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Ocular surface inflammatory disorders, such as dry eye, are becoming increasingly prevalent. Developing new treatment strategies targeting harmful bacteria could provide significant therapeutic benefits. The purpose of this study was to characterize the common ocular pathogen Staphylococcus aureus and the rarer endophthalmitis-associated species Enterococcus faecalis isolated from the ocular surface of dry eye disease patients in Norway. Together the 7 isolates (5 S. aureus and 2 E. faecalis) comprise the complete set of members of each species isolated in our previous study of the ocular microbiome of 61 dry eye sufferers. We aimed to investigate the pathogenic potential of these isolates in relation to ocular surface health. To this end, we used whole genome sequencing, multiplex PCR directed at virulence genes and antibiotic susceptibility tests encompassing clinically relevant agents. The E. faecalis isolates showed resistance to only gentamicin. S. aureus isolates displayed susceptibility to most of the tested antibiotics, except for two isolates which showed resistance to trimethoprim/sulfamethoxazole and three isolates which were resistant to ampicillin. Susceptibilities included sensitivity to several first-line antibiotics for treatment of ocular infections by these species. Thus, treatment options would be available if required. However, spontaneous resistance development to gentamicin and rifampicin occurred in some S. aureus which could be a cause for concern. Whole genome sequencing of the isolates showed genome sizes ranging from 2.74 to 2.83 Mbp for S. aureus and 2.86 Mbp for E. faecalis, which is typical for these species. Multilocus sequence typing and phylogenetic comparisons with previously published genomes, did not suggest the presence of eye-specific clusters for either species. Genomic analysis indicated a high probability of pathogenicity among all isolates included in the study. Resistome analysis revealed the presence of the beta-lactamase blaZ gene in all S. aureus isolates and the dfrG gene in two of them; while E. faecalis isolates carried the lsa(A) gene which confers intrinsic resistance to lincosamides and streptogramin A in this species. Screening for virulence factors revealed the presence of various pathogenicity associated genes in both S. aureus and E. faecalis isolates. These included genes coding for toxin production and factors associated with evading the host immune system. Some of the identified genes (tst, hylA & hylB) are suggested to be linked to the pathophysiology of dry eye disease. Lastly, the presence of specific S. aureus virulence genes was confirmed through multiplex PCR analysis., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: To report the first case of acute Abiotrophia defectiva endophthalmitis post-keratoplasty and review the current literature., Methods: A 47-year-old male, post-keratoplasty, presented with vision loss and severe anterior chamber reaction. Diagnostic investigations included vitreous cultures and molecular analysis., Results: Abiotrophia defectiva was identified. Despite aggressive treatment, visual acuity remained low. We reviewed a total of 14 post-procedural cases of A. defectiva endophthalmitis, focusing on antibiotic and steroidal treatment regimens and long-term prognosis., Conclusion: We emphasize aggressive treatment of external disease prior to intraocular surgery. In cases of A. defectiva endophthalmitis, we advocate judicious use of steroids.

Introduction: Pediatric infectious endophthalmitis is a rare, severe ocular infection that can have devastating consequences. It may be exogenous or endogenous, with exogenous endophthalmitis being more common. Current data on the etiology, microbiology, antibiotic treatments and outcomes in pediatric cases is limited., Purpose: To summarize the etiology, microbiology, visual outcomes and management of pediatric endophthalmitis., Methods: A literature review was conducted on cases of pediatric endophthalmitis published from 1980 to 2022, identified through searches of PubMed, Medline, Web of Science and Google Scholar databases., Results: A total of 796 patients were included. Ocular trauma was the most common cause with 623 patients (78.3%), followed by posteye surgery with 100 patients (12.6%) and endogenous endophthalmitis with 67 patients (70 eyes) (8.4%). Among culture-positive cases, gram-positive microorganisms predominated. Treatment involved pars plana vitrectomy in 608 patients (76%) and intraocular antibiotics in 590 patients (74%). Favorable visual acuity (≥20/200) was achieved in 30.5% of patients, 20% had no light perception and 12.5% developed poor anatomical outcomes with phthisis bulbi., Conclusion: Our review provides insights into the etiology, epidemiology, microbiology, treatment and visual outcomes of pediatric endophthalmitis based on available literature worldwide., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Fungal endophthalmitis is a chronic inflammatory condition of the eye's posterior segment that can lead to irreversible vision loss. While relatively rare in western countries, its incidence is notably higher in Asia, particularly India. The condition's prevalence is exacerbated by factors such as intravenous drug use, antibiotics, and ocular surgeries. Fungal endophthalmitis can be categorized as endogenous, arising from systemic infection, or exogenous, linked to external sources such as trauma or surgery. The fungal agents responsible vary by region, with Candida species common in the West and Aspergillus and Fusarium species more prevalent in India. Management typically involves vitrectomy and intravitreal antifungal drugs such as amphotericin B and voriconazole, though treatment is often complicated by multidrug resistance and culture-negative cases. Recent proteomic and transcriptomic analyses have highlighted the early and sustained activation of the host immune response during infection involving key inflammatory and oxidative stress-related proteins. Given the potential for excessive inflammation to cause retinal damage, targeted immunotherapies are crucial. Immunomodulation, which aims to balance the immune response, shows promise in preserving vision while effectively combating the infection. Key targets for immunomodulation include pro-inflammatory cytokines (TNF-α, IL-1β, IL-6, IL-17), chemokines (CCL2, CXCL8), Toll-like receptors (TLR2, TLR4), and the complement system. Additionally, modulating the activity of macrophages, neutrophils, regulatory T cells, and Th17 cells, as well as targeting inflammasomes, can help control inflammation. Biologic agents and small molecule inhibitors offer further avenues for precise immune response modulation. This review underscores the importance of a comprehensive understanding of host-pathogen interactions in the development of effective therapies for fungal endophthalmitis.

