Clinical Outcomes of Rose Bengal Mediated Photodynamic Antimicrobial Therapy on Fungal Keratitis with Their Microbiological and Pathological Correlation.

PURPOSE: To report the clinical outcome of Photodynamic Antimicrobial Therapy (PDAT) with Rose Bengal (RB) used as an early adjuvant therapy in patients with fungal keratitis and their microbiological and pathological correlation. METHODS: Patients with microbiologically confirmed fungal keratitis underwent PDAT-RB along with topical natamycin 5% drops hourly and oral ketoconazole 200 mg twice a day. This was performed by applying rose bengal (0.1%) to the de-epithelialized cornea for 30 minutes, followed by irradiation with a 6 mW/cm2 custom-made green LED source for 15 minutes (5.4 J/cm2). The corresponding fungal isolates were tested in vitro using PDAT-RB and corneal buttons were evaluated for correlation. RESULTS: Following informed consent, seven patients (male-5, female-2, mean age 47.7 years) with fungal keratitis were recruited. There were 3 cases each of Fusarium and Aspergillus flavus and 1 case of Acremonium sp. The average vertical and horizontal diameters of the corneal infiltrate were 4.12 ± 0.55 and 3.99 ± 1.19 mm, respectively. The average depth of corneal involvement was 283 ± 75.27µ as measured by anterior segment OCT. The clinical resolution was achieved in the cases with Fusarium keratitis with an average time of 39 days. Three cases of A. flavus and a single patient with Acremonium keratitis worsened and needed therapeutic keratoplasty (TPK) for resolution. Post-TPK, the corneal tissues grew A. flavus in one out of three cases and Acremonium sp. in one case. In vitro PDAT-RB experiment was performed on the corresponding fungal isolates grown from the corneal scraping. PDAT-RB produced clear inhibition of Fusarium and Acremonium sp. with no effect on the growth of A. flavus. Histopathologically, 2 out of 4 (50%) corneal buttons showed fungal filaments. CONCLUSIONS: While the in vitro and in vivo results of PDAT-RB matched for Fusarium sp. and Aspergillus flavus keratitis being favourable in the former and non-favourable in the latter, these results were discrepant in Acremonium sp.

Enterobacter endophthalmitis: Clinical settings, susceptibility profile, and management outcomes across two decades.

Purpose: To describe the clinical presentation and management of Enterobacter endophthalmitis and compare with previous in-house published literature. Methods: This was a retrospective interventional comparative case series involving 44 cases with culture proven Enterobacter endophthalmitis from April 2006 to August 2018 who underwent vitrectomy/vitreous biopsy, intravitreal antibiotics with or without additional procedures as appropriate. The current outcomes were compared to the outcomes previously reported a decade back from our center. The mean age at presentation, predisposing factor, number of interventions, interval between inciting event and presentation, type of intravitreal antibiotic used, anatomic, and the functional outcomes were analyzed and compared to the previous series. Results: There were 30 males. Mean age was 22.73 ± 21.35 years (median 14 years). Inciting event was open globe injury in 34 (77.27%) eyes, 4 (9.09%) eyes following cataract surgery, 3 (6.81%) eyes with endogenous endophthalmitis, 2 (4.54%) eyes following keratoplasty, and 1 eye (2.27%) following trabeculectomy. Presenting visual acuity was favorable (≥20/400) in 2 eyes (4.54%), at the final visit it was in 11 eyes (25%). The organisms were most sensitive to ciprofloxacin (95.12%), amikacin (90.47%), and ceftazidime (85.36%). A comparison of the current study with previous in-house study showed that number of eyes with presenting vision ≥20/400 as well as final vision ≥20/400 were comparable. Susceptibility was highest to ciprofloxacin 39 (95.12%) (previous series) and 33 (92%) (current series). Conclusion: Enterobacter organisms show susceptibility to ciprofloxacin, amikacin, and ceftazidime. Susceptibility profile, clinical presentations, and management remain largely similar over many years. Final outcome is unfavorable.

