Serous macular detachment in Waldenström macroglobulinemia: a report of four cases.

PURPOSE: To describe a series of 4 patients with Waldenström macroglobulinemia and serous macular detachment, and propose a mechanism for development of subretinal fluid based on optical coherence tomography (OCT) findings. DESIGN: Retrospective observational case series. METHODS: The records of patients with Waldenström macroglobulinemia and OCT documentation of serous macular detachment at Wills Eye Institute were reviewed. Data collection included clinical examination, as well as findings on fluorescein angiography (FA) and OCT. RESULTS: Four patients (8 eyes) with Waldenström macroglobulinemia and serous retinal detachment were identified. All eyes had varying degrees of venous stasis retinopathy and intraretinal edema overlying the macular detachment. Three patients had no FA leakage, while 1 patient had macular leakage in a petaloid pattern. Focal outer retinal defects within the detached retina were seen in 4 eyes on OCT imaging. In one eye, development of cystoid macular edema was observed before the outer retinal defect and serous macular detachment. All patients with serous macular detachment had some degree of outer retinal disruption. CONCLUSION: Discontinuity of the outer retina within the macular detachment may enable immunoglobulins along with accumulated intraretinal fluid to flow into the subretinal space, creating a serous retinal detachment. Even with systemic treatment of the underlying Waldenström macroglobulinemia, the visual prognosis was guarded.

Endophthalmitis after open globe injury: microbiologic spectrum and susceptibilities of isolates.

PURPOSE: To present the microbiologic spectrum and susceptibilities of isolates in posttraumatic endophthalmitis, and to provide a review of the literature. DESIGN: Retrospective consecutive case series. METHODS: A review of 1182 consecutive open globe injuries was performed, identifying 10 patients with culture-proven endophthalmitis. RESULTS: Thirteen organisms were isolated from 10 eyes with posttraumatic endophthalmitis. Isolated organisms included Streptococcus species (46.2%), coagulase-negative Staphylococcus (23.1%), and Bacillus cereus (15.4%). All organisms tested were susceptible to vancomycin and tobramycin. The most commonly isolated organisms from an aggregate posttraumatic endophthalmitis pool of 372 cases obtained by literature-based meta-analysis were coagulase-negative Staphylococcus (21.5%) and Bacillus cereus (18.5%). CONCLUSION: We report a high prevalence of gram-positive pathogens and a notable prevalence of Bacillus cereus in posttraumatic endophthalmitis. Susceptibility results suggest that posttraumatic endophthalmitis isolates are generally susceptible to vancomycin and tobramycin.

Intravitreal triamcinolone acetonide for diabetic macular edema.

PURPOSE: Intravitreal injection of triamcinolone acetonide has been advocated to treat exudative diabetic macular edema. The purpose of the study was to evaluate the clinical outcome of an intravitreal injection of triamcinolone acetonide as treatment for diffuse diabetic macular edema. METHODS: This study was a retrospective, interventional, clinical case series examining 210 eyes of 174 patients who received an intravitreal injection of 1 or 4 mg of triamcinolone acetonide for treatment of diffuse diabetic macular edema. Inclusion criteria were clinically significant macular edema, visual acuity loss, and leakage shown by fluorescein angiography. Main outcome measures were visual acuity and intraocular pressure. Mean follow-up time +/- SD was 6.6 +/- 3.1 months. RESULTS: In the study group, visual acuity improved significantly (P < 0.001) from a median of 20/200 (mean logMAR, 0.92) at baseline to 20/80 (mean logMAR, 0.82) at 6 months. Mean intraocular pressure +/- SD increased from 15.4 +/- 3.4 mmHg (median, 16 mmHg; range, 6-26 mmHg) to a maximal value of 20.4 +/- 6.2 mmHg (median, 19 mmHg; range, 12-51 mmHg) during the follow-up period. Complications included culture-negative sterile endophthalmitis in six cases and cataract extraction in five eyes. CONCLUSIONS: Intravitreal injection of 1 to 4 mg of triamcinolone acetonide may benefit patients by improving visual acuity in eyes with clinically significant diabetic macular edema. This study did not provide significant evidence to justify its routine use in clinical practice for all patients with diabetic macular edema. A randomized clinical trial on this issue would provide more conclusive evidence and help identify those patients most likely to benefit from intravitreal triamcinolone acetonide.

Presumed sterile endophthalmitis following intravitreal triamcinolone acetonide injection.

BACKGROUND AND OBJECTIVE: To report acute postoperative, presumed sterile endophthalmitis following intravitreal injection of triamcinolone acetonide (IVTA). PATIENTS AND METHODS: Retrospective, interventional, multicenter study of patients with acute sterile endophthalmitis following IVTA injection. RESULTS: A total of 922 IVTA injections were performed. Eight eyes of 8 patients with presumed sterile endophthalmitis were identified. The incidence of endophthalmitis was 0.87% (95% confidence interval, 0.38% to 1.70%). Median time to presentation was 1.5 days (range, 1 to 7 days). Median presenting visual acuity was 20/563 (range, 20/80 to light perception). Initial treatment included vitreous tap and injection of antibiotics (n = 4), pars plana vitrectomy and injection of intravitreal antibiotics (n = 2), or systemic treatment alone with oral levofloxacin (n = 2). Six of 6 intraocular cultures were sterile. Median follow-up was 5.9 months (range, 4 to 9 months) with a median visual acuity at last follow-up of 20/75 (range, 20/40 to counting fingers). CONCLUSIONS: Acute presumed sterile endophthalmitis following IVTA injection presents early in the postoperative period. Visual outcomes are generally good.

