Orbital aspergillosis in immunocompetent patients.

PURPOSE: To describe clinical, ultrasonographic, radiological and histopathological features of orbital aspergillosis in immunocompetent patients. METHODS: Medical records of immunocompetant individuals with orbital aspergillosis between November 1995 and November 2010 were reviewed. RESULTS: Thirty-five cases (27 males, 8 females) were reviewed. Mean age at presentation was 37.63 (8-73) years and mean duration of symptoms was 12.03 (0.5-84) months. Proptosis (22.63%) and mass lesion (13.37%) were the commonest presenting complaints. Presenting visual acuity was better than 6/9 in 21 (60%) and no perception of light in 3 (8%). Ocular motility restriction was noted in 25 (71%). The commonest clinical differential diagnosis was non-specific orbital inflammatory disease (NSOID) (10.29%) followed by malignancy (7.20%). CT showed infiltrative lesions with bone destruction in 22 (63%), contiguous paranasal sinus involvement in 22 (63%) and intracranial extension in 10 (29%). Diagnosis was by histopathology and microbiological evaluation. Fungal cultures revealed Aspergillus flavus in 30 (86%) and Aspergillus fumigatus in 5 (14%). Treatment included conservative medical management in 18 (51%) and surgical debulking in 17 (49%). Average follow-up was 37.6 (3-183) months, and patient survival was 33/35 (94%). CONCLUSIONS: Though orbital aspergillosis is commonly seen in immunocompromised patients, it should be suspected in young immunocompetent individuals presenting with proptosis of insidious onset and infiltrating lesions involving the paranasal sinuses. Definitive diagnosis is achieved by histopathological and microbiological evaluation. Systemic steroids should be avoided prior to definitive diagnosis. Prolonged systemic antifungal therapy with an option of additional debulking of lesions provides good disease control with improved survival.

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

PURPOSE: To describe the outcomes and clinicomicrobiological profile of 11 years of a protocol-based management in neonatal endogenous endophthalmitis. METHODS: This was a retrospective interventional study of endogenous endophthalmitis in 31 eyes of 26 neonates. The protocol for active infection included systemic antimicrobials, vitreous and/or aqueous tap, and intravitreal antimicrobials under topical or general anesthesia along with core vitrectomy in selected cases. Blood, urine, umbilicus, aqueous, and vitreous samples underwent microbiological evaluation. Retinopathy of prematurity screening and treatment were done when indicated. Primary outcome was anatomic status assessed by comprehensive eye examination and by fundus photography whenever possible. RESULTS: Twenty-one of 26 babies (81%) were preterm. Two types of presentations included those with a fulminant appearance (24 eyes) and those with focal retinitis detected during routine screening (7 eyes). Vitreous culture was positive in 12/20 eyes (60%). Pseudomonas aeruginosa (8) was the most common isolate. Incorrect initial diagnosis was common. Treatment included intravitreal injections in 26 eyes, 10 of which also underwent vitrectomy. Twenty-four of the 26 patients (92%) received parenteral antimicrobials and 17 had evidence of systemic infection. All eyes with a fulminant presentation developed phthisis, while all focal fungal cases were salvaged. CONCLUSIONS: Neonatal endogenous endophthalmitis has 2 distinct presentations. Focal retinal infections have good visual and anatomical outcomes while fulminant nosocomial cases do poorly. Management under topical anesthesia can be an alternative strategy for sick babies that cannot undergo surgery under general anesthesia due to systemic morbidity. Awareness about early diagnostic signs may help early referral.

Microbial keratitis following vegetative matter injury.

The purpose of the present study was to analyze the microbiological profile of cases of keratitis following trauma with vegetative matter in a tertiary care center. A retrospective review of the medical records of 49 patients with keratitis following vegetative matter injury over a 3-month period was performed. All patients underwent corneal scraping for smears and inoculation onto various culture media. The microbiological profile was based on the smear and culture reports. For patients who were culture-negative, outcome after standard empirical antibacterial therapy as per hospital protocol was analyzed. Thirteen patients with corneal ulcers had fungal etiology, eight had bacterial etiology, and two had protozoal etiology, while 13 patients were polymicrobial and 13 were culture-negative. Polymicrobial infections were mainly bacterial (eight cases), and the remaining five cases had coexistent fungal and bacterial etiology. The treatment was directed to the specific organism and patients improved with medical or surgical therapy. Only a third of culture-negative cases showed fungal etiology on biopsy or histopathology after keratoplasty while a third showed improvement with therapy. Corneal infections following vegetative matter trauma show a varied etiological profile; however, bacterial and polymicrobial infections are more prevalent. Empirical anti-fungal therapy, as commonly practiced, must be avoided in cases with vegetative matter injury.

Review of endogenous endophthalmitis caused by Salmonella species including delayed onset Salmonella typhi endophthalmitis.

Endogenous endophthalmitis is a rare but serious condition that occurs when bacteria cross the blood-ocular barrier and multiply within the eye. We provide a literature review of Salmonella endogenous endophthalmitis by reviewing eight reported cases and integrating this with our experience of one case in which a four-year-old child presented with acute endophthalmitis of four days duration. He had suffered typhoid fever two months back. Vitreous biopsy revealed Salmonella typhi. Despite aggressive surgical and medical treatment, the eye developed retinal necrosis, detachment, and phthisis. Blood, aqueous, and vitreous cultures were the most frequent means of establishing the diagnosis in the reported cases. The visual outcome in most cases of endogenous Salmonella endophthalmitis is blindness in the affected eye, which has not improved since its first report in 1979. Endogenous endophthalmitis due to Salmonella typhi should be incorporated into standard literature on complications of acute and relapse phases of typhoid fever.

