Diagnosis, Clinical Presentations, and Outcomes of Nocardia Endophthalmitis.

PURPOSE: To describe the clinical presentations, diagnosis, and management outcomes of Nocardia endophthalmitis. DESIGN: Retrospective, interventional, multicenter case series. METHODS: The study was conducted in a multicentric institutional practice setup and included 25 eyes of 25 patients with culture-proven Nocardia endophthalmitis. Anterior chamber fluid and/or vitreous and/or intraocular lens were submitted for microbiological evaluation in all cases. Patients with non-Nocardia etiology and those that were culture negative were excluded. Case records were studied and data regarding demography, clinical presentations, interventions received, and final visual and anatomic outcomes were noted. The main outcome measures were final visual outcomes and factors determining them. RESULTS: The mean age of the patients was 54.7 ± 22.9 years. By the etiology of infection, 18 (75%) eyes were post-cataract surgery (operated elsewhere), 3 (12.5%) eyes were posttrauma, and 3 (12.5%) eyes were endogenous. The final follow-up was a mean of 14.25 ± 30.35 months, median 2 months. The odds of a favorable outcome were 42.5 (95% confidence interval [CI] 3.15 to 571.84, P = .0047) when the vision was more than hand motions at presentation, 9.42 (95% CI 0.92 to 95.89, P = .05) in male sex, 21 (95% CI 0.9 to 489.7, P = .05) when presentation was within 48 hours, and 2.5 (95% CI 0.23 to 26.48, P = .44) with primary vitrectomy instead of a biopsy. The in vitro susceptibility was poor for vancomycin and was best for amikacin. CONCLUSIONS: The visual outcome in Nocardia endophthalmitis is very guarded when presenting vision is poor. On diagnostic confirmation or high index of suspicion, intravitreal amikacin is preferred.

Fabrication of nonfouling, bactericidal, and bacteria corpse release multifunctional surface through surface-initiated RAFT polymerization.

Infections after surgery or endophthalmitis are potentially blinding complications caused by bacterial adhesion and subsequent biofilm formation on the intraocular lens. Neither single-function anti-adhesion surface nor contacting killing surface can exhibit ideal antibacterial function. In this work, a novel (2-(dimethylamino)-ethyl methacrylate-co-2-methacryloyloxyethyl phosphorylcholine) (p (DMAEMA-co-MPC)) brush was synthesized by "grafting from" method through reversible-addition fragmentation chain transfer polymerization. 1-Bromoheptane was used to quaternize the p (DMAEMA-co-MPC) brush coating and to endow the surface with bactericidal function. The success of the surface functionalization was confirmed by atomic force microscopy, water contact angle, and spectroscopic ellipsometry. The quaternary ammonium salt units were employed as efficient disinfection that can eliminate bacteria through contact killing, whereas the 2-methacryloyloxyethyl phosphorylcholine units were introduced to suppress unwanted nonspecific adsorption. The functionalized poly(dimethyl siloxane) surfaces showed efficiency in reducing bovine serum albumin adsorption and in inhibiting bacteria adhesion and biofilm formation. The copolymer brushes also demonstrated excellent bactericidal function against gram-positive (Staphylococcus aureus) bacteria measured by bacteria live/dead staining and shake-flask culture methods. The surface biocompatibility was evaluated by morphology and activity measurement with human lens epithelial cells in vitro. The achievement of the p (DMAEMA+-co-MPC) copolymer brush coating with nonfouling, bactericidal, and bacteria corpse release properties can be used to modify intraocular lenses.

CANDIDA ENDOPHTHALMITIS FROM THE REACTIVATION OF A DORMANT LENTICULAR FUNGAL ABSCESS IN A PREMATURE INFANT.

BACKGROUND/PURPOSE: To report a case of fungal endophthalmitis from reactivation of a dormant lenticular fungal abscess in a severely premature infant. METHODS: Single retrospective case report. RESULTS: A female born at 23 and 6/7 weeks and weighing 620 g was diagnosed at age 29 weeks post menstrual age with persistent tunica vasculosa lentis, lenticular opacity, and aggressive posterior retinopathy of prematurity, and received bilateral intravitreal injection of bevacizumab. At the time of injection she was receiving systemic antibiotics for sepsis and fungemia. The retinopathy of prematurity regressed, as did the tunica vasculosa lentis, but a small plaque remained on the lens. At 5.5 months of age, patient presented with hypopyon and elevated intraocular pressure. Culture of intraocular fluid demonstrated Candida albicans. CONCLUSION: Candida lenticular abscess is a rare complication of systemic fungemia in premature infants. Bevacizumab-induced regression of tunica vasculosa lentis may have decreased the ability of systemically administered antifungal medications to reach the colonized lens.