Purpose: To compare visual outcomes of endophthalmitis following intravitreal injections (IVIs) and cataract extraction by causative organism., Methods: Searches in Cochrane Central Register of Controlled Trials, MEDLINE, and Embase identified articles reporting visual outcomes by causative organisms in post-IVI and cataract extraction endophthalmitis cases from January 2010 to February 2022. A random-effects meta-analysis compared visual improvement among endophthalmitis cases caused by causative organisms., Results: Eighty-five out of 3,317 retrieved studies were included. The highest degree of visual acuity improvement in both post-IVI and postcataract extraction endophthalmitis was seen in cases caused by coagulase-negative staphylococci, followed by gram-negative organisms and other gram-positive organisms such as streptococci and enterococci. Culture-negative cases showed more visual acuity improvement than culture-positive cases in post-IVI endophthalmitis. These results remained consistent when accounting for endophthalmitis treatment, IVI type, condition requiring IVI treatment, follow-up period, and initial preprocedural visual acuity., Conclusion: Coagulase-negative staphylococci and gram-negative organisms show the most visual acuity improvement in both post-IVI and postcataract extraction endophthalmitis. Other gram-positive organisms such as streptococci and enterococci are associated with less visual improvement. This updated systematic review and meta-analysis revealed that the results of the Endophthalmitis Vitrectomy Study are consistent decades later despite advancements in surgical practices and the evolution of microorganisms over time.

Objectives: To describe the clinical and microbiological characteristics of patients with endogenous endophthalmitis (EE), determine factors associated with outcome and propose a management plan for EE., Methods: Retrospective case series in two tertiary referral centers from 2010 to 2022., Results: Sixty-four eyes of 53 patients were included. Bilateral involvement occurred for 11/53 patients (21%). Ocular symptoms were the only first manifestation of the disease in 36/53 (68%) of cases; signs of sepsis were evident in 17/53 (32%). Imaging tests detected at least one extraocular focus of infection in 34/53 patients (64%), with contrast-enhanced thoraco-abdominopelvic computed tomography showing relevant findings in 28/50 (56%) of cases. EE was microbiologically confirmed in 43/53 patients (81%); the organisms involved were: Gram-positive bacteria (19/53, 36%), Gram-negative bacteria (13/53, 25%) and Candida sp. (11/53, 21%). Klebsiella pneumoniae was the most common bacteria (10/32, 31%). Blood cultures were positive in 28/53 patients (53%) and eye samples in 11/41 eyes (27%). All patients were treated with systemic antimicrobial therapy, 39/64 eyes (61%) received anti-infective intravitreal injection(s) and 17/64 eyes (27%) underwent vitrectomy. Four patients (8%) died due to uncontrolled systemic infection. Final visual acuity (VA) was < 20/400 in 28/57 eyes (49%) and ocular structural loss (bulbar phthisis or enucleation/evisceration) was reported in 18/64 eyes (28%). In multivariate analysis, initial VA was the only parameter associated with visual and/or structural loss of the eye (OR = 24.44 (4.33-228.09) and 5.44 (1.33-26.18) respectively)., Conclusions: EE remains a severe infection with a poor ocular outcome. We propose a standard protocol to improve diagnosis and medical management., Competing Interests: Declarations of competing interest The authors have no competing interests to declare that are relevant to the content of this article. The authors declare they have no financial interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

During outdoor work in April 2022, a 48-year-old man was stabbed by a tree branch and underwent intraocular foreign body extraction and repair of the scleral wound with sutures and amniotic membrane graft at a local hospital. Steroid therapy with prednisone was prescribed after a diagnosis of uveitis. Vitrectomy was performed in June 2023; a fungal culture was positive, and ITS sequencing identified the organism as Paradictyoarthrinium diffractum. Empiric antifungal therapy did not have an effect, and, because of deterioration of the condition, the left eye was enucleated in October 2023. P. diffractum is a mangrove host-specific saprophytic fungus that has not been reported in humans., Competing Interests: Declarations of competing interest The authors have no competing interests to declare., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: To report a case of presumed teclistamab-associated sclerouveitis with hypopyon., Methods: Case report., Results: A 62-year-old woman with relapsed refractory multiple myeloma presented with right eye pain and decreased vision 1 week after starting teclistamab and was found to have sclerouveitis with hypopyon. She received intravitreal vancomycin and ceftazidime because of the concern for infectious endophthalmitis, but cultures were negative. Systemic workup for infectious and inflammatory etiologies was unremarkable. Her signs and symptoms improved with topical steroids and a 1-week pause in teclistamab. This case constituted a Naranjo Adverse Drug Reaction Probability Scale score of 5, representing a "probable" association., Conclusion: Teclistamab, a novel bispecific antibody recently approved for the treatment of relapsed or refractory multiple myeloma, may be associated with sclerouveitis with hypopyon.

Purpose: To review the etiology and antibiotic susceptibility patterns of infectious endophthalmitis over 11 years in different age groups., Methods: Microbiology records of culture-positive endophthalmitis cases from January 2011 and December 2021 were reviewed for the age groups 0-30, 31-60, and >60 years. Additionally, data was also analysed for trends in antibiotic susceptibility between different age groups., Results: A total of 5590 patients were clinically diagnosed with endophthalmitis. Of these, 1316 (23.5%) patients were culture positive comprising of 1097 bacteria (83.3%) and 219 fungal (16.6%). Gram-positive bacteria predominated the culture-proven bacterial endophthalmitis group with 709 cases (62.6%). Streptococcus pneumoniae (9.3%) was the most prevalent organism in the age group between 0 and 30 years, while Staphylococcus epidermidis (6%) was the most prevalent organism in the age group of 31-60 years. In comparison, Pseudomonas aeruginosa (4.1%) was the most abundant organism in the age group >60 years. Interestingly, Aspergillus flavus (13.24%) was the predominant fungal pathogen in all age groups. There was an increasing trend in antibiotic resistance from younger to older age groups and this pattern was observed for almost all drugs tested except vancomycin and amikacin., Conclusion: While infection can occur at any age, the etiology also seems to vary. This study helps us understand the demography of endophthalmitis along with choice of empirical antibiotics that would influence treatment outcomes. Although vancomycin currently holds good for the treatment for gram-positive infections, gram-negative infections calls for an immediate need for newer drugs or advanced treatment options.