ENTEROCOCCUS ENDOPHTHALMITIS: Clinical Settings, Antimicrobial Susceptibility, and Management Outcomes.

PURPOSE: To report the clinical presentation and management outcome of patients with endophthalmitis caused by Enterococcus species and to report the susceptibility profile of the isolates. METHODS: Twenty-nine cases with culture-proven Enterococcus endophthalmitis from January 2005 to May 2018 underwent vitrectomy/vitreous biopsy, intravitreal antibiotic with or without additional procedures. The undiluted vitreous was subjected to microbiologic evaluation. A favorable anatomical outcome was defined as preservation of the globe, absence of hypotony, attached retina, and absence of active inflammation at the last visit. Favorable visual outcome was final visual acuity ≥20/400. RESULTS: There were 24 men (82.8%). Mean age at presentation was 32.89 ± 25.25 years (median 24 years). Inciting event was open globe injury in 18 (62%), endogenous in 5 (17.24%), postcataract surgery in 3 (10.34%), postscleral buckling in 2 (6.89%), and postkeratoplasty in 1 (3.44%). Enterococcus casseliflavus was the commonest species isolated (14/29, 48.27%) followed by E. faecalis (9/29, 31%). Susceptibility to vancomycin was seen in 27/29 isolates (93%). Visual acuity was ≤20/400 in all eyes at presentation and ≥20/400 in 10/29 cases (34.48%) at final visit. Anatomical success was seen in 18/29 eyes (62%). Corneal involvement was high at 24/29 eyes (82.75%). CONCLUSION: Enterococcus is not an uncommon organism in the setting of endophthalmitis after open globe injury. Resistance to vancomycin is rare. Multidrug resistance pattern is restricted to E. faecalis. Visual outcome is poor despite early and appropriate therapy due to inherent organism virulence.

Types of organisms and in-vitro susceptibility of bacterial isolates from patients with microbial keratitis: A trend analysis of 8 years.

PURPOSE: To report the distribution and trends of types of organisms and antibiotic susceptibility of the bacterial isolates obtained from patients with microbial keratitis. METHODS: Microbiology records of culture-positive microbial keratitis that underwent a diagnostic corneal scraping and cultures were reviewed. Fungal, bacterial, and parasitic culture results and antibiotic susceptibility profile of bacteria were analyzed and comparisons were made between two halves of the study period (2007-2010 vs. 2011-2014). RESULTS: A total of 3981 corneal scrapings were processed during the 8-year study period. Pathogen was recovered in culture in 1914 (48.1%) samples. Fungi, bacteria, and parasites constituted 38.7%, 60%, and 1.3% of the total isolates, respectively. The common fungal isolates were Aspergillus spp. (224/868, 25.8%) and Fusarium spp. (200/868, 23.0%), while common Gram-positive bacteria were Streptococcus pneumoniae (217/1125, 19.3%) and Staphylococcus aureus (185/1125, 16.4%), and common Gram-negative bacteria was Pseudomonas spp. (99/219, 45.2%). There was no significant difference in proportion of bacterial (P = 0.225) and fungal (P = 0.421) keratitis between the first half and second half of the study period. There was a significant increase in proportion of Gram-positive isolates (P = 0.015) [353/758 (46.6%) vs. 772/1482 (52.1%)] and decrease in proportion of Gram-negative organisms (P = 0.044) [88/758 (11.6%) vs. 131/1482 (8.8%)] in the recent years. In-vitro antibiotic susceptibility testing showed decrease in susceptibility to moxifloxacin for Pseudomonas spp. (P = 0.016) in recent years. CONCLUSION: Prevalence of fungal and bacterial keratitis has remained unchanged over the years. This study shows a significant increase in Gram-positive bacterial infection and decrease in Gram-negative bacterial infection of the cornea in the recent years.

Clinical presentations, risk factors and outcomes of ceftazidime-resistant Gram-negative endophthalmitis.