Prevention of Staphylococcus epidermidis Endophthalmitis by Different Moxifloxacin Prophylaxis Routes.

BACKGROUND: To investigate postoperative endophthalmitis (POE) prevention by moxifloxacin prophylaxis. METHODS: After crystalline lens removal and intraocular lens (IOL) implantation, 18 rabbit eyes were injected intracameral with different coagulase negative staphylococci (CNS) inoculums in order to determine the minimum inoculum required for a reproducible POE model. Another 28 similar eyes were divided into Group A, which was implanted with standard IOLs with intracameral injection of 100 µg/0.1 ml moxifloxacin, Group B implanted with moxifloxacin presoaked IOLs, Group C treated as Groups A and B, and Group D (control) implanted with standard IOLs only. At the end of surgery, all eyes were injected with the minimal inoculum that had developed POE, and treated with topical moxifloxacin for 24 hours. They were then evaluated using 3 different POE scores. RESULTS: The minimum CNS concentration that developed reproducible POE was 5x10(5) CFUs/0.1 ml. Scores: 1. Clinical endophthalmitis was judged in 5/7 (71%), 4/7 (57%), 2/7 (28%) and 7/7 (100%) of Groups A-D eyes, respectively, p=0.005 and 0.057 for Groups B and C compared to D, respectively. 2. Endophthalmitis Scores for Groups A-D were 14.5±6.8, 10.6±4.5, 12.0±3.9 and 18.6±1.7, respectively, p=0.015, and ~0.07 for Groups B and C compared to D, respectively. 3. Hypoyon was noted in 2/6 (33%), 2/7 (28%), 2/7 and 6/7 (86%) of the Group A-D eyes, respectively, p=0.053, 0.03 and 0.03 for Groups A-C compared to D, respectively. CONCLUSION: POE can be best prevented by prophylactic moxifloxacin by presoaked IOLs treatment.

Detection of Encephalitozoon cuniculi in the feline cataractous lens.

PURPOSE: Identification of Encephalitozoon cuniculi (E. cuniculi) as a possible causative agent for cataracts and uveitis in cats. METHODS: Within a 12-month study period, cats that were presented with focal anterior cortical or mature cataract and secondary uveitis underwent a complete ophthalmic examination, complete blood count, serum biochemistry, serologic tests for E. cuniculi and tests for feline immunodeficiency virus (FIV), feline infectious peritonitis (FIP), feline leukemia virus (FeLV) and Toxoplasma gondii (T. gondii). PCR for DNA detection of E. cuniculi and T. gondii as well as cytologic examination of aqueous humor after paracentesis and phacoemulsified lens material were also performed. In addition histopathologic examination of the resected anterior lens capsule and attached lens epithelial cells was performed. Serologic testing for antibodies against E. cuniculi was also performed in 100 ophthalmologically healthy cats. RESULTS: Eleven (19 eyes) European shorthair cats with a median age of 3.5 years were included. Nine of 11 cats had bilateral cataracts, with 12/19 eyes having focal anterior cortical cataracts and 7/19 eyes having mature cataracts. In 14/19 eyes anterior uveitis was present. All cats had a positive antibody titer (1:80-1:10,000) for E. cuniculi. Encephalitozoon cuniculi DNA was detected by PCR and sequencing in 18/19 lenses and in 10/19 aqueous samples. Five tentative positive results were detected by cytologic examination. Spores were detected in 15/19 samples of lens material with histopathologic staining. Only 2/100 ophthalmologically healthy cats showed a positive antibody titer for E. cuniculi. CONCLUSION: Encephalitozoon cuniculi is a cause of focal anterior cortical cataract and anterior uveitis in cats.

Septic lens implantation syndrome in a cat.

A 13-year-old female spayed domestic shorthair cat was presented initially for a change in the appearance of the left eye. On initial examination, a small penetrating wound was suspected as the cause for a corneal scar, an anterior cortical incipient cataract and mild iritis. The cat was not re-presented until 1 year later at which time ocular pain was marked. Severe anterior uveitis and glaucoma were diagnosed and the eye enucleated. Histopathology documented intralenticular coccoid bacteria and septic lens implantation syndrome.

External ocular surface and lens microbiota in contact lens wearers with corneal infiltrates during extended wear of hydrogel lenses.