Purpose: To investigate the clinical features of endogenous Klebsiella pneumoniae endophthalmitis (EKPE) and the molecular characteristics of pathogenic K. pneumoniae ., Methods: A retrospective study was conducted between January 2014 and January 2021. Clinical data were extracted. K. pneumoniae isolates cultured from EKPE patients' specimens were characterized by antimicrobial susceptibility testing, multilocus sequence typing, capsular serotyping, and virulence gene profiles. Virulence phenotypes were confirmed by mouse lethality assay., Results: Thirty-nine patients (47 eyes) were diagnosed with EKPE. Administration of systemic antibiotics and eye treatment within 24 hours of ocular symptom onset was statistically associated with better visual outcomes ( p = .007). Sixteen K. pneumoniae isolates were collected, three of which were carbapenem-resistant and avirulent. Only salmochelin encoding gene was harbored by all isolates., Conclusions: Systemic and eye treatment administered within 24 hours from the onset improves visual prognosis. Besides hypervirulent strains, avirulent carbapenem-resistant K. pneumoniae can cause EKPE.

Objective: To identify characteristics and visual outcomes of coagulase-negative staphylococcal (CoNS) endophthalmitis in the era after the Endophthalmitis Vitrectomy Study., Design: Single-centre retrospective analysis., Participants: Forty-two samples from 40 patients with documented CoNS endophthalmitis., Methods: Visual acuity outcomes of CoNS endophthalmitis were assessed in relation to species and type of treatment instituted (i.e., pars plana vitrectomy [PPV] versus vitreous tap and injection of intravitreal antibiotics [T&I]) on 42 samples from 40 patients., Results: Staphylococcus epidermidis was the most prevalent CoNS in our study. Cataract surgery and intravitreal injections were the most common sources for acute CoNS endophthalmitis. Eyes presenting with hand motion or better vision had similar mean final vision after either intravitreal antibiotics or PPV, whereas those with light perception or worse vision at onset had better outcomes after PPV only. Subanalysis showed that patients with S. epidermidis endophthalmitis (n = 39 eyes) had similar visual outcomes with either intravitreal injections or PPV regardless of visual acuity. Hypopyon and vitritis are not always present., Conclusions: Patients with S. epidermidis endophthalmitis may benefit similarly from either early vitrectomy or intravitreal antibiotic injections regardless of visual acuity. This finding may be a supplement to the complements the management standards set forth by the Endophthalmitis Vitrectomy Study., (Copyright © 2023. Published by Elsevier Inc.)

Background: Candida endophthalmitis is a severe complication of candidemia. Currently, the recommended treatment of fungal endophthalmitis is a combination of intravitreal and systemic antifungal drugs, and in some cases vitrectomy is also required. Intravitreal therapies that are commonly used are amphotericin B and voriconazole, although recently the use of intravitreal caspofungin has been described in a few case reports. However, clinical experience with intravitreal caspofungin is still limited., Case Presentation: We report a case of bilateral candida tropicalis endophthalmitis, initially managed with repeated 100 μg/0.1 ml caspofungin intravitreal injections and posteriorly treated with pars plana vitrectomy in both eyes., Conclusions: Intravitreal caspofungin could be a safe intravitreal alternative to habitual antimycotic drugs in cases with resistant candida endophthalmitis. Abbreviations: Intensive Care Unit (ICU); Best-Corrected Visual Acuity (BCVA).

The aim of this study was to investigate the efficacy of the ithmid kohl/zinc-oxide nanoparticles (ZnONPs), ithmid kohl/Aloe vera, and ZnONPs/Aloe vera in the treatment of bacterial endophthalmitis. The endophthalmitis model was prepared by contaminating both eyes of 24 healthy adult male albino rabbits with a clinical isolate of Klebsiella pneumoniae. The animals were randomly divided into eight groups (A-H) according to the treatment. Group A received 1 ml of ithmid kohl/ZnONPs ointment, group B received 1 ml of ithmid kohl/Aloe vera gel ointment, group C received 1 ml of ZnONPs/Aloe vera gel ointment, and groups D, E, and F were treated with 1 ml of ithmid kohl solution (0.5 g/ml in distilled water), 1 ml of ZnONPs (0.5 g/ml) colloidal dispersion, and 1 ml of Aloe vera gel, respectively. Group G received 100 μl of a tetracycline antibiotic solution (final concentration: 16 µg/ml), and group H received sterile distilled water (no treatment). In vitro antibacterial activity was evaluated against K. pneumoniae using the agar well diffusion. The combination of ithmid kohl/ZnONPs was the most effective formulation for treating endophthalmitis model in infected rabbits within 2 days. In vitro antibacterial assay confirmed the potential of the ithmid kohl/ZnONPs formulation, which had the largest zone of inhibition (31 mm) among the compounds tested. The preparation of the ithmid kohl/ZnONPs formulation and its in vivo experiment in albino rabbits for the treatment of bacterial endophthalmitis was an innovative approach that has shown promise and may potentially serve as a viable alternative in clinical practice., (© 2024. The Author(s).)

