[Quantitative evaluation of infectious keratitis by anterior segment optical coherence tomography]. / Évaluation quantitative des kératites infectieuses par tomographie en cohérence optique du segment antérieur.

The clinical evaluation of infectious keratitis takes place largely through biomicroscopic examination, which presents limitations in the evaluation of the depth of the infiltrate and the exact thickness of the cornea, whether edematous or thinned. In this study, we aim to quantify the human corneal inflammatory response in treated infectious keratitis by anterior segment optical coherence tomography (AS-OCT). Patients with infectious keratitis were recruited prospectively in the ophthalmology department of the military hospital of Rabat between November 2017 and May 2019. Over the study period, 32 patients were included. A standardized scanning protocol was used. The thickness of the infiltrate, when present, and corneal thickness in any area of thinning and any surrounding edematous areas were measured. The various thicknesses gradually decreased over the course of follow-up, providing objective evidence of therapeutic efficacy in the early stages. Improvement in corneal edema and thinning was faster in the early stage. AS-OCT scanning can be used along with slit lamp examination to quantify and objectively follow infectious keratitis.

Mucormycosis Endophthalmitis in a Silicone Oil-Filled Eye of an Immunocompetent Patient.

Purpose:: Fungal endophthalmitis following pars plana vitrectomy with silicone oil tamponade is an infrequent entity. Filamentous fungi like aspergillus are generally associated with endophthalmitis. Mucor is a rarely implicated pathogen in cases of endophthalmitis with only two reported cases in medical literature. Both these cases had uncontrolled diabetes which predisposed them to develop mucor endophthalmitis.Methods: We report a non-diabetic patient who developed mucor endophthalmitis after uneventful vitreous surgery for myopia associated retinal detachment.Results: Mucor species induced endophthalmitis in a silicone oil-filled eye of a non-diabetic patient is reported. The eye went into pthisis bulbi.Conclusions: To the best of our knowledge, this is the first report of mucor endophthalmitis in a silicone oil-filled globe of an immunocompetent patient.

Toxic anterior segment syndrome caused by autoclave reservoir wall biofilms and their residual toxins.

PURPOSE: To identify etiology of toxic anterior segment syndrome (TASS) after uneventful phacoemulsification. SETTING: EyeMD Laser and Surgery Center, Oakland, California. DESIGN: Retrospective case series. METHODS: Patient charts with TASS were reviewed. Reservoirs of 2 autoclaves associated with these cases were cultured for bacterial contamination. Cultures were performed on 23 other autoclave reservoirs at surgery centers in the local area. The main outcome measures were the incidence of TASS and prevalence of bacterial biofilm contamination of autoclave reservoirs. RESULTS: From 2010 to 2013, 11 935 consecutive cataract surgeries were performed at 1 center by multiple surgeons with no reported TASS. Between January 1, 2014, and January 15, 2015, 10 cases of TASS occurred out of 3003 cataract surgeries; these patients' charts were reviewed. Cultures of 2 Statim autoclave reservoir walls grew Bacillus species, Williamsia species, Mycobacterium mucogenicum, and Candida parapsilosis. Scanning electron microscopy of reservoir wall sections showed prominent biofilm. The 2 autoclaves were replaced in January 2015. Subsequently, 2875 cataract surgeries were performed with no reported TASS (P < .001, χ2 test). Eighteen of 23 additional regional autoclaves were also contaminated with bacterial biofilms. CONCLUSIONS: Toxic anterior segment syndrome was strongly associated with bacterial biofilm contamination of autoclave reservoirs. An etiological mechanism might involve transport of heat-stable bacterial cell antigens in the steam with deposition on surgical instrumentation. Data suggest widespread prevalence of bacterial biofilms on fluid-reservoir walls, despite adherence to manufacturer guidelines for cleaning and maintenance. Prevention or elimination of autoclave fluid-reservoir biofilms might reduce the risk for postoperative TASS. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Prophylactic Vancomycin Drops Reduce the Severity of Early Bacterial Keratitis in Keratoprosthesis.

