, 95%CI] and 3.76 [1.36 - 10.37, 95% CI] respectively.

CONCLUSION

This is the largest, single-centre, prospective study on risk factors for poor visual outcome in postoperative and posttraumatic endophthalmitis. The independent risk factor for 3-month follow-up visual acuity of < 6/18 was the presenting visual acuity of < or =LP in postoperative endophthalmitis and a retained IOFB in posttraumatic endophthalmitis. The independent risk factor for 3-month visual acuity of < 6/120 was the presence of vitreous membranes on ultrasonography in postoperative endophthalmitis, and trauma by a needle (hypodermic/ sewing) and retained IOFB in posttraumatic endophthalmitis.

[Immediate vitrectomy as a method of choice in the treatment of endophthalmitis]

This study is evaluation of the results of surgical treatment in case of postoperative endophthalmitis. The results of 16 pars plana vitrectomies in 16 patients with clinical evidences of postoperative endophthalmitis were analyzed. Successful management of postoperative endophthalmitis depends on timely diagnosis and institution of appropriate therapy.

Retinal Function Assessed by ERG Before and After Induction of Ocular Aspergillosis and Treatment by the Anti-fungal, Micafungin, in Rabbits

This study was conducted to evaluate the effectiveness of a new antifungal drug, micafungin, and standard antifungal drugs against endophthalmitis induced in a rabbit by intravitreal injection of Aspergillus fumigatus, an important fungal pathogen. Effectiveness was evaluated by the preservation of b-wave amplitude at 72 h after injection of the fungus relative to the b-wave amplitude at baseline before any intravitreal injections. A 0.06 ml inoculum of 10(6) conidia of A. fumigatus was injected into the vitreous of the right eye of all rabbits; and, 12 h later, a 0.06 ml solution containing one of 3 antifungal drugs or saline was injected into the vitreous of both eyes. All three antifungal drugs produced significant b-wave preservation at 72 h in infected eyes compared to that in infected eyes receiving saline injections. There was no statistically significant difference between the effects of micafungin and amphotericin B in the right eyes with fungal endophthalmitis, and both produced significantly more preservation of b-wave amplitude than voriconazole. Amphotericin B, but neither micafungin nor voriconazole produced significant reduction of the b-wave amplitude in the left eyes.

Endophthalmitis caused by Streptococcus pneumoniae

PURPOSE

To investigate clinical settings, management strategies, antibiotic sensitivities, and visual acuity outcomes of endophthalmitis caused by Streptococcus pneumoniae.

DESIGN

Retrospective, observational case series.

METHODS

Records were reviewed of all patients with culture-positive endophthalmitis caused by Streptococcus pneumoniae treated at the Bascom Palmer Eye Institute between January 1, 1989 and December 31, 2003.

MAIN OUTCOME MEASURES

Visual acuity and antibiotic sensitivities.

RESULTS

Twenty-seven eyes of 27 patients met study inclusion criteria. The median follow-up was 7 months (range, 3 months to 10 years). Clinical settings included acute postoperative (10 eyes), corneal stitch abscess (5), corneal ulcer (3), bleb-associated (4), post-trauma (3), and endogenous (2). Eighteen cases (67%) were acute-onset (less than 3 weeks from event), with a median interval between event and presentation of endophthalmitis of 5 days (range, 1 day to 16 days). Nine cases (33%) were delayed-onset (median, 27 months; range, 3 to 121 months). Initial visual acuity was hand motions or better in 11 cases (41%). Initial therapeutic procedures included vitreous tap and injection of intravitreal antibiotics in 15 eyes (56%), pars plana vitrectomy and injection of intravitreal antibiotics in 10 eyes (37%), and evisceration in 2 eyes (7%). Seventeen (68%) of 25 eyes received intravitreal dexamethasone. Twelve patients (48%) received additional doses of intraocular antibiotics, and 11 patients (44%) underwent secondary surgical intervention within one week of diagnosis. The Streptococcus pneumoniae isolates showed sensitivity patterns as follows: 27/27 vancomycin, 13/13 clindamycin, 6/6 cefazolin, 11/11 ciprofloxacin, 14/14 moxifloxacin, 24/26 (92%) ofloxacin, 12/14 (86%) levofloxacin, 13/14 (93%) gatifloxacin, and 1/13 (8%) gentamicin. The organism was sensitive to at least one antibiotic administered initially in all cases. Final visual acuity was 20/400 or better in 8/27 (30%) cases, but 10 eyes (37%) had a final vision of no light perception.

CONCLUSION

Despite prompt treatment with appropriate antibiotics, endophthalmitis caused by Streptococcus pneumoniae is associated with a poor visual prognosis.