Aim: Analyze antibiotic susceptibility in the Endophthalmitis Management Study (EMS) and compare it with the current intravitreal antibiotic practice trend of members of the Vitreoretinal Society of India (VRSI) practicing in India., Methods: The microbiology work-up of undiluted vitreous included microscopy, culture-susceptibility, polymerase chain reaction (PCR), and next-generation sequencing (NGS). VRSI members were invited to the survey. The EMS conventional culture-susceptibility (PCR and NGS excluded) results were compared vis-a-vis gram-positive cocci (GPC), gram-negative bacilli (GNB), and less commonly used antibiotics with the current recommended intravitreal antibiotics. p < 0.05 was considered significant., Results: Culture and positivity (culture + PCR/NGS) positivity was 28.8% and 56.1%, respectively. GPC was most susceptible to cefazolin, linezolid, and vancomycin; GNB was most susceptible to amikacin, ceftazidime, colistin, and imipenem. There was no susceptibility difference between cefazolin and vancomycin (p = 0.999) and between ceftazidime and imipenem (p = 1.0). Colistin was superior to ceftazidime (p = 0.047) against GNB. The GNB resistant to amikacin (n = 14) were equally susceptible to ceftazidime and colistin; resistant to ceftazidime (n = 16) were susceptible to colistin; and resistant to colistin (n = 7) were susceptible to ceftazidime. The preference of VRSI members (n = 231) practicing in India was a vancomycin-ceftazidime combination (82%), vancomycin for GPC (94%), ceftazidime for GNB (61%), and voriconazole for fungi (74%)., Conclusion: In EMS, GPC had good susceptibility to vancomycin; GNB had good susceptibility to ceftazidime and colistin. Given the lower resistance of colistin, a vancomycin-colistin combination could be an alternative empiric treatment in post-cataract endophthalmitis in India., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Endogenous bacterial endophthalmitis (EE) is an intraocular infection with a poor prognosis. Timely diagnosis and prompt treatment are crucial to prevent vision loss. In this communication, we describe a case of EE caused by Streptococcus pyogenes (Group A Streptococcus [GAS]) in an HIV-positive patient with poorly controlled type 2 diabetes mellitus (DM). A 60-year-old man with a history of HIV and poorly controlled type 2 diabetes, presented with progressive blurry vision, left eye pain, redness, and headache. EE was diagnosed based on the clinical presentation and gram stain analysis of blood culture. Treatment with vitreous tap, intravitreal, topical antibiotics, and systemic antibiotics significantly improved the patient's symptoms. The case highlights the rarity of GAS as a causative agent of EE, particularly in patients with risk factors such as HIV infection and DM., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Fungal endophthalmitis is an intraocular infection that rarely develops in immunocompetent individuals., Case: A 35-year-old healthy, immunocompetent male presented with a 1-week history of pain and redness in the left eye. Visual acuity was 20/50. Dilated fundus examination revealed focal chorioretinitis in the posterior pole with associated vitritis, suspicious for a fungal etiology. He was started empirically on oral voriconazole and valacyclovir. A comprehensive systemic workup returned negative. Inflammation worsened and a diagnostic vitrectomy was performed which revealed Candida dubliniensis . The dose of oral voriconazole was increased, and intravitreal voriconazole and amphotericin B injections were added for refractory disease. Treatment response was gauged by fungal pillar height on optical coherence tomography. Eight months of oral voriconazole and 68 intravitreal antifungal injections were required to achieve complete regression and a final visual acuity of 20/20., Conclusion: Candida dubliniensis endophthalmitis can affect immunocompetent individuals and require a prolonged treatment course.

Background: Fungus endophthalmitis is a rare and serious infection that is treated with systemic and topical antifungal drugs. There is no clear consensus on the treatment of fungal endophthalmitis with intravitreal injections (IVIs) of voriconazole. This systematic review aims to summarize the literature on IVIs of voriconazole for fungal endophthalmitis. Methods: We conducted a systematic review of the literature to determine the effectiveness and safety of IVIs of voriconazole in the treatment of fungal endophthalmitis. We searched databases such as PubMed and Embase using the following search terms "Endophthalmitis" AND "Intravitreal Injections" AND "Voriconazole" with date limits of January 1, 1900, to December 31, 2022. We included all reports on humans, which described clinical outcomes of IVIs of voriconazole in the treatment of fungal endophthalmitis, including randomized controlled trials (RCTs) and case series. A descriptive synthesis of the data was conducted with a pooling of data for interventions. Results: One RCT and 21 retrospective studies were analyzed in this review. In these reports, a wide range of heterogeneous treatment regimens was used, including IVI in combination with other drugs, systemic therapy in combination with other agents, and surgery. Combined with other treatments, intravitreal voriconazole results in a favorable anatomical and clinical cure that was well tolerated. Conclusions: Reports on IVIs of voriconazole for fungal endophthalmitis demonstrate a heterogeneous approach to treatment. Of these, IVIs of voriconazole in anatomical and clinical outcomes appeared to be highly effective, although more data on its safety are needed.