BACKGROUND: Artificial cornea transplantation, keratoprosthesis, improves vision for patients at high risk of failure with human cadaveric cornea. However, post-operative infection can cause visual loss and implant extrusion in 3.2-17% of eyes. Long-term vancomycin drops are recommended following keratoprosthesis to prevent bacterial keratitis. Evidence, though, in support of this practice is poor. We investigated whether prophylactic vancomycin drops prevented bacterial keratitis in an animal keratoprosthesis model. METHODOLOGY: Twenty-three rabbits were assigned either to a prophylactic group (n = 13) that received vancomycin 1.4% drops 5 times/day from keratoprosthesis implantation to sacrifice, or a non-prophylactic group (n = 10) that received no drops. All rabbits had Staphylococcus aureus inoculation into the cornea at 7-12 days post-implantation and were sacrificed at predetermined time-points. Prophylactic and non-prophylactic groups were compared with slit-lamp photography (SLP), anterior segment optical coherence tomography (AS-OCT), and histology, immunohistochemistry and bacterial quantification of excised corneas. Corneal vancomycin pharmacokinetics were studied in 8 additional rabbits. RESULTS: On day 1 post-inoculation, the median SLP score and mean±SEM AS-OCT corneal thickness (CT) were greater in the non-prophylactic than the prophylactic group (11 vs. 1, p = 0.049 and 486.9±61.2 vs. 327.4±37.1 µm, p = 0.029 respectively). On days 2 and 4, SLP scores and CT were not significantly different. Immunohistochemistry showed a greater CD11b+ve/non-CD11b+ve cell ratio in the non-prophylactic group (1.45 vs. 0.71) on day 2. Bacterial counts were not significantly different between the two groups. Corneal vancomycin concentration (2.835±0.383 µg/ml) exceeded minimum inhibitory concentration (MIC) for Staphylococcus aureus only after 16 days of vancomycin drops. Two of 3 rabbits still developed infection despite bacterial inoculation after 16 days of prophylactic drops. CONCLUSIONS: Prophylactic vancomycin drops provided short-term benefit, but did not prevent infection. Achieving MIC in the cornea was not sufficient to prevent Staphylococcus aureus keratitis. Patients should continue to be counselled regarding the risk of infection following keratoprosthesis.

Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a Northern California eye department.

PURPOSE: To evaluate post-cataract-surgery endophthalmitis rates in relation to changing practice patterns in antibiotic administration. SETTING: Kaiser Permanente, Diablo Service Area, California. DESIGN: Ecological time-trend study. METHODS: During 2007 through 2011, 3 time periods were identified based on increasing adoption of intracameral injections after phacoemulsification cataract surgery. In 2007, patients primarily received postoperative antibiotic drops without intracameral injection. During 2008 and 2009, in addition to the surgeons' usual postoperative topical drop regimen, patients received intracameral cefuroxime unless contraindicated by allergy or posterior capsule rupture (PCR). During 2010 and 2011, all patients received an intracameral injection of cefuroxime, moxifloxacin, or vancomycin while topical antibiotics were used according to surgeon preference. The rates of postoperative endophthalmitis during these 3 periods were calculated. Also evaluated separately were consecutive patients without PCR from a subgroup of 3 surgeons who used intracameral injection alone without perioperative topical antibiotics. RESULTS: Nineteen cases of endophthalmitis occurred in 16,264 cataract surgeries. The respective rates per 1000 during the 3 time periods (2007, 2008 and 2009, 2010 and 2011) were as follows: 3.13 (95% confidence interval [CI], 1.43-5.93); 1.43 (95% CI, 0.66-2.72); 0.14 (95% CI, 0-0.78). One case of endophthalmitis was observed in 2038 patients without PCR who received intracameral injection only without topical antibiotics (rate per 1000: 0.49; 95% CI, 0.01-2.73). CONCLUSIONS: The adoption of intracameral antibiotic injection coincided with a decline in the rate of postoperative endophthalmitis, and a low infection rate was observed with intracameral injection alone.

Long-term, multicenter evaluation of subconjunctival injection of triamcinolone for non-necrotizing, noninfectious anterior scleritis.

