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

Purpose: To report the clinical presentation, microbiology, and management outcome of endogenous endophthalmitis in Indian patients. Methods: Retrospective chart review of culture-positive (vitreous/urine/blood) endogenous endophthalmitis cases treated in tertiary eye care facility in India was done. Results: The study included 173 eyes of 117 patients. Mean patient age was 25.41 ± 20.46 years (median 24 years). Pre-disposing systemic illness could not be elicited in 79 (67.63%) patients. Commonest predisposing systemic condition in patients where it could be detected (n = 79) was pyrexia of unknown origin (25/79 = 32.0%). Following treatment, 45 out of 173 (26.0%) eyes regained vision of ≥20/400. Commonest isolated organism from vitreous was Streptococcus pneumoniae (36 eyes, 20.8%) and fungi were isolated in 24 (13.8%) eyes, the commonest being Candida spp. (8/24, 33.33%). Favorable functional outcome was seen in 26% eyes and favorable anatomic outcome in 43% eyes. Those with an underlying systemic illness were older (P = 0.02), had greater urine culture positivity (P = 0.003), lesser vitreous culture positivity (0.001), greater gram negative etiology (P = 0.0006), and greater fungal etiology (P = 0.01) as compared to those cases without underlying systemic illness. Conclusion: Endogenous endophthalmitis in India often presents in young immunocompetent individuals without any underlying systemic illness and with negative blood or urine microbiologic work up. Underlying systemic illness leads to greater gram-negative and fungal etiology. Overall visual outcome is poor inspite of prompt management.

Coexisting choroidal neovascularization and active retinochoroiditis-an uncommon presentation of ocular toxoplasmosis.

BACKGROUND: Choroidal neovascularization during the active stage of Toxoplasma retinochoroiditis is an uncommon clinical presentation. The authors retrospectively reviewed medical charts of patients with coexisting choroidal neovascular membrane and active Toxoplasma retinochoroiditis. FINDINGS: Three patients presented with coexisting choroidal neovascular membrane and active Toxoplasma retinochoroiditis. All lesions had adjacent subretinal hemorrhage. The diagnosis was confirmed based on clinical presentation, fundus fluorescein angiography (FFA), and optical coherence tomography (OCT) findings. The patients were managed with a combination of treatments including intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF), oral anti-Toxoplasma treatment, and oral corticosteroids. In all patients, the retinitis lesion resolved in 6 weeks and the coexisting choroidal neovascular membrane resolved over 6 to 12 weeks. CONCLUSIONS: Recurrences in Toxoplasma retinochoroiditis are common as satellite lesions adjacent to an old atrophic scar. Coexisting choroidal neovascularization with active Toxoplasma retinochoroiditis is an important presentation and should be suspected in the presence subretinal hemorrhage and managed with a combination of anti-Toxoplasma treatment and intravitreal anti-VEGF.

Microbiologic spectrum and susceptibility of isolates in delayed post-cataract surgery endophthalmitis.

The objective of this study was to evaluate the microbiological spectrum and antimicrobial susceptibility of isolates in delayed post-cataract surgery endophthalmitis. A retrospective review of 33 consecutive patients with culture proven delayed post-cataract surgery endophthalmitis was done from January 2006 to March 2013. There were 22 bacterial and eleven fungal cases. Common isolates were Streptococci (seven cases), coagulase-negative staphylococci (five), Gram-negative bacilli (seven), Nocardia (two), Aspergillus (five), Candida (five). Gram-positive cocci were most susceptible to vancomycin and gatifloxacin (91.7%). Gram-negative isolates were most susceptible to ofloxacin (85.7%). Fungi being slow growing organisms are an important cause of delayed post-cataract surgery endophthalmitis.

An outbreak of Ralstonia pickettii endophthalmitis following intravitreal methotrexate injection.

PURPOSE: To report an outbreak of endophthalmitis in three eyes of two patients following intravitreal methotrexate, caused by Ralstonia pickettii. DESIGN: Retrospective, noncomparative, consecutive case series. METHODS: Medical records and microbiology results of two patients who presented with acute endophthalmitis following intravitreal methotrexate injection in November 2013 were reviewed. RESULTS: Following intravitreal injections, the patients experienced pain and decrease in vision in the affected eye within 24 hours of receiving intravitreal methotrexate injection. The presenting visual acuity in case 1 was 20/50 in the left eye. The presenting visual acuity in case 2 was hand motions in the right eye and counting fingers at 1 m in the left eye. Both the patients received methotrexate prepared in the same manufacturing facility. Both the patients underwent vitreous biopsy and intravitreal injection of vancomycin 1 mg/0.1 mL, amikacin 400 µg/0.1 mL, and dexamethasone 400 µg/0.1 mL. Microbiology cultures from vitreous, and used and unused vials of methotrexate from the same batch grew R. pickettii. After 8 months of follow-up, both the patients had visual acuity 20/60 or better. CONCLUSION: R. pickettii can be rarely associated with outbreak of endophthalmitis. Timely intervention can be associated with good visual outcome in such patients.