Infective endophthalmitis is an ophthalmic infection that in severe cases can cause complete loss of vision. In children, the defense against infection is low and eye tissue is not fully developed, leading to increased vulnerability to endophthalmitis. Children may be unable to understand the symptoms; thus, developing a method for prevention and treatment of this disease in children is important. Therefore, we analyzed the clinical and pathogenic characteristics of infectious endophthalmitis in children and provided evidence for clinical treatment. The clinical data of 78 children (78 eyes) with infectious endophthalmitis were retrospectively analyzed. The clinical characteristics, pathogen distribution, drug sensitivity, clinical medication, and treatments were summarized and analyzed. In total, 74 (94.87%) had ocular infections caused by trauma and 75 (96.15%) were from rural townships. A total of 108 sterile specimens were examined, with a positive detection rate of 37.04%. The sensitivity rates of Gram-positive cocci and bacilli to vancomycin were 100%. The sensitivity rates of Gram-negative bacilli to ceftazidime, piperacillin/tazobactam, amikacin, gentamicin, ciprofloxacin, and levofloxacin were 100%. Of the 78 patients, 53 (67.95%) received intravitreal injection and 54 (69.23%) underwent vitrectomy. Trauma is the main factor leading to infectious endophthalmitis in children, wherein Gram-positive bacteria are the most common pathogens. Thus, a timely understanding of the pathogen and drug sensitivity is needed. Intravitreal injection and vitrectomy are effective treatments., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: To evaluate factors that inform systemic antifungal choices in patients with endogenous fungal endophthalmitis (EFE)., Design: Single-institution retrospective case series., Methods: Charts of EFE patients from 2010 to 2023 were reviewed. Patients treated systemically for EFE with a minimum of 14 days of follow-up were included. Outcome measures included time to improvement in vitritis or chorioretinitis, systemic therapy modification, and need for surgical intervention., Results: A total of 20 eyes of 16 patients were included. Candida species were most common (43.8%), followed by culture-negative EFE (37.5%) and Aspergillus species (18.8%). In all, 90% of eyes had vitritis and/or macula-involving chorioretinitis. The majority of Candida infections (60%) or culture-negative EFE (75%) were treated initially with oral antifungals. Patients with a history of immune compromise, positive fungal culture, or positive Fungitell assay were more likely to be treated with early intravenous (IV) antifungal therapy. Two patients required systemic antifungal therapy modification because of worsening chorioretinitis, in 1 case due to voriconazole-resistant Aspergillosis that demonstrated chorioretinal lesion growth despite intravitreal amphotericin B injections and systemic voriconazole, and in the second case due to worsening chorioretinitis from Candida dubliniensis infection that regressed upon switch from oral to IV fluconazole., Conclusions: Initial systemic treatment decisions in patients with EFE were driven by systemic culture positivity, systemic symptoms, or comorbidities. Intravitreal antifungal therapy may be insufficient to arrest progression of chorioretinal lesions in some cases. Larger studies are needed to determine whether visible end-organ damage in the form of chorioretinitis may be useful for guiding systemic therapy changes., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To investigate the factors associated with treatment outcomes of postcataract surgery fungal endophthalmitis outbreaks related to contaminated viscoelastics., Design: Retrospective analysis of clinical data from multiple institutions., Subjects: This study included 228 eyes of 210 patients who were diagnosed with postcataract surgery fungal endophthalmitis related to the use of viscoelastic material (Unial, Unimed Pharmaceutical Inc); they were followed up for 6 months after the diagnosis., Methods: Clinical features and causative species were identified and treatment outcomes were analyzed in patients who underwent 6 months of follow-up. Propensity score matching was conducted to elucidate the impact of vitrectomy timing and intraocular lens (IOL) removal on treatment outcomes., Main Outcome Measures: Clinical factors and selection of treatment modalities associated with treatment outcomes at 6 months., Results: Baseline visual acuity (P < 0.01), age (P = 0.05), and the presence of corneal edema (P < 0.01) were closely associated with poor best-corrected visual acuity (BCVA) at 6 months. Patients who underwent immediate vitrectomy after diagnosis showed significantly better BCVA at 6 months (mean logarithm of minimum angle of resolution 0.26 ± 0.43 vs. 0.52 ± 0.52, P = 0.03) and greater degree of visual improvement (mean -0.17 ± 0.37 improvement vs. 0.10 ± 0.57 deterioration, P = 0.03) than those who underwent deferred vitrectomy. Patients who underwent IOL removal during vitrectomy required a lower number of intravitreal antifungal agent injections (mean 8.9 ± 9.1 vs. 16.7 ± 12.2, P < 0.01) and showed a lower incidence of repeated vitrectomy (20% vs. 82%, P < 0.01) than in those without IOL removal., Conclusions: In postcataract fungal endophthalmitis, prompt vitrectomy at the time of diagnosis resulted in better treatment outcomes, and IOL removal reduced the treatment burden. Prompt and aggressive surgical intervention should be considered for postcataract fungal endophthalmitis., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the use of a subtenon's vancomycin injection for the treatment of subretinal abscess secondary to methicillin-resistant Staphylococcus aureus endogenous endophthalmitis., Methods: A 17-year-old man developed endogenous endophthalmitis with subretinal abscess in his right eye secondary to methicillin-resistant Staphylococcus aureus bacteremia from axillary necrotizing fasciitis. Despite prompt treatment with IV vancomycin and an intravitreal vancomycin injection, the patient displayed minimal improvement. The patient was subsequently treated with a subtenon's vancomycin injection. The injection technique is described in detail, as well as a review of the treatment options available for bacterial subretinal abscesses., Results: On presentation, examination revealed minimal vitritis and a large yellow subretinal abscess superotemporally extending close to the macula with subretinal fluid inferotemporally involving the macula. Four days postintravitreal vancomycin injection, the abscess remained stable and the patient developed an exudative detachment temporally. Vancomycin was injected superotemporally in the subtenon's space with no complications during the procedure or during his postoperative recovery. At seven days postinjection, the subretinal abscess and exudative retinal detachment resolved completely with necrosis at the area of previous abscess., Conclusion: We present the first successful case of subtenon's vancomycin injection for the treatment of bacterial subretinal abscess. Our case demonstrates that subtenon's injection of antibiotics is a safe and effective nonsurgical management option for bacterial subretinal abscesses.

Introduction: Endogenous endophthalmitis (EE) is a severe intraocular infection due to hematogenous spread of bacteria from an extraocular site. Recognition of the primary source of hematogenous spread of bacteria is essential to establish an adequate therapy and avoid other major complications. Infected cutaneous tumor has never been reported as a possible source of EE., Purpose: To describe the first case of EE due to hematogenous spread of methicillin-sensitive Staphylococcus aureus from an infected cutaneous basal cell carcinoma. Systemic antibiotic therapy and surgical excision of the cutaneous lesion were performed., Conclusion: Severe and long-standing skin infections should be considered as a rare cause of EE.

Background: Aeromonas veronii is a very rare and highly pathogenic microorganism. We investigate the clinical characteristics and significance of endogenous endophthalmitis caused by Aeromonas veronii in our patient., Case Presentation: A 30-year-old Asian women with systemic lupus erythematosus, uremia, and hypertension developed acute infectious endophthalmitis caused by Aeromonas veronii. After emergency vitrectomy and antibiotic therapy, the clinical condition worsened requiring enucleation., Conclusions: Aeromonas veronii can cause infection in the human eye, which can manifest as acute endophthalmitis. Early diagnosis and targeted therapy are important for successful treatment., (© 2024. The Author(s).)

Background: Bacterial endophthalmitis is an acute progressive visual threatening disease and one of the most important causes of blindness worldwide. Current treatments are unsatisfactory due to the emergence of drug-resistant bacteria and the formation of biofilm., Purpose: The aim of our research was to construct a novel nano-delivery system with better antimicrobial and antibiofilm effects., Methods: This study developed a novel antibiotic nanoparticle delivery system (MXF@UiO-UBI-PEGTK), which is composed of (i) moxifloxacin (MXF)-loaded UiO-66 nanoparticle as the core, (ii) bacteria-targeting peptide ubiquicidin (UBI 29-41 ) immobilized on UiO-66, and (iii) ROS-responsive poly (ethylene glycol)-thioketal (PEG-TK) as the surface shell. Then the important properties of the newly developed delivery system, including biocompatibility, toxicity, release percentage, thermal stability, ability of targeting bacteria, and synergistic antibacterial effects on bacterial biofilms and endophthalmitis, were evaluated., Results: In vitro, MXF@UiO-UBI-PEGTK exhibited significant antibiotic effects including the excellent antibiofilm property against Staphylococcus aureus, Pseudomonas aeruginosa , and methicillin-resistant Staphylococcus aureus at high levels of ROS. Moreover, MXF@UiO-UBI-PEGTK demonstrated outstanding efficacy in treating bacterial endophthalmitis in vivo., Conclusion: This novel nanoparticle delivery system with ROS-responsive and bacteria-targeted properties promotes the precise and effective release of drugs and has significant potential for clinical application of treating bacterial endophthalmitis., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 Yu et al.)