PURPOSE: We sought to characterize the long-term outcomes and complications of subconjunctival triamcinolone acetonide injection (STI) for non-necrotizing, noninfectious anterior scleritis. DESIGN: Retrospective, interventional, noncomparative, multicenter study. PARTICIPANTS: Sixty-eight eyes of 53 patients from 9 participating hospitals in the United States, Singapore, and Australia. Only eyes with 6 or more months of follow-up were included. INTERVENTION: Subconjunctival injection of 2 to 8 mg of triamcinolone acetonide was administered to eyes with non-necrotizing, noninfectious anterior scleritis. MAIN OUTCOME MEASURES: Resolution of signs and symptoms, time to recurrence of scleritis, and side effect profile. RESULTS: Median follow-up was 2.3 years (range, 6 months to 8.3 years). Sixty-six eyes (97.0%) experienced improvement of signs and symptoms after 1 injection. Twenty-four months after a single injection, 67.6% of eyes remained recurrence-free, whereas at 48 months, 50.2% were recurrence-free. Some 55.0% of patients who had adverse effects from systemic medications were off all systemic medications at last follow-up; 55.0% of patients who were taking systemic medications at the time of first triamcinolone acetonide injection were not taking prednisone and immunosuppressants at this time; 76.2% of patients still requiring systemic agents had associated systemic disease. Fourteen eyes (20.6%) had ocular hypertension not requiring intraocular pressure (IOP)-lowering therapy. Two eyes (2.9%) were treated with topical IOP-lowering agents alone, and 2 eyes required surgical intervention for glaucoma. None developed scleral necrosis or melt. CONCLUSIONS: This retrospective, international study carried out at 9 hospitals suggests that STI can treat non-necrotizing, noninfectious anterior scleritis with side effects limited to elevated IOP in a few patients. Although no cases of scleral melt or necrosis were observed, we cannot definitively conclude that this may not occur after STI. Intraocular pressure should be closely monitored after STI. Subconjunctival triamcinolone acetonide injection may be useful as adjuvant therapy or to decrease systemic medication burden. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Assessment of the use of anterior segment optical coherence tomography in microbial keratitis.

PURPOSE: To investigate the imaging capabilities of anterior segment optical coherence tomography (AS OCT) in microbial keratitis and to assess whether measurements of the quantitative parameters, infiltrate thickness and corneal thickness, were possible. DESIGN: Prospective, noncomparative, observational case series. METHODS: The study was conducted at a university hospital clinical setting. Seven patients (eyes) with suspected microbial keratitis underwent standard clinical examination and treatment based on slit-lamp clinical findings. AS OCT scanning was performed on presentation and at two follow-up appointments. All scans were carried out with the scanning beam passing through the center of the infiltration and at a specific meridian. Examination was carried out by the same operator. RESULTS: Corneal infiltration was imaged as a hyperreflective area in the corneal stroma on high-resolution AS OCT scans. Retrocorneal pathologic features and anterior chamber inflammatory cells could be imaged. Corneal and infiltrate thickness could be measured with calipers in six cases. In one case, corneal and infiltrate thickness could not be measured because of a thick inflammatory plaque attached to the endothelium. In this case, the width of the plaque was measured on serial scans. CONCLUSIONS: AS OCT imaging provides a range of parameters that can be used to assess microbial keratitis and the treatment response objectively.

Role of swarming migration in the pathogenesis of bacillus endophthalmitis.

PURPOSE: Bacillus cereus causes one of the most rapidly blinding forms of bacterial endophthalmitis. Migration of B. cereus throughout the eye during endophthalmitis is a unique aspect of this disease that may contribute to intraocular virulence. This study was conducted to analyze the contribution of swarming and intraocular migration to the pathogenesis of experimental endophthalmitis. METHODS: Eyes were injected intravitreally with 100 colony-forming units (CFU) of either wild-type, nonswarming, or swarming-complemented strains of B. cereus. Pathogenicity was compared throughout the course of infection by biomicroscopy, histology, electroretinography, and bacterial and inflammatory cell quantitation. RESULTS: Wild-type, nonswarming, and swarming-complemented B. cereus strains grew to a similar number in the vitreous throughout the course of infection. Unlike the wild-type and swarming-complemented strains, the nonswarming mutant did not migrate to the anterior segment during infection. The rate of decrease in retinal responses of eyes infected with the all strains was similar, resulting in near complete elimination of retinal function by 12 hours. All Bacillus strains caused similar degrees of posterior segment inflammation and retinal destruction. However, the accumulation of inflammatory cells in the anterior chamber, hyphemae, and corneal ring abscesses did not occur in eyes infected with the nonswarming mutant. CONCLUSIONS: The deficiency in swarming had little effect on retinal function loss or the overall course or severity of experimental B. cereus endophthalmitis. However, a deficiency in swarming prevented Bacillus from migrating to the anterior segment, leading to less severe anterior segment disease.