Filamentous fungal endophthalmitis: results of combination therapy with intravitreal amphotericin B and voriconazole.

PURPOSE: To report outcomes of exogenous fungal endophthalmitis treated with combination of intravitreal antifungal agents. DESIGN: Retrospective, non-randomized, interventional, consecutive case series. METHODS: Twelve eyes of twelve consecutive cases of filamentous fungal endophthalmitis were treated with a combination of intravitreal amphotericin-B and intravitreal voriconazole (AmB-Vo Regime) along with pars plana vitrectomy at a single center. Clinical characteristics, microbiology results, treatment strategy, visual, and anatomical outcomes were analyzed. RESULTS: Ten cases out of the twelve were postoperative endophthalmitis of which nine were part of a post cataract surgery cluster. The remaining included endophthalmitis following keratitis post pterygium excision (1) and following open globe injury (2). The most common fungus was Aspergillus terreus, which was isolated in 8/12, followed by A. flavus in 2/12 and Fusarium solani in 1/12. The presenting visual acuity ranged from light perception (LP) to counting fingers. The visual acuity at final follow-up was 20/400 or better in 7/12 eyes (58.33%) and 20/60 in 2/12 eyes (range 20/60 to LP). All eyes with corneal involvement had final visual acuity 20/400 or worse. Globe salvage was achieved in all cases. CONCLUSION: Combining intravitreal amphotericin-B and voriconazole could be a novel treatment strategy in the management of endophthalmitis caused by filamentous fungus. Eyes with corneal involvement had poor visual outcome either with or without therapeutic penetrating keratoplasty.

A novel clinical sign in macular telangiectasia type 2.

The objective of the study is to report, and propose a hypothesis for, a novel clinical sign in patients with macular telangiectasia type 2. Nine consecutive patients with macular telangiectasia and visible parafoveal graying were examined. The parafoveal graying decreased in intensity with continuous light exposure from an indirect ophthalmoscope. After dark adaptation for 15 minutes, the intensity of parafoveal graying increased again. This phenomenon appears to be a novel and global sign in patients with macular telangiectasia type 2. It could be a possible photochemical reaction occurring due to the release of chromophores from the abnormal Müller cells.

The role of intravitreal trimethoprim/sulfamethoxazole in the treatment of toxoplasma retinochoroiditis.

The authors evaluate the role of intravitreal trimethoprim/sulfamethoxazole in the treatment of toxoplasma retinochoroiditis (TRC) in four patients. Intravitreal injection of trimethoprim/sulfamethoxazole 1.28 mg/0.08 mL with dexamethasone 400 µg/0.1 mL was injected weekly or biweekly. After the initiation of treatment, a reduction in intraocular inflammation was observed clinically and on optical coherence tomography within 1 week. Three patients regained visual acuity of 20/20, and one patient improved to 20/40 with residual macular scarring. No evidence of retinal toxicity was noted on full-field electroretinogram. Intravitreal trimethoprim/sulfamethoxazole and dexamethasone combination may be an alternative treatment strategy in patients with TRC.

Acute-onset postoperative endophthalmitis caused by multidrug-resistant Klebsiella pneumoniae.

The purpose of this paper is to report outcomes of intravitreal imipenem in the treatment of multidrug-resistant Klebsiella-related postoperative endophthalmitis. This observational case series consists of three eyes from three patients seen between 2013 and 2014. Multidrug-resistant Klebsiella pneumoniae is characterized by a rapid, fulminant course and severe intraocular inflammation. Intravitreal imipenem may be used to treat such infection.

Stenotrophomonas maltophilia endogenous endophthalmitis: clinical presentation, antibiotic susceptibility, and outcomes.