Purpose: To present three cases of acute endophthalmitis following intravitreal sustained-release dexamethasone (Ozurdex) with atypical presentation and to discuss the management of these patients., Methods: A retrospective case series of three patients with endophthalmitis following intravitreal sustained-release dexamethasone (Ozurdex) implantation who presented between July 2020 and August 2020., Results: Two of three patients who were treated with topical steroid and antibiotic therapy alone showed favorable outcomes and were managed without the need for intravitreal antibiotics or implant removal. One patient who showed initial response to topical therapy subsequently required pars plana vitrectomy, implant removal, and a single empirical dose of intravitreal antibiotics and antifungal agent due to persistent inflammation., Conclusion: Postintravitreal Ozurdex endophthalmitis, although a rare entity, can present with atypical features of a painless white eye and a delayed onset intraocular inflammation. Although all cases of endophthalmitis should be treated as infective until proven otherwise, it is fair to consider a trial of conservative treatment with topical steroids and antibiotics initially with close monitoring. In cases with poor response to topical therapy, pars planar vitrectomy and implant removal should be strongly considered., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Opthalmic Communications Society, Inc.)

Polyvinyl pyrrolidone or povidone-iodine (PVP-I) is a water-soluble complex formed by the combination of iodine and a water-soluble polymer, polyvinyl pyrrolidone. This complex exerts bactericidal, fungicidal, and virucidal action by gradually releasing free iodine at the site of application to react with pathogens. In ophthalmology, PVP-I is used as a disinfectant and antiseptic agent for preoperative preparation of the skin and mucous membranes and for treating contaminated wounds. PVP-I has been shown to reduce effectively the risk of endophthalmitis in various ocular procedures, including cataract surgery and intravitreal injections; however, it has also been used in the treatment of conjunctivitis, keratitis, and endophthalmitis, with promising results especially in low-resource situations. PVP-I has been associated with complications such as postoperative eye pain, persistent corneal epithelial defects, ocular inflammation, and an attendant risk of keratitis. In cases of poor PVP-I tolerance, applying PVP-I at lower concentrations or using alternative antiseptics such as chlorhexidine should be considered. We provide an update on the efficacy of PVP-I in the prophylaxis and treatment of conjunctivitis, keratitis, and endophthalmitis and a comprehensive analysis of the current literature regarding the use of PVP-I in the management of these ocular conditions. Also, PVP-I-related adverse effects and toxicities and its alternatives are discussed. The goal is to present a thorough evaluation of the available evidence and to offer practical recommendations for clinicians regarding the therapeutic usage of PVP-I in ophthalmology., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To review the risk of endophthalmitis in same-day bilateral anti-VEGF injections., Methods: We searched 12 literature databases for studies on the risk of endophthalmitis after same-day bilateral intravitreal anti-VEGF injections. Data extraction was made independently by two authors and discussed afterward until reaching consensus., Results: Seventeen studies were included with a total of 138,478 intravitreal anti-VEGF injections (69,239 bilateral injections sessions) given in at least 7579 patients. In total, 33 cases of endophthalmitis had occurred, and no cases were bilateral. The incidence of endophthalmitis ranged from 0 to 0.53% per intravitreal injection across studies., Conclusions: We suggest that clinicians can consider same-day treatment of both eyes of patients in need of bilateral intravitreal anti-VEGF injection therapy, but larger studies are needed to quantify the exact risk of endophthalmitis., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To report two cases of syphilis masquerading as chronic refractory macular diseases., Case Descriptions: Two patients had been diagnosed with neovascular age-related macular degeneration (neovascular AMD) and diabetic macular edema (DME), respectively. The disease worsened despite repeated intravitreal injections of anti-vascular endothelial growth factor (VEGF) and also surgical treatment (in suspected case of DME). Systemic evaluations were positive for syphilis. Intravenous penicillin was started, and the macular diseases improved. The lesions were well controlled afterward., Conclusions: The current two cases demonstrated that ocular syphilis can masquerade as refractory chronic retinal diseases such as DME and neovascular AMD. Laboratory evaluations for syphilis may be needed, not only for uveitis but also for refractory retinal diseases. Indocyanine green angiography may be helpful to reveal occult syphilis., (© 2024. The Author(s).)

Purpose: Although pivotal trials have demonstrated efficacy of anti-vascular endothelial growth factor therapy in neovascular age-related macular degeneration, there is a paucity of clinical data about the long-term (>5 years) treatment., Methods: Retrospective analysis of all patients with neovascular age-related macular degeneration who were actively treated, had received >40 anti-vascular endothelial growth factor injections, and were followed for ≥5 years. Snellen-corrected visual acuity, initial drug choice, and times elapsed between treatments were collected. Rates of endophthalmitis and outcomes of submacular hemorrhage were also evaluated., Results: A total of 88 patients (162 eyes) met the inclusion criteria: the average patient age was 86.3 years with an average follow-up period of 7.6 years. The average total number of injections per eye was 69 (18.0 SD); a total of 11,208 injections were given throughout the study period, and 6 cases (0.05%) of endophthalmitis were observed. Overall, there was a clinical and statistical difference in average Snellen-corrected visual acuity at Injections #2,#3, #4, #5, #6, #10, and #20, as compared with baseline ( P = 0.03, P < 0.01, P = 0.02, P < 0.01, P = 0.01, P = 0.01, P < 0.01, respectively). Patients in the Snellen-corrected visual acuity subgroup 20/20 to 20/40 maintained vision until injection #30. Seven eyes experienced a visually significant submacular hemorrhage., Conclusion: This neovascular age-related macular degeneration cohort received on average eight anti-vascular endothelial growth factor injections per year for approximately 8 years; eyes with good (≥20/40) initial baseline vision maintained their visual acuity, whereas those with worse Snellen-corrected visual acuity (≤20/50) had a robust initial improvement that diminished with time. Most patients were maintained on the same initial drug of choice and the rate of endophthalmitis was low.