BACKGROUND: To describe the clinical features and outcomes of patients diagnosed with ceftazidime-resistant Gram-negative endophthalmitis and the role of intravitreal imipenem in these cases. DESIGN: Retrospective consecutive interventional case series at a tertiary eye care centre in South India. PARTICIPANTS: Consecutive cases of ceftazidime-resistant Gram-negative endophthalmitis from April 2010 to December 2014. Fifty-six cases diagnosed during this time period were included. METHODS: All cases were managed with vitreous biopsy/vitrectomy, microscopy and undiluted vitreous culture, antimicrobial susceptibility of bacterial isolates and received intravitreal antibiotics. MAIN OUTCOME MEASURES: Anatomic and visual outcome of these cases, antimicrobial susceptibility pattern of intravitreal imipenem and outcome of cases injected with it. RESULTS: Commonest presentation was acute endophthalmitis following cataract surgery (27 eyes, 48.21%). Pseudomonas aeruginosa was isolated in 33 eyes (58.93%; 95% CI 46.05-71.81%). Nineteen eyes (34%; 95% CI 21.59-46.41%) developed phthisis; 14 eyes (25%; 95% CI 13.66-36.34%) had vision <20/200; 17 eyes (30.35%; 95% CI 18.31-42.39%) eyes had an ambulatory vision >20/200 (logMAR 1); 6 eyes (10.71%; 95% CI 2.61-18.81%) had a reading vision >20/40 (logMAR 0.3). Trend was towards better anatomic (72.73% vs. 40%) (P = 0.05) and visual improvement in the imipenem group (logMAR 3.94 + 0.21 to 2.43 + 1.4; P = 0.002), as compared with non-imipenem group (logMAR 2.99 + 1.3 to 2.55 + 1.4; P = 0.13). CONCLUSIONS: Outcome of ceftazidime-resistant Gram-negative endophthalmitis is poor. P. aeruginosa is the commonest isolated organism. All cases were sensitive to imipenem. There was a trend towards better anatomic outcome in imipenem-treated eyes.

Clinical features, microbiological profile and treatment outcome of patients with Corynebacterium endophthalmitis: review of a decade from a tertiary eye care centre in southern India.

AIMS: To report the clinical and microbiological profile along with treatment outcome of patients with endophthalmitis caused by Corynebacterium sp. METHODS: This is a retrospective, consecutive, non-comparative case series of patients with culture-proven Corynebacterium endophthalmitis seen between August 2004 and July 2014. RESULTS: Of 5439 patients clinically diagnosed as infective endophthalmitis, vitreous samples were culture positive for bacteria in 1488 (27%). Sixteen patients (1%) were identified as Corynebacterium endophthalmitis. The clinical settings included trauma (n=10), post-cataract surgery (n=5) and post-penetrating keratoplasty (n=1). In 7/16 (44%) patients, the organisms were visualised in direct microscopy. Tested by disc-diffusion method, all isolates were vancomycin sensitive. However, 9 of 10 isolates were resistant to ceftazidime and 5 of 14 isolates were resistant to amikacin. Initial treatment strategies included pars plana vitrectomy with intravitreal antibiotics (vancomycin and amikacin/ceftazidime) injection (n=9) and pars plana lensectomy along with pars plana vitrectomy and intravitreal antibiotics (vancomycin and amikacin/ceftazidime) injection (n=7). Final visual acuity was 20/200 or better in 11 (69%) of 16 patients. CONCLUSIONS: The prevalence of corynebacterial endophthalmitis is low. The organisms are susceptible to vancomycin, and early appropriate treatment results in favourable outcome.

Corynebacterium spp as causative agents of microbial keratitis.