OBJECTIVE: To describe clinical presentation, antibiotic susceptibility, and outcomes in patients with Stenotrophomonas maltophilia endogenous endophthalmitis. DESIGN: Retrospective case series. PARTICIPANTS: Four eyes of four patients with S. maltophilia endogenous endophthalmitis. METHODS: Retrospective chart review of culture-positive S. maltophilia endogenous endophthalmitis treated at L V Prasad Eye Institute, Hyderabad, India, between January 2007 and December 2012, was done. Collected information included demographic, clinical, and microbiology data. RESULTS: These four patients with S. maltophilia endogenous endophthalmitis cases accounted for 0.47% (4/836) of total bacterial endophthalmitis cases treated in this period. All patients were from a rural setting and younger than 40 years. Two of the four patients had a history of immune compromise or hospitalization. The visual acuity at presentation was less than 20/320 in all patients. Common presenting features were severe anterior and posterior segment inflammation and hypopyon. All patients underwent vitrectomy with injection of intravitreal antibiotics and dexamethasone. Direct microscopy of the vitreous sample was positive in all cases. All isolates were sensitive to fluoroquinolones and chloramphenicol; sensitivity to aminoglycosides and third-generation cephalosporins was highly variable. The final visual acuity was 20/80 or more in three patients. The time to presentation did not seem to influence the visual or anatomical outcome. CONCLUSION: S. maltophilia is a rare cause of endogenous endophthalmitis and usually occurs in young and apparently healthy individuals. Clinical presentation is moderate to severe, and recovery is variable. Fourth-generation fluoroquinolones and chloramphenicol were the most sensitive antibiotics against S. maltophilia in this series of patients.

Intravitreal triamcinolone acetonide as an adjuvant in the management of acute retinal necrosis.

OBJECTIVE: To determine the role of intravitreal triamcinolone acetonide (IVTA) as an adjuvant in the management of acute retinal necrosis (ARN). DESIGN: Interventional case series. PARTICIPANTS: Four eyes of 4 patients diagnosed with ARN were studied. METHODS: This pilot case series included 4 patients who presented with clinical features suggestive of ARN. IVTA was injected 1 to 2 weeks after initiation of antiviral therapy and concurrent usage of oral corticosteroids. The disease course and clinical outcome were observed. The patients received additional treatment depending on the sequelae of ARN. RESULTS: Signs of reduction in vitritis and resolution of retinitis were observed as early as 1 week after IVTA was administered. In all 4 patients, inflammation promptly resolved with no untoward effects like raised intraocular pressure or worsening of the retinitis. A final visual acuity of 20/40 or better was achieved in 3 of 4 patients after appropriate treatment of ARN-related complications. CONCLUSIONS: Intravitreal triamcinolone under antiviral cover could be a useful adjunct to systemic steroids in the treatment of ARN.

Endophthalmitis after open globe injuries: changes in microbiological spectrum and isolate susceptibility patterns over 14 years.

BACKGROUND: The objective of this study was to evaluate the microbiologic spectrum and antimicrobial susceptibility of isolates in post-traumatic endophthalmitis and compare with our earlier published report. A retrospective review was conducted on 581 consecutive patients with culture-proven post-traumatic endophthalmitis at L. V. Prasad Eye Institute, India, from January 2006 to March 2013. FINDINGS: A total of 620 isolates from 581 patients were identified (565 bacteria and 55 fungi). The most common isolate was Bacillus spp. (106/620, 17.1%) closely followed by Streptococcus pneumoniae (105/620, 16.9%), and coagulase-negative Staphylococci (97/620, 15.6%). In our earlier report, the commonest bacteria included Streptococcus spp. (30/139, 21.6%) and gram-positive coagulase-negative micrococci (26/139, 18.7%). Gram-positive isolates were usually susceptible to vancomycin (98.2%). Gram-negative isolates were generally susceptible to gatifloxacin (92.9%), ofloxacin (89.4%), chloramphenicol (88.6%, Pseudomonas isolates were often resistant), amikacin (83.5%), and ceftazidime (77.2%). Fourteen years ago, the most sensitive antibiotic was ciprofloxacin for both gram-positive bacteria (95.12%) and gram-negative bacteria (100%). CONCLUSIONS: The microbiological spectrum of post-traumatic endophthalmitis has remained unchanged over the last 14 years, and Bacillus spp. continues as the most common infecting organism. Vancomycin is the drug of choice for empiric coverage of gram-positive bacteria. Susceptibility of gram-negative bacteria to commonly used antimicrobials (amikacin and ciprofloxacin) has decreased by 10% - 15% and to ceftazidime has increased by 10.5%.

Pharmacokinetics of intravitreal antibiotics in endophthalmitis.