In this meta-analysis, we aim to compare the efficacy and safety of pars plana vitrectomy (PPV) versus tap-and-inject (TAI) of intravitreal antibiotics for the management of endophthalmitis secondary to intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents. A systematic literature search was conducted on Ovid MEDLINE, EMBASE, and Cochrane Central (January 2005-October 2022). The primary analysis compared initial PPV versus TAI and the secondary analysis examined the efficacy and safety of TAI alone compared to TAI followed by PPV. The quality of non-randomized observational studies was assessed using the Newcastle-Ottawa Scale. The quality of the evidence was assessed for each outcome. A random effects meta-analysis was performed. Weighted mean differences (WMDs) with 95% confidence intervals were reported. Of the 7474 screened studies, nine studies reporting on 153 eyes were included. The change in mean best corrected visual acuity (BCVA) between endophthalmitis presentation and last follow-up did not significantly differ between the initial TAI versus PPV groups (WMD = 0.05 units; 95% CI -0.12 to 0.22; p = 0.59; heterogeneity p = 0.41). The difference in pre- to post-treatment mean BCVA did not significantly differ between eyes that received TAI alone or TAI followed by PPV (WMD = 0.04 units; 95% CI -0.42 to 0.51; p = 0.85; heterogeneity p = 0.74). While the meta-analysis revealed no significant difference in the change in BCVA between PPV and TAI to treat endophthalmitis secondary to anti-VEGF agents, the quality of evidence was low with potential for confounding and selection bias. Further well-designed studies in this setting are needed., (© 2023 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Competing Interests: Competing interests: None declared.

Purpose: The purpose of this study was to describe a case of endogenous endophthalmitis (EE) after severe COVID-19 disease, review patient outcomes with EE after COVID-19 infection, and review evidence regarding risk factors for developing EE., Methods: This is a review of health records, imaging, intravitreal injection, and pars plana vitrectomy for bilateral fungal EE after severe COVID-19 disease, and is a literature review on outcomes in EE after COVID-19 disease., Results: Sixty-three year-old man with diabetes and hypertension was admitted to hospital for severe COVID-19 disease for 3 months. His stay required intensive care unit admission, intubation, high-dose corticosteroids, tocilizumab, and was complicated by bacteremia, empyema, and fungal esophagitis. He developed floaters and bilateral vision loss (visual acuity 20/40 in the right eye, counting fingers in the left eye) with vitritis 2.5 months into his stay that did not respond to intravitreal voriconazole. Pars plana vitrectomy was performed for both eyes, resulting in visual acuity of 20/40 in the right eye, 20/30 in the left eye. Vitreous cultures were positive for Candida albicans . Endogenous endophthalmitis after COVID-19 disease has been reported in 22 patients to date, and outcomes are poor, with 40%+ of eyes legally blind (20/200 or worse). Although influenced by availability of imaging modalities and degree of training of the evaluating physician, misdiagnosis can affect ¼ of cases, delaying treatment. Age, male sex, and diabetes increase the risk of severe COVID-19, which requires prolonged hospitalization, invasive catheterization, and immunosuppression, which in turn increases the risk of nosocomial infection., Conclusion: Low threshold for suspecting EE in patients presenting with floaters and decreased vision after severe COVID-19 disease is necessary to ensure prompt recognition and treatment.

Purpose: To investigate if inflammation score (IS), calculated from the cornea, anterior chamber, iris, and vitreous, indicates endophthalmitis severity., Methods: In a prospective study, consecutive adults with a clinical diagnosis of post-cataract endophthalmitis within 6 weeks of surgery were recruited. Patients were allocated to IS-based primary treatment (IS < 10: intravitreal injection and IS ≥ 10: vitrectomy) and randomized to two intravitreal antibiotics combinations (vancomycin + ceftazidime and vancomycin + imipenem). Undiluted vitreous microbiology work-up included culture susceptibility, polymerase chain reaction, Sanger sequencing, and targeted next-generation sequencing., Results: The average age of 175 people was 63.4 ± 10.7 years and included 52.6% small incision cataract surgery and 47.4% phacoemulsification surgery. Severe endophthalmitis (IS ≥ 20), diagnosed in 27.4% of people, had a shorter time to symptoms (average 5.4 vs 8.7 days; P = 0.018), poorer presenting vision (all ≤ hand motion), higher culture positivity (50% vs 30.7%; P = 0.032), and higher Gram-negative bacterial infection (70.8% vs 46.2%; P = 0.042). For IS ≥ 20 discriminant and Gram-negative infection, Spearman's coefficient was 0.7 [P < 0.0001, 95% confidence interval (CI) 0.59-0.82], with an area under the receiver operating characteristic curve of 0.9 (95% CI 0.85-0.94, P < 0.0001), a Youden index J of 0.74, a sensitivity of 87.2%, and a specificity of 87.5%. The final vision of >20/400 and >20/100 was regained in 50.2% and 29.1% of people, respectively. The susceptibility of common Gram-positive cocci and Gram-negative bacilli was the highest for vancomycin (95.0%) and colistin (88.6%), respectively. NGS detected polymicrobial infection in 88.5% of culture-negative endophthalmitis., Conclusions: Higher inflammation scores indicated severe disease and Gram-negative infection in post-cataract endophthalmitis., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Background: Where routine prophylactic antibiotics have been adopted following cataract surgery, rates of endophthalmitis have been decreasing. Intracameral and topical antibiotics are currently used to prevent endophthalmitis after cataract surgery. When applying topical antibiotics, there are different recommendations on the frequency and duration of therapy. The development of bacterial resistance to the excessive and long-term use of antibiotics is a growing problem worldwide. The goal is to achieve a good antibiotic effect with the shortest possible use of antibiotics., Objective: The aim of this study was to compare the effectiveness of a new combination therapy of dexamethasone and levofloxacin for seven days after cataract surgery with the previous regimen of dexamethasone, neomycin sulfate, and polymyxin B, which was given for 21 days., Methods: A retrospective analysis of medical records and administered a questionnaire was conducted to assess the effectiveness of postoperative therapy in our cataract surgery patients. The study involved 52 patients who underwent surgery within the last year, performed by a single surgeon at our institution. The findings can help us improve the quality of care we provide and optimize our patients' overall quality of life., Results: We conducted an in-depth study on 52 individuals who underwent cataract surgery at our institution. The prescribed therapeutic regimen for the participants included administering Ducressa solution four times daily for the first seven days and Maxidex solution three times daily for the subsequent 14 days. The study found that none of the participants experienced complications after surgery, and all found it easy to instill the medication. The prescribed regimen effectively managed the postoperative recovery of the participants, and the medication was well-tolerated., Conclusion: Our research found that a new combination of levofloxacin and dexamethasone, when used topically, may require a shorter treatment period, reducing the risk of antibiotic resistance and providing a safe alternative for endophthalmitis prevention., Competing Interests: None declared., (© 2024 Tomislav Kuzman, Ivana Gabric, Ana Meter, Ivan Skegro, Sanja Masnec, Miro Kalauz, Ana Pupic-Bakrac.)