[Ultrasound findings in endophthalmitis]

The ultrasound examination is the integral part of diagnostic procedure in endophthalmitis. During the ultrasound examination we may follow the organization of opacities in the vitreous, membranes formation, the thickening of the choroid, posterior vitreous membrane detachment, detachment of the choroid, the retinal detachment, chorideal abscess or granuloma, the edema of the optic nerve head and thickening of sclera. Not all of these ultrasound findings are always present. In our retrospective study, ultrasound findings of 17 eyes of 17 patients hospitalized at the Department of Ophthalmology at the School of Medicine, Palacký University in Olomouc during the period September 1999 - December 2002, were followed. Ultrasound findings in all eyes were evaluated and the final central visual acuity (VA) was followed. In eyes with VA 6/60 (20/200 or 0.1) or worse, the posterior vitreous membrane was not at all or only partially detached. In this group the finding of choroid thickening was more common. The finding of incomplete or absent posterior vitreous membrane detachment, and/or the thickening of the choroid might be prognostic unfavorable ultrasound finding in endophthalmitis.

Pseudohypopyon Following Intravitreal Triamcinolone Acetonide Injection

OBJECTIVE

To report a case of a pseudohypopyon that developed after intravitreal injection of triamcinolone acetonide for choroidal neovascularization from age-related macular degeneration.

METHODS

Observational case report.

RESULTS

A 62-year-old woman received an intravitreal injection of triamcinolone acetonide for the treatment of a choroidal neovascular membrane that developed as a result of age-related macular degeneration. A layer of yellowish deposits was observed in the anterior chamber 1 day after the injection. The patient denied any pain or reduced vision, and there was no redness noted on examination. The deposits cleared spontaneously on the fourth postoperative day.

CONCLUSIONS

Pseudohypopyon may develop after intravitreal injection of triamcinolone acetonide. Distinguishing this from a true hypopyon is important because the treatment and prognosis are very different for the two conditions.

[Acute endophthalmitis of 15-year old boy in the course of acute lymphoblastic leukemia. Part II--Electrophysiological examinations]

PURPOSE

The aim of the study is to present objective estimation of visual function in eyes affected by leukemia.

MATERIAL AND METHODS

The boy who was described in the first part of this study was examined. Visual evoked potential (VEP), full-field flash electroretinography (FERG), electrooculography (EOG), were done according to ISCEV standards.

RESULTS

The function of retina was decreased proportionally to the areas of infiltration. The amplitude of VEP peaks was lowered when the involvement of the central nervous system occurred. In the eye with retinal infiltration abnormal EOG was present a few months earlier than pigment epithelium destruction was seen in ocular fundus.

CONCLUSIONS

Functional deficits may be irreversible.

Hydrophobic acrylic versus heparin surface-modified polymethylmethacrylate intraocular lens: a biocompatibility study

BACKGROUND

The implant of intraocular lenses (IOLs) following cataract surgery induces a foreign-body reaction to the IOL and a response on the part of the lens epithelial cells (LECs). The purpose of this study was to compare these aspects after the implantation of two different IOL materials.

METHODS

Thirty-six cataract patients were randomised to receive two different foldable lens: an acrylic hydrophobic IOL (Acrysof MA30BA) and a heparin surface-modified (HSM) polymethylmethacrylate IOL (Pharmacia & Upjohn 809C) after phacoemulsification. Slit-lamp biomicroscopy with specular technique was used to assess the inflammatory cell adhesion on the anterior IOL surface, anterior capsule opacification (ACO) and membrane growth from the rhexis edge at 7, 30, 90, 180 and 360 days after surgery.

RESULTS

The 809C group showed a higher percentage of patients with slight inflammatory cell adhesion on the anterior cell surface and a higher small cellular density during the whole follow-up period. The epithelioid cell response was greater in the 809C group than the Acrysof group but the difference between the two groups was not statistically significant. The ACO increased during the follow-up in both groups but was significantly higher in the 809C group.

CONCLUSION

Acrysof lenses are more biocompatible than HSM IOLs, showing a lower grade of inflammatory cell adhesion and ACO. The implantation of these lenses may be particularly indicated in patients with pathologies predisposing to blood-aqueous barrier damage.

Red eyes as the initial presentation of systemic meningococcal infection

The present paper is a report of a 14-month-old boy who presented with fever, coryzal symptoms and red eyes. The patient developed a generalized tonic clonic convulsion on day 2 of his illness. Ophthalmological assessment demonstrated bilateral hypopyon and vitreous opacity resulting from endophthalmitis. Cerebrospinal fluid was positive for Neisseria meningitidis (A, C, Y, W 135) by latex agglutination. He was treated with high dose intravenous cefotaxime and intravitreal ceftazidime. He made good recovery and his vision was preserved. In view of the potential morbidity and mortality associated with systemic meningococcal infection, the presence of red eye and hypopyon provides important diagnostic clues indicating the need to investigate beyond superficial conjunctivitis. It should prompt the clinician to recognize endopthalmitis early and accurately diagnose this serious disease.