Endophthalmitis after penetrating keratoplasty: microbiologic spectrum and susceptibility of isolates.

PURPOSE: To present the microbial spectrum and susceptibilities of isolates in endophthalmitis following penetrating keratoplasty. DESIGN: Interventional case series. METHODS: The 1,074 consecutive cases of endophthalmitis presenting to Wills Eye Hospital between 1989 and 2000 were reviewed. Fourteen patients with endophthalmitis after penetrating keratoplasty were identified, and vitreous biopsy isolates from these patients were examined. RESULTS: Eleven (78.6%) of 14 vitreous samples were culture-positive, and two others (14.3%) had organisms viewed on pathology specimen, for a total of 13 (92.9%) organism-proven cases of endophthalmitis. Isolates included 10 (76.9%) gram-positive cocci (six Streptococcus sp., three Staphylococcus sp., one identified on pathology specimen only) and three (23.1%) gram-negative organisms (Proteus mirabilis, Serratia marcescens, one identified on pathology specimen only). Susceptibilities to organism-appropriate antibiotic testing are reported, including cefazolin (six of eight, 75.0%), ciprofloxacin (four of seven, 57.1%), nafcillin (four of six, 66.7%), and vancomycin (seven of seven, 100.0%). CONCLUSION: This is the largest series on microbial susceptibilities in postpenetrating keratoplasty endophthalmitis. We report a high percentage of culture-positivity, and a high incidence of gram-positive species, and in particular Streptococcus species, with all tested gram-positive organisms susceptible to vancomycin.

Acute endophthalmitis following intravitreal triamcinolone acetonide injection.

PURPOSE: To report the clinical features, causative organisms, management, and visual acuity outcomes of eight eyes of eight patients who developed acute postoperative endophthalmitis following intravitreal injection of triamcinolone acetonide (IVTA). DESIGN: Retrospective, multicenter, interventional, case series. METHODS: A retrospective, interventional, case series of all patients with acute postoperative endophthalmitis following IVTA at seven academic clinical centers between March 2001 and July 2002. RESULTS: A total of 922 IVTAs were performed. Eight eyes of eight patients with acute postoperative endophthalmitis were identified in the 6 weeks following IVTA for an incidence of 0.87% (95% confidence interval of 0.38% to 1.70%). The median time to presentation was 7.5 days (range, 1-15 days) after IVTA. The most common clinical findings were iritis (n = 8), vitritis (n = 8), hypopyon (n = 8), pain (n = 7), red eye (n = 6), and decreased vision (n = 5). The median presenting visual acuity was 20/1127 (range, 20/60 to light perception). Initial treatment consisted of vitreous tap and injection of antibiotics (n = 6) or pars plana vitrectomy and injection of intravitreal antibiotics (n = 2). Intraocular cultures yielded identification in seven patients. One demonstrated intracellular gram-positive cocci in chains with numerous polymorphonuclear cells on gram stain. The median postinfection vision was 20/400 (range, 20/40 to no light perception). Three patients ended up with no light perception visual acuity, including enucleation (n = 1) and phthisis (n = 1). CONCLUSIONS: Acute postoperative endophthalmitis following IVTA occurs rapidly and can result in severe loss of vision.

Infectious and presumed noninfectious endophthalmitis after intravitreal triamcinolone acetonide injection.

PURPOSE: To report potentially distinguishing characteristics between bacterial endophthalmitis and presumed noninfectious endophthalmitis associated with intravitreal triamcinolone acetonide injection. METHODS: Records of two patients with culture-proven bacterial endophthalmitis and six patients with presumed noninfectious endophthalmitis from intravitreal triamcinolone acetonide injections were analyzed retrospectively. RESULTS: Two eyes in two patients with culture-proven bacterial endophthalmitis had decreased vision and hypopyon or vitritis, but no pain or conjunctival injection 2 weeks after intravitreal triamcinolone acetonide injection. Seven eyes in six patients with presumed noninfectious endophthalmitis had blurred vision, hypopyon, and variable pain all within 2 days of intravitreal triamcinolone injection. All seven eyes were followed up closely and had rapid resolution of hypopyon and symptoms. CONCLUSION: Bacterial endophthalmitis after intravitreal triamcinolone acetonide injection may present in an atypical, relatively delayed manner with decreased vision but no pain or redness. Presumed noninfectious endophthalmitis presents within 2 days after the injection, may be accompanied by discomfort, and has a hypopyon that may be the triamcinolone material itself or a sterile inflammatory reaction. In these eyes, the hypopyon and symptoms quickly resolve without treatment.