OBJECTIVES: To determine whether carriage of microbes on the contact lens or ocular surfaces during extended wear (EW) with soft hydroxyethyl methacrylate (HEMA)-based contact lenses predisposes the wearer to adverse events. METHODS: Participants (non-contact lens wearers) were enrolled in a clinical study involving wear of HEMA-based hydrogel lenses on a six night EW basis with weekly replacement. Type and number of bacteria colonizing the lower lid margins, upper bulbar conjunctiva, and contact lenses during EW after one night, 1 week, 1 month, and thereafter every 3 months for 3.5 years were determined. The association of bacteria with adverse responses was compared between carriers (defined as having significant microbes cultured from two or more samples with 1 year) and noncarriers, and the strength of the association was estimated using multivariate logistic regression. RESULTS: Carriers of gram-positive bacteria on lenses (particularly coagulase negative staphylococci or Corynebacterium spp.) were approximately three and eight times more likely to develop contact lens-induced peripheral ulcers (CLPUs) and asymptomatic infiltrates (AIs), respectively. Staphylococcus aureus was most frequently isolated from lenses during CLPU. Carriers of gram-negative bacteria on lenses were five times more likely to develop contact lens-induced acute red eye (CLARE). Haemophilus influenzae was isolated most frequently from lenses during CLARE and AI events. CONCLUSIONS: Bacterial carriage on contact lenses during EW predisposes the wearer to the development of corneal inflammatory events including CLARE, CLPU, and AI.

Comparison of histologic lesions of endophthalmitis induced by Blastomyces dermatitidis in untreated and treated dogs: 36 cases (1986-2001).

OBJECTIVE: To compare prevalence of organisms and histologic changes in eyes from dogs with blastomycosis that were either untreated or undergoing treatment with itraconazole. DESIGN: Retrospective study. ANIMALS: 36 dogs with endophthalmitis associated with blastomycosis. PROCEDURE: Signalment, results of ophthalmic examination, and duration of treatment with itraconazole were extracted from medical records. Histologic sections from eyes were examined for prevalence and viability (ie, budding) of fungal organisms. A scoring system was devised to assess the degree of inflammation. RESULTS: Clinically, all eyes were blind and had signs of severe endophthalmitis. Histologically, the type and degree of inflammation and prevalence of Blastomyces dermatitidis were not significantly different between dogs treated with itraconazole and untreated dogs or among groups of dogs treated for different time periods (4 to 14, 15 to 28, or 29 to 72 days). Replication of the organisms in vascular tissues as well as avascular spaces in the eyes was similar in treated and untreated dogs. Lens rupture was seen in 12 of 29 (41%) eyes. CONCLUSIONS AND CLINICAL RELEVANCE: Persistence of inflammation in eyes of dogs with naturally occurring blastomycosis is likely attributable to the continued presence of B. dermatitidis, regardless of the duration of treatment with itraconazole. Lens capsule rupture, a common and previously unreported histologic finding, may contribute to cataract formation and continued inflammation.

Recurrent endogenous candidal endophthalmitis in a premature infant.

Endogenous Candida endophthalmitis resulting from candidemia in low-birth-weight infants usually occurs as a retinochoroiditis, which is effectively treated with systemic antifungal agents. We report a case of Candida endophthalmitis that recurred 4 months after completion of systemic antifungal therapy. The recurrent Candida infection affected primarily the iris and lens, rather than the retina and choroid. Vitrectomy was required for diagnosis and treatment.

Systemic candidiasis with cataract formation in a premature infant.

Endogenous Candida endophthalmitis is a well-recognized complication in low-birth-weight premature infants. The incidence of systemic candidiasis in premature and low-birth-weight infants is approximately 3%. As many as half of these infants will develop Candida endophthalmitis. Eye involvement typically presents as one or more tiny white "fungal ball" chorioretinal lesions with overlying vitritis. Lens involvement is extremely rare. We report a case of cataract due to Candida albicans in a premature, low-birth-weight infant unresponsive to systemic and intracameral antifungal therapy and requiring lensectomy with vitrectomy.

Paecilomyces lilacinus endophthalmitis with secondary keratitis: a case report and literature review.

A case of endogenous fungous endophthalmitis with secondary pupillary block glaucoma and corneal invasion requiring penetrating keratoplasty is reported. Initially Paecilomyces lilacinus was isolated from a vitreous and a lens aspirate, but a second vitreous tap revealed Aspergillus fumigatus and P lilacinus. This case highlights the difficulty of diagnosing endogenous fungous endophthalmitis presenting without risk factors and the difficulties of managing such cases using the antifungous agents available. To our knowledge, this is the first case report documenting a progression to stromal keratitis from endogenous endophthalmitis secondary to P lilacinus.