Traumatic endophthalmitis presenting as isolated retinal vasculitis and white-centered hemorrhages: Case report and review of literature.

The article reports a case and review of the literature of endophthalmitis presenting as isolated retinal vasculitis. A 26-year-old male was observed to have white-centered retinal hemorrhages and retinal vasculitis following an occult scleral perforation. At presentation, the visual acuity was 20/60. With clinical suspicion of early endophthalmitis, he underwent wound exploration, scleral tear repair, vitreous biopsy and administration of intravitreal antibiotics. Microbiology evaluation revealed significant presence of methicillin-resistant coagulase-negative Staphylococcus epidermidis. Final visual acuity improved to 20/20 at 6 weeks postoperatively. Literature search revealed eight similar cases, all of them due to Staphylococcus species. Retinal vasculitis and white-centered retinal hemorrhages can be a presenting sign of early endophthalmitis, especially with non-fulminant pathogens like S. epidermidis.

An outbreak of acute post-cataract surgery Pseudomonas sp. endophthalmitis caused by contaminated hydrophilic intraocular lens solution.

OBJECTIVE: To report the investigation for the source of infection and the clinical course and treatment response of 11 cases of acute post-cataract surgery endophthalmitis that developed during an outbreak. DESIGN: Retrospective, consecutive, interventional case series. PARTICIPANTS: Eleven patients who developed acute postoperative endophthalmitis after an uneventful cataract surgery with intraocular lens implantation from September 6 to 29, 2010, at a tertiary eye care center in South India. METHODS: Aqueous aspirates, vitreous aspirates, and environmental surveillance specimens were sampled. All specimens were subjected to smear and culture. Positive cultures were subjected to antibiotic susceptibility. Genotypic diversity was determined by polymerase chain reaction (PCR) with enterobacterial repetitive intergenic consensus (ERIC) primers of each strain and was used to establish the clonal relationship between clinical and environmental isolates. The clinical patterns were analyzed. MAIN OUTCOME MEASURES: Positive microbiology, molecular diagnostic similarity among the culture positive endophthalmitis cases, and surveillance specimens. RESULTS: Aqueous and vitreous samples showed gram-negative bacilli in the smears of 8 of 11 eyes, and cultures grew Pseudomonas aeruginosa in 5 of 11 eyes. Among the samples from various surveillance specimens cultured, only the hydrophilic acrylic intraocular lenses and their solution grew P. aeruginosa, with antibiotic susceptibility pattern identical to the clinical isolates. The isolates from the patients and the intraocular lens solution revealed matching patterns similar to an American Type Culture Collection (ATCC) strain of P. aeruginosa on ERIC-PCR. The intraocular lenses of the same make were discontinued at our hospital, and the endophthalmitis did not recur. The final visual acuity improved to ≥ 20/50 in 8 of 11 patients (72.7%). One patient developed retinal detachment, but was treated successfully, and 2 other patients progressed to phthisis bulbi. CONCLUSIONS: Positive microbiology and the ERIC-PCR results proved that contamination of hydrophilic intraocular lenses and the preservative solution was the source of infection in this outbreak. Early detection and a planned approach during the outbreak helped us to achieve good visual and anatomic outcomes, even though the offending organism was identified as P. aeruginosa.

Fungal keratitis caused by Chaetomium atrobrunneum.

PURPOSE: We report a case of mycotic keratitis caused by a rare fungus Chaetomium atrobrunneum. METHODS: Clinical examination, slit-lamp examination, and microbiological evaluation of corneal ulcer were done, and its treatment outcome was studied. The fungal etiology was established by conventional microbiological techniques: polymerase chain reaction and speciation by DNA sequencing. RESULTS: Based on morphological features of the isolate and DNA sequence analysis of the internal transcribed spacer region, the isolate was identified as C. atrobrunneum. The keratitis was resolved completely by topical natamycin and oral ketoconazole. CONCLUSION: To best of our knowledge, this is the first reported case of keratitis caused by a rare fungus, C. atrobrunneum, which was successfully treated with dual therapy.

Natamycin in the treatment of keratomycosis: correlation of treatment outcome and in vitro susceptibility of fungal isolates.

In this study, 60 fungal isolates from 60 patients with fungal keratitis were tested in vitro for their susceptibility to natamycin and the mean minimum inhibitory concentrations of natamycin (MICn) were correlated with clinical outcome. The mean MICn for various groups of fungi from patients with either early (<10 days) or late (≥ 10 days) presentation was correlated with the outcome. Aspergillus flavus showed resistance to natamycin with a high mean MICn (>16 µg/ml). While the clinical response in all patients with early A. flavus keratitis was good it was poor in late cases (5/8 patients, 62.5%). Fusarium species, Acremonium species and dematiaceous fungi were sensitive with low mean MICn (Fusarium: 5.7-7.2 µg/ml, Acremonium: 5.7-6.8 µg/ml, dematiaceous: (1.6-4 µg/ml). However, 46.6% (7/15) patients in Fusarium and 57.1% (4/7) in Acremonium group needed keratoplasty. We conclude that despite susceptibility of most fungal species causing keratitis to natamycin, the treatment outcome is poor in advanced fungal keratitis.

Acute postoperative endophthalmitis by Gemella haemolysans.

Endophthalmitis is a rare and serious post-surgical complication. We report a case of acute postoperative endophthalmitis after an uneventful cataract surgery caused by a commensal organism, Gemella haemolysans. The patient was successfully treated with vitrectomy and intravitreal antibiotics like vancomycin, along with topical cefazolin.