Relationship of plcR-regulated factors to Bacillus endophthalmitis virulence

The explosive, destructive course of Bacillus endophthalmitis has been attributed to the production of toxins during infection. In this study we analyzed the contribution of toxins controlled by the global regulator plcR to the pathogenesis of experimental Bacillus endophthalmitis. Isogenic plcR-deficient mutants of Bacillus cereus and Bacillus thuringiensis were constructed by insertional inactivation of plcR by the kanamycin resistance cassette, aphA3. Rabbit eyes were injected intravitreally with approximately 100 CFU of wild-type B. cereus or B. thuringiensis or a plcR-deficient mutant. The evolution of endophthalmitis resulting from each plcR-deficient mutant was considerably slower than that caused by each wild-type strain. Retinal function was not eliminated until 42 h postinfection in rabbits with endophthalmitis caused by the plcR-deficient mutants, whereas wild-type infections resulted in a complete loss of retinal function within 18 h. The intraocular inflammatory cell influx and retinal destruction in plcR-deficient endophthalmitis approached the severity observed in wild-ype infections, but not until 36 h postinfection. Gross and histological examinations of eyes infected with plcR mutants demonstrated that the anterior and posterior segment changes were muted compared to the changes observed in eyes infected with the wild types. The loss of plcR-regulated factors significantly attenuated the severity of Bacillus endophthalmitis. The results therefore suggest that plcR may represent a target for which adjunct therapies could be designed for the prevention of blindness during Bacillus endophthalmitis.

Spectrum and clinical profile of post cataract surgery endophthalmitis in north India

PURPOSE

To determine the spectrum, clinical profile and risk factors for poor visual outcome in patients of post cataract surgery endophthalmitis.

METHODS

Data from 124 eyes were analysed. Various clinical and microbiological parameters were evaluated and risk factors for unfavourable outcome identified.

RESULTS

The mean age of the patients was 59.50 +/- 13.75 years; 60.5% were males. The median surgery-symptom interval was 7 days (mean 15.81 +/- 24.01) and the medium symptom-presentation interval 7.5 days (mean 14.19 +/- 19.13). Corneal infiltrates were seen in 29%, hypopyon in 62 (50%). Smear positivity was 52.5% and culture positivity 38%. Equivocal microbiological positivity was seen in 22 (18%), bacterial 12 (10%), fungal 27 (21.5%), polymicrobial 8 (6.5%) and negative 55 (44%). 20% eyes had total loss of vision at last follow-up. Poor visual acuity at presentation, presence of intraocular lens, shorter surgery-symptom interval, corneal and surgical wound infiltrates, loss of red reflex, microbiological positivity of the vitreous tap and systemic diabetes mellitus were significant risk factors for unfavourable outcome.

CONCLUSION

Our data highlights a low culture positivity and a predominance of fungal pathogens as a cause of post cataract surgery endophthalmitis. The visual outcome in these patients is still dismal and better treatment strategies should be evolved keeping in mind the microbiological spectrum. The risk factors identified may be helpful in prognosticating the outcome in such patients.

Pars plana vitrectomy with or without silicone oil endotamponade in post-traumatic endophthalmitis

BACKGROUND

Results of core vitrectomy in post-traumatic endophthalmitis are poor. Our initial results of complete vitrectomy with primary silicone oil endotamponade were promising. A comparative study of this procedure with conventional core vitrectomy was therefore carried out.

METHODS

A prospective randomized controlled study of 24 consecutive cases of post-traumatic endophthalmitis was conducted. Patients were randomized into two groups in the absence of clinical improvement after primary tap and treatment with intravitreal vancomycin and amikacin: group 1 consisted of patients who underwent core vitrectomy alone, group 2 of patients who underwent complete vitrectomy with silicone oil endotamponade. All patients included in the study received intravenous antibiotics and underwent lensectomy. Patients were followed up 1, 2, 4 and 12 weeks postoperatively. In all patients of group 2, silicone oil was removed 6 weeks after primary surgery. The mean duration of follow-up was 112+/-55 days.

RESULTS

Vision of 20/400 or better was obtained in 58.33% of cases (14/24). Visual acuity of only one patient in group 1 was >or=20/200, compared with that of 58.3% of patients (7/12) in group 2 ( P=0.02). Intra-operative retinal breaks were found in 50% (6/12) of the patients belonging to group 1, but did not affect the final visual outcome. In group 1, 33.33% (4/12) developed rhegmatogenous retinal detachment in the immediate post-operative period. Only one of these patients had useful final visual outcome after resurgery.