Intravitreal antibiotics are the mainstay of treatment in the management of infectious endophthalmitis. Basic knowledge of the commonly used intravitreal antibiotics, which includes their pharmacokinetics, half-life, duration of action and clearance, is essential for elimination of intraocular infection without any iatrogenic adverse effect to the ocular tissue. Various drugs have been studied over the past century to achieve this goal. We performed a comprehensive review of the antibiotics which have been used for intravitreal route and the pharmacokinetic factors influencing the drug delivery and safety profile of these antibiotics. Using online resources like PubMed and Google Scholar, articles were reviewed. The articles were confined to the English language only. We present a broad overview of pharmacokinetic concepts fundamental for use of intravitreal antibiotics in endophthalmitis along with a tabulated compendium of the intravitreal antibiotics using available literature. Recent advances for increasing bioavailability of antibiotics to the posterior segment with the development of controlled drug delivery devices are also described.

Scleral buckle infections: microbiological spectrum and antimicrobial susceptibility.

BACKGROUND: The purpose of the present study was to evaluate the microbiological spectrum and antimicrobial susceptibility in patients with scleral buckle infection. Medical records of all the patients diagnosed as buckle infection at L. V. Prasad Eye Institute between July 1992 and June 2012 were reviewed in this non-comparative, consecutive, retrospective case series. FINDINGS: A total of 132 eyes of 132 patients underwent buckle explantation for buckle infection during the study period. The incidence of buckle infection at our institute during the study period was 0.2% (31 out of 15,022). A total of 124 isolates were identified from 102 positive cultures. The most common etiological agent isolated was Staphylococcus epidermidis (27/124, 21.77%) followed by Mycobacterium sp. (20/124, 16.13%) and Corynebacterium sp. (13/124, 10.48%). The most common gram negative bacilli identified was Pseudomonas aeruginosa (9/124, 7.26%). The median interval between scleral buckling surgery and onset of symptoms of local infection was 30 days. All eyes underwent buckle explantation and median time interval between primary SB surgery and explantation was 13 months. Recurrent retinal detachment was observed in two cases at 7 and 48 months, respectively, after buckle explantation. Gram positive, gram negative, and acid-fast organisms isolated from 2003 to 2012 were most commonly susceptible to vancomycin (100%), ciprofloxacin (100%), and amikacin (89%). Susceptibility to ciprofloxacin during the same time period was observed in 75% (15/20), 100% (13/13), and 87% (7/8) of gram positive, gram negative, and acid-fast isolates, respectively. CONCLUSION: Scleral buckle infection is relatively rare and has a delayed clinical presentation. It is most commonly caused by gram positive cocci. Based on the current antimicrobial susceptibility, ciprofloxacin can be used as empirical therapy in the management of scleral buckle infections.

Combined ceftazidime and amikacin resistance among Gram-negative isolates in acute-onset postoperative endophthalmitis: prevalence, antimicrobial susceptibilities, and visual acuity outcome.

BACKGROUND: The purpose of this study is to evaluate the prevalence, antimicrobial susceptibilities, and visual acuity outcome of acute-onset postoperative Gram-negative bacterial endophthalmitis cases resistant to both ceftazidime and amikacin seen between 2005 and 2010 at L. V. Prasad Eye Institute, a tertiary care ophthalmic Centre in South India. Medical records of all patients with Gram-negative bacterial endophthalmitis resistant to both amikacin and ceftazidime between 1 January 2005 and 31 December 2010 were reviewed in this non-comparative, consecutive, retrospective case series. Favorable outcome was defined as a best-corrected visual acuity of ≥20/200. RESULTS: Sixty five (39.6%) of 164 culture-positive postoperative endophthalmitis were caused by Gram-negative organisms. Among these 65 isolates, 32 (49%; 95% confidence interval (CI) 37% to 61%) were resistant to ceftazidime, 17 (26%; 95% CI 15% to 37%) to amikacin, and 12 (18.5%; 95% CI 9% to 27%) to both ceftazidime and amikacin. Eight Pseudomonas isolates, three Enterobacter isolates, and one Haemophilus isolate were resistant to both ceftazidime and amikacin. The isolates were sensitive to fluoroquinolones (42%) and imipenem (50%). Presenting visual acuity was light perception in 10 (83.3%) cases. A final visual acuity ≥20/200 was achieved in 5/12 (41.7%) of these patients. CONCLUSION: In the current study, Pseudomonas was the most common Gram-negative bacteria resistant to both amikacin and ceftazidime. The emergence of multidrug-resistant bacteria causing endophthalmitis is a matter of concern in India. Alternative antibiotics like imipenem or fluoroquinolones may be considered for the management of these resistant organisms.