PURPOSE: To report the clinical and microbiological profile of keratitis caused by Corynebacterium spp. METHODS: The medical and microbiology records of 22 patients, who had presented at the L V Prasad Eye Institute, Bhubaneswar, between June 2009 and December 2012, and whose corneal scrapings had yielded significant growth of Corynebacterium spp, were retrospectively reviewed. A detailed ocular examination was performed before the respective corneal scraping was sent for a microbiological work-up. The data collected from each record included age, gender, predisposing factors (ocular and systemic), clinical presentation, management and outcome of treatment. RESULTS: The mean age of the patients was 43.8±24.4 years. Ocular predisposing factor was present in 14 (63.6%) eyes. Surgical intervention was required in 12 (54.5%) patients. In vitro susceptibility (Kirby-Bauer disc diffusion method) results of Corynebacterium spp to vancomycin (17/19, 89.5%), cefazolin (16/20, 80%), chloramphenicol (11/20, 55%), ofloxacin (13/19, 68.4%), ciprofloxacin (10/20, 50%) and gatifloxacin (10/19, 52.6%) were variable. Drug resistance (more than one drug) was seen in nine (40.9%) Corynebacterium isolates, of which, two (22.2%) showed multidrug resistance to three or more classes of antibiotics. CONCLUSIONS: Corynebacteria can cause severe corneal infection requiring surgical intervention.

Comparison Between Polymicrobial and Fungal Keratitis: Clinical Features, Risk Factors, and Outcome.

PURPOSE: To compare the clinical features, risk factors, and outcome of polymicrobial keratitis with monomicrobial keratitis due to fungus. DESIGN: Retrospective, comparative interventional case series. METHODS: Consecutive cases of microbial keratitis with significant growth of more than 1 organism in culture and culture-proven fungal keratitis treated with natamycin alone were retrieved from the microbiology department. Complete success was defined as resolution of the infiltrate with scar formation on medical treatment, partial success as resolution following tissue adhesive application, and failure as inadequate response to medical therapy with increasing infiltrate size, corneal melting, and/or perforation necessitating therapeutic penetrating keratoplasty (PKP) or evisceration. RESULTS: There were 34 eyes of 34 patients with polymicrobial keratitis and 60 cases of fungal keratitis. Compared to patients with fungal keratitis, patients with polymicrobial keratitis were significantly older (50.03 ± 9.81 years vs 42.79 ± 12.15 years, P = .0038), with larger infiltrates at presentation (61.8% vs 24.1%, P = .0007), a higher association with endophthalmitis (11.8% vs 0%, P = .03), previous history of corneal graft (20.6% vs 0%, P = .0012), and prior topical corticosteroid use (23.5% vs 5%, P = .019). In the polymicrobial group, a combination of bacteria and fungus was more frequently isolated (23, 67.6%), among which filamentous fungi (25, 39.1%) and coagulase-negative staphylococci (14, 21.9%) comprised a majority. Complete success was significantly lower in the polymicrobial group compared to the fungal keratitis group (39.3% vs 73.7%, P = .0045). In multivariate logistic regression analysis comparing factors affecting the outcome between the 2 groups, older age (P = .027) and ulcers larger than 6 mm (P = .001) at presentation adversely affected outcome. CONCLUSIONS: Polymicrobial keratitis with fungus and bacteria was more common and more challenging to treat, with a poorer outcome than fungal keratitis. Medical treatment may be effective; however, therapeutic PKP provided globe salvage at best. Early PKP may be advocated for larger ulcers at presentation.

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.

Intravitreal triamcinolone acetonide in the management of exogenous bacterial endophthalmitis.

PURPOSE: To determine the effectiveness of intravitreal triamcinolone acetonide in the management of bacterial endophthalmitis. DESIGN: Interventional case series. METHODS: This pilot case series included five patients (three patients after trauma and two patients after cataract surgery) with culture proven bacterial endophthalmitis. After 48 to 72 hours of the initial surgical procedure, 4 mg/0.1 ml of intravitreal triamcinolone acetonide was injected, after confirmation that the vitreous isolate was sensitive to the initially administered intravitreal antibiotics. All patients received oral ciprofloxacin 750 mg twice each day for seven days. The course of inflammation and the clinical outcome were noted. RESULTS: In all the five cases, there was complete resolution of inflammation with favorable clinical outcome at the end of one month that was maintained at the end of three months. CONCLUSION: Intravitreal triamcinolone acetonide could be a treatment option in the selected cases of bacterial endophthalmitis.