CONCLUSION

Complete vitrectomy with primary silicone oil endotamponade is a useful treatment modality which improves the anatomical and functional results in post-traumatic endophthalmitis.

Actinobacillus actinomycetemcomitans endogenous endophthalmitis: report of two cases and review of the literature

Endogenous endophthalmitis due to Actinobacillus actinomycetemcomitans is an unusual disease with serious sequelae. Of the 4 cases published in the literature only 1 recovered useful vision after treatment. This study reports on 1 additional patient and expands on the previously described brief ophthalmology case report of another patient with marked visual impairment at presentation and good visual recovery after treatment. Of the 5 patients described, 4 had pre-existing heart abnormalities, 3 had permanent pacemakers and 2 had periodontal disease. Definite endocarditis by Duke criteria was present in 3 patients. Endocarditis should be ruled out in every patient with A. actinomycetemcomitans endophthalmitis, even in the absence of systemic complaints and prior penicillin prophylaxis. Eye specimen cultures should be incubated for 10 d. A thorough dental examination should be done in each patient and any periodontal disease should be promptly treated.

Group B Streptococcus endogenous endophthalmitis : case reports and review of the literature

PURPOSE

To report five cases of group B Streptococcus endogenous endophthalmitis (GBSEE) and to review the literature.

DESIGN

Retrospective, noncomparative, interventional case series and literature review.

PATIENTS

All patients with this condition treated at the Singapore National Eye Centre from 1994 through 2001.

INTERVENTIONS

Core or complete vitrectomy and intravitreal and systemic antibiotics.

METHODS

A review of the systemic and ocular characteristics and treatment.

MAIN OUTCOME MEASURE

Visual outcome.

RESULTS

Group B Streptococcus endogenous endophthalmitis developed in four patients after the onset of septic arthritis and in one patient with cervical epidural abscess after acupuncture, presenting as a diffuse endophthalmitis. Group B Streptococcus was isolated in the blood, vitreous, and joints. Despite the use of high-dose intravenous antibiotics within 72 hours of ocular presentation, intravitreal antibiotic injection, and vitrectomy (two eyes), all eyes lost light perception and became phthisical. A survey of the literature revealed that GBSEE is rare and that 17 cases have been reported since 1985. For purposes of analysis, four of these cases were excluded because of inadequate details and our five cases were included. Group B Streptococcus endogenous endophthalmitis was found to arise from hematogenous spread from cutaneous sites of infection (16.7%), pharyngitis (11.1%), and pneumonia (11.1%). Septic arthritis (38.9%) and endocarditis (33.3%) were concomitant sites of infection along with endophthalmitis. The septic arthritis typically involved multiple joints. Four patients (22.2%) had diabetes mellitus and three had other underlying predisposing illness. Although most patients received intravenous (83.3%) and intravitreal (55.6%) antibiotics and four eyes underwent therapeutic vitrectomy, useful vision was preserved in only four eyes. Two patients died of sepsis.

CONCLUSIONS

Group B Streptococcus endogenous endophthalmitis is a devastating condition often associated with septic arthritis. The visual prognosis is poor, despite therapy.

Ocular manifestations of injection drug use

Injection drug use can result in a variety of severe ocular conditions. Hematogenous dissemination of various fungi and bacteria may produce endophthalmitis with resultant severe visual loss. Retinal arterial occlusive disease may result from talc and other particulate emboli. Most commonly, life-threatening systemic diseases such as endocarditis and HIV infection secondarily affect the eye. Because many of these conditions may result in blindness if untreated, accurate diagnosis and prompt initiation of therapy are essential.

The eye in systemic sepsis

Metastatic or endogenous endophthalmitis (EE) is a serious consequence of systemic sepsis. It is defined as intraocular infection resulting from haematogenous spread of organisms in which the initial focus of infection is at a site distal to the eye. A red/sore eye in a patient with a known septic focus needs urgent attention as EE can be a major cause of visual loss. Early diagnosis and treatment are associated with better visual outcome. This article focuses on the two main causes of EE, namely bacterial and fungal infections, and also briefly mentions dissemination of cytomegalovirus to the eye in immunocompromised patients. Although conscious patients may notice an ocular problem, unconscious or very sick patients may not; vigilance by medical staff in looking for early signs of this is extremely important.

The Enterococcus faecalis fsrB gene, a key component of the fsr quorum-sensing system, is associated with virulence in the rabbit endophthalmitis model

We used a rabbit endophthalmitis model to explore the role of fsrB, a gene required for the function of the fsr quorum-sensing system of Enterococcus faecalis, in pathogenicity. A nonpolar deletion mutant of fsrB had significantly reduced virulence compared to wild type. Complementation of mutation restored virulence. These data corroborate the role of fsrB in E. faecalis pathogenesis and suggest that the rabbit endophthalmitis model can be used to study the in vivo role of quorum sensing.