Posttraumatic exogenous Nocardia endophthalmitis.

PURPOSE: To report a case of posttraumatic exogenous Nocardia endophthalmitis. DESIGN: Interventional case report. METHOD: A 46-year-old man presented with counting fingers vision, severe eye pain, hypopyon, and an iris mass consistent with endophthalmitis following a penetrating injury to the left eye. RESULTS: Despite oral fluconazole and repeated intravitreal injections of vancomycin, gentamicin, and amphotericin B, the eye remained painful with a persistent hypopyon and recurrent iris masses. Cultures of the vitreous and iris masses remained negative for organisms. Despite vitrectomy and sector iridectomy of the iris mass with repeat injections of intravitreal antibiotics, the patient continued to have severe pain, poor vision, and developed new iris masses. Enucleation cultures confirmed Nocardia asteroides. CONCLUSIONS: Posttraumatic exogenous Nocardia endophthalmitis is extremely rare, and its clinical signs can mimic a fungal infection.

Post-operative endophthalmitis: diagnosis and management

Endophthalmitis is a most devastating complication of intraocular surgery, which, without appropriate therapy, rapidly leads to severe visual loss. Its incidence has been low following cataract surgery; however, with the advent of sutureless surgery, the number of cases has been on the rise. The theorized reason, in addition to the other causes of endophthalmitis, is bacterial access to the anterior chamber through the cataract wound. Prompt recognition of early symptoms and signs of endophthalmitis is essential for diagnosis and treatment in the early stages of this disorder. Treatment does require tertiary medical care. Samples need to be taken for culture prior to beginning antimicrobial therapy. The techniques for obtaining culture will be discussed. Appropriate antibiotics need to be started promptly after culture specimens are obtained. Patients often present outside regular working hours and so an appropriate protocol for management will facilitate diagnosis and therapy. This presentation will review appropriate protocols with reference to Endophthalmitis Vitrectomy Study. (Au)

Eyes removed for primary ulcerative keratitis with endophthalmitis: microbial and histologic findings.

OBJECTIVES: To study the microbiological and histological findings in patients whose eyes are removed for primary ulcerative keratitis with suppurative endophthalmitis. METHODS: Survey of consecutive cases of ulcerative keratitis with histologically defined endophthalmitis treated by enucleation or evisceration. RESULTS: Eighteen cases of ulcerative keratitis with suppurative endophthalmitis were identified. Thirteen corneal ulcers were culture positive (72%). Microorganism were found in histologic sections of the anterior segment of 9 eyes (50%), but no microorganisms were identified in the vitreous. Two eyes (11%) had culture-positive endophthalmitis. Half of the patients in this study who had undergone elective intraocular surgery had done so within 4 months of enucleation. CONCLUSIONS: Considerable vitreous inflammation can occur with microbial keratitis in the absence of histologically demonstrable microorganisms in the vitreous. Microbial keratitis associated with suppurative endophthalmitis is usually caused by virulent organisms. The factors that contributed to the spread of purulent inflammation inside the eye could not be assessed in this morphologic study because of the lack of clinical data.

Acute endophthalmitis outbreak after cataract surgery.

PURPOSE: To evaluate the source of organisms causing an epidemic of postoperative endophthalmitis and to emphasize the importance of prompt intervention with an early diagnosis. SETTING: S.B. Ankara Hospital Eye Department, Ankara, Turkey. METHODS: Thirteen patients who had surgery on the same day and developed acute postoperative endophthalmitis were evaluated. Clinical patterns were observed and intraocular cultures and stains performed in 10 eyes. Broad-spectrum intravitreal antibiotics were injected on an empirical basis. RESULTS: Intravitreal cultures showed Pseudomonas aeruginosa in four cases and coagulase-negative staphylococci in three cases; three cases were culture negative. P. aeruginosa were also isolated from irrigation solutions used on the same day. Two patients with P. aeruginosa had a visual acuity of 20/200 and 20/300, respectively. CONCLUSION: The different culture results were probably related to the amount of inoculation, individual risk factors, and the subconjunctival antibiotic injection given at the end of surgery. That one patient with P. aeruginosa endophthalmitis retained a visual acuity of 20/200 shows the importance of rapid intravitreal antibiotic treatment.