Endophthalmitis after penetrating trauma. Risk factors and visual acuity outcomes.

PURPOSE: To identify clinical characteristics that were associated with an increased incidence of endophthalmitis in eyes with penetrating ocular trauma. METHODS: In part 1, a retrospective analysis was performed on 258 consecutive patients with penetrating ocular trauma presenting to the Bascom Palmer Eye Institute between October 1987 and January 1991. In part 2 of the study, 28 consecutive patients with culture-proven endophthalmitis were identified from the Clinical Microbiology Registry from April 1987 through September 1987 and February 1991 through August 1993. Clinical variables were evaluated in each part for association with an increased risk of endophthalmitis. RESULTS: In part 1 of the study, endophthalmitis developed in 13 (5%) of the 258 patients. Endophthalmitis did not occur in eyes that had blunt injury. In those eyes with a lacerating injury, there was an increased relative risk of infection in eyes with disruption of the crystalline lens. This risk factor was found statistically significant by univariate and multivariate analysis. In part 2 of the study, lens disruption was present in 24 (86%) of 28 patients with culture-proven endophthalmitis. Of the 41 patients with infection from part I and part II, 22 (54%) achieved visual acuity of 20/ 400 or greater. Endophthalmitis caused by coagulase-negative staphylococci had the best visual outcome, with 7 (64%) of 11 patients obtaining visual acuity of 20/ 400 or greater. CONCLUSION: Lens disruption in eyes with penetrating trauma is a significant risk factor for the development of endophthalmitis. The prognosis for useful vision in eyes with posttraumatic endophthalmitis is best when infection is caused by less virulent organisms.

Herpes simplex virus type 1 replicates in the lens and induces cataracts in mice.

In a mouse model, cataracts were produced after corneal inoculation with herpes simplex virus type 1 (HSV-1) strain F. Viral antigen was detected in vivo by the immunoperoxidase technique in lens fibers and occasionally in lens epithelial cell nuclei at 4 and 5 days postinoculation. HSV-1 replication within the lens was further demonstrated by virus isolation from lenses that had been inoculated in vitro. Lens lesions in mice were present as early as 4 days postinoculation and by later times (23 to 60 days postinoculation), severe degenerative changes typical of cataracts were present in many of the lenses examined histologically. Viral DNA was detected in extracts of lenses from infected animals at 5 and 11 days postinoculation. In contrast to HSV-1 F, the KOS strain of HSV-1 produced intraocular infection and cataracts at a much lower frequency in mice. Lens lesions appear to be induced directly by viral replication within the lens; however, other mechanisms involving inflammation in adjacent eye structures may also be involved in the pathogenesis of these lesions. Based upon these data, it is reasonable to consider the possibility that HSV-1 may be involved in the production of cataracts in humans in some cases.

Postinflammatory cataracts in the mouse: induction by human mycoplasma-like organisms.

Cataracts often occur in humans secondary to uveitis. Uveitis may be caused by various infectious agents, but rarely is the agent detected in the cataract. Mycoplasma-like organisms (MLO) were recently reported to cause human uveitis and retinitis. Cataracts were often present in those inflamed eyes. MLO are intracellular cell wall deficient pathogenic bacteria. They are pleomorphic tubulospherical and filamentous organisms with a characteristic ultrastructural appearance. No MLO culture system has been found despite 20 years of effort. The diagnosis of MLO disease rests on detection of the organisms in parasitised cells by a transmission electron microscope and response to antibiotics. In human intraocular inflammatory disease MLO are detectable in parasitised leucocytes and retinal pigment epithelial cells at the disease sites. Inoculation of MLO from a human source into mouse eyelids produced intraocular, chronic, progressive, inflammatory disease, with intraocular leucocytes parasitised by MLO in 15 of 100 mice versus 0 in 200 controls (p less than 0.05). This report describes the cataracts with MLO-parasitised intralenticular leucocytes in the inflamed eyes of 14 of those 15 mice versus 0 in 200 control mice (p less than 0.05). The results indicate that MLO penetrated the lens capsules to produce the cataracts, and they suggest that MLO could cause human cataracts. Alternative methods for detection of MLO and rifampin treatment of MLO intraocular disease are discussed.