Vancomycin-resistant Gram-positive bacterial endophthalmitis: epidemiology, treatment options, and outcomes.

BACKGROUND: The purpose of this study is to evaluate the microbiological profile and treatment outcomes of vancomycin-resistant Gram-positive bacterial endophthalmitis. Medical records of all patients with Gram-positive bacterial endophthalmitis resistant to vancomycin presenting between 1 January 2005 and 31 December 2010 were reviewed in this noncomparative, consecutive, retrospective case series. Favorable outcome was defined as a best-corrected visual acuity of ≥20/200. RESULTS: Out of 682 culture-positive endophthalmitis isolates, 448/682 (65.6%) were associated with Gram-positive bacteria. In vitro resistance to vancomycin was noted in 7/448 (1.56%). Three cases were posttraumatic, three were postoperative, and one was endogenous in origin. Four Bacillus isolates, two Staphylococcus isolates, and an Enterococcus isolate were resistant. Isolates resistant to vancomycin were sensitive in vitro to ciprofloxacin in 6/7 (86%) patients. Presenting visual acuity was light perception in all seven cases. Favorable outcome was achieved in only 1/7 (14.3%) cases. CONCLUSIONS: Vancomycin-resistant endophthalmitis is uncommon and usually associated with poor visual outcome. Bacillus sp. is the most frequent Gram-positive bacteria resistant to vancomycin. Fluoroquinolones like ciprofloxacin may be considered as a useful alternative in vancomycin-resistant endophthalmitis.

Polymicrobial endophthalmitis: prevalence, causative organisms, and visual outcomes.

BACKGROUND: The purpose of the present study is to evaluate the prevalence, causative organisms, and visual acuity outcome in patients with culture-proven polymicrobial endophthalmitis. The method used in this study is the non-comparative, consecutive case series using a retrospective analysis of patients diagnosed with polymicrobial endophthalmitis for the period 2000 to 2010. RESULTS: Polymicrobial endophthalmitis was identified in 43/1,107 (3.88%) patients. Forty-two patients had two isolates, and one patient had grown three isolates, yielding a total of 87 isolates. Gram-positive cocci were the most common isolate (n = 53; 60.9%) including Staphylococcus epidermidis (n = 14/53; 16.1%) and Streptococcus pneumoniae (n = 13/53; 13.8%). The etiologies included posttraumatic (n = 31/43; 72.1%) and postoperative (n = 9/43; 20.9%) endophthalmitis. Antibiotic susceptibilities among Gram-positive bacteria were vancomycin (100%) and chloramphenicol (96%). Susceptibilities among Gram-negative bacteria were ciprofloxacin (86.4%) and ofloxacin (81.2%). A maximum number of secondary interventions were done in traumatic cases (38.7%) and cases having coinfection with Gram-negative bacteria and fungus (66.7%). Visual acuity (VA) < 20/200 was more frequently observed in posttraumatic cases (n = 27/31; 87.1%) as compared with postoperative cases (n = 4/9; 44.4%). Of the 43 patients, only 9 patients (20.9%) achieved a VA ≥ 20/200 on final follow-up. Four out of twelve patients (33.3%), with fungus as one of the isolates, had a VA ≥ 20/200. CONCLUSIONS: Although polymicrobial infection in endophthalmitis is uncommon, it is generally associated with poor visual acuity outcomes especially in eyes with open-globe injuries. Coinfection with Gram-negative bacteria or fungi was associated with most unfavorable visual outcome.

Recalcitrant Pseudomonas keratitis after epipolis laser-assisted in situ keratomileusis: case report and review of the literature.

We report a case of recalcitrant microbial keratitis after epipolis laser-assisted in situ keratomileusis (epi-LASIK) surgery caused by Pseudomonas aeruginosa and review the literature on resistant Pseudomonas keratitis after excimer laser surgery. Microbial keratitis occurred two weeks after epi-LASIK surgery and was resistant to fluoroquinolones, aminoglycosides and macrolides but sensitive to meropenem. The patient had total corneal melting and required therapeutic penetrating keratoplasty. The globe could be salvaged and the distance visual acuity was 6/60 in the right eye. Recalcitrant Pseudomonas keratitis might require a therapeutic graft and necessitate the use of intravenous meropenem to prevent recurrence of infection.