Background: To report a case of endophthalmitis in a silicone oil (SO)-filled eye associated with Staphylococcus cohnii. After vitrectomy, the environment for bacterial growth in the eye is removed, and SO has antibacterial effect on a variety of microorganisms. Endophthalmitis is seen in about 0.040% cases after pars plana vitrectomy and is even more uncommon in cases where SO is used., Methods: The patient was diagnosed as endophthalmitis and admitted to our hospital for emergency. The main concern is if intraocular infection can be controlled and the visual prognosis. In this case, multiple intravitreal antibiotics injection and anterior chamber washout were performed. Not only that, phacoemulsification was performed., Results: Hypopyon became less after 3 operations were performed. The infection was under control finally., Conclusion: To the best of our knowledge, it is the first report of S. cohnii endophthalmitis in an SO-filled globe of an middle-aged patient. It is important to treat infective endophthalmitis with antibiotics promptly. Delayed therapy may affect the visual prognosis., Competing Interests: The author has no conflicts of interest to declare., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: To describe a series of post-coronavirus disease 2019 (COVID-19) endogenous endophthalmitis (EE) patients from a multispecialty tertiary hospital in North India., Methods: A retrospective chart review including all consecutive cases with EE following confirmed COVID-19 disease from July 2020 to June 2021., Results: Seven eyes of four patients (three female and one male) were included. Two patients had confirmed bilateral fungal (Aspergillus sp.) EE and two patients had presumed fungal EE (one bilateral and one unilateral). Three of these four patients received systemic steroids as part of COVID-19 treatment previously. Five eyes were managed with initial intravitreal injection (IVI), followed by pars plana vitrectomy (PPV), and two eyes were managed with only IVI. All patients received systemic antifungal agents. Intraocular inflammation resolved in all eyes with treatment. One patient of EE also developed voriconazole-induced transient visual hallucination, which resolved on discontinuing the medication., Conclusion: This case series represents a series of EE cases following COVID-19 disease or its sequelae or as a result of prior treatment for COVID-19. Ophthalmologists and physicians must be vigilant about these complications and initiate prompt management at the earliest., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Klebsiella pneumoniae bacteremia is known to present a virulent clinical course, including multiple metastatic infections, which is not uncommon in Asia. However, there are limited data on the incidence and risk factors for ocular involvement in K. pneumoniae bacteremia. We retrospectively reviewed the medical records of all patients with K. pneumoniae bacteremia who underwent ophthalmologic examination in a tertiary center in Seoul, Korea, from February 2012 to December 2020. Two retinal specialists reviewed the findings of the ophthalmologic examinations and classified them as endophthalmitis, chorioretinitis, and no ocular involvement. Of 689 patients, 56 [8.1%; 95% confidence interval (CI) 6.2-10.4] had ocular involvement, and 9 (1.3%; 95% CI 0.6-2.5) were diagnosed with endophthalmitis. Of 47 patients with chorioretinitis, 45 (95.7%) improved with systemic antibiotic therapy alone. Community-onset bacteremia (100% vs 62.1% vs 57.4%, P = 0.04), cryptogenic liver abscess (55.6% vs 11.8% vs 8.5%, P = 0.003), and metastatic infection (66.7% vs 5.8% vs 10.6%, P < 0.001) were more common in endophthalmitis than in no ocular involvement or chorioretinitis. In the multivariable analysis, cryptogenic liver abscess [adjusted odds ratio (aOR), 6.63; 95% CI 1.44-35.20] and metastatic infection (aOR, 17.52; 95% CI 3.69-96.93) were independent risk factors for endophthalmitis. Endophthalmitis was not associated with 30-day mortality. Endophthalmitis is rare in Asian patients with K. pneumoniae bacteremia. Targeted ophthalmologic examination in those with cryptogenic liver abscess, metastatic infection, or ocular symptoms may be more appropriate than routine examination of all patients., Competing Interests: The authors declare no conflict of interest.

Background: Endophthalmitis following intravitreal injection is a potentially devastating complication of anti-VEGF injections. Post-injection endophthalmitis due to Enterococcus faecalis is rare, and no previous case of Morganella morganii endophthalmitis after intravitreal injection has been reported., Case Presentation: We present the first reported case of Morganella morganii and Enterococcus faecalis endophthalmitis after intravitreal injection in an immunocompetent patient in the absence of recent ocular surgery. Our patient presented with hand movement visual acuity one day after anti-VEGF injection and demonstrated no clinical improvement despite repeated intravitreal ceftazidime and vancomycin injections. A decision was made to proceed with early vitrectomy given failure of intravitreal antibiotics. Visual acuity improved to 6/90 at 12 weeks after vitrectomy without any evidence of disease recurrence., Conclusions: Post-injection endophthalmitis due to concurrent Morganella morganii and Enterococcus faecalis infections can have visually devastating consequences despite repeated empirical and targeted intravitreal antibiotics. Lack of clinical improvement following intravitreal antibiotics should warrant consideration of early vitrectomy. Our experience is a pertinent reminder of the ever-growing threat of uncommon and multi-resistant bacteria that must be considered when treating infections such as post-injection endophthalmitis., (© 2023. Crown.)

Purpose: To compare features of endogenous endophthalmitis associated with injection drug use (IDU) to endogenous endophthalmitis from other etiologies., Methods: The authors retrospectively collected data on patients with endogenous endophthalmitis due to IDU or other causes from three academic tertiary care centers over a six-year period. Differences in presenting characteristics, culture results, treatment, and visual acuity were compared between groups., Results: Thirty-eight patients (34%) had IDU-associated endogenous endophthalmitis while 75 patients (67%) had endogenous endophthalmitis from other causes. Compared with patients in the non-IDU group, IDU patients were significantly younger, more frequently male, had longer duration of symptoms at diagnosis, and were less likely to have bilateral disease ( P < 0.05 for all). Injection drug use patients were less likely to have a systemic infection source identified (29% vs. 71%, P < 0.001) or have positive cultures (47% vs. 80%, P < 0.001). The IDU group was less likely to be admitted to the hospital (71% vs. 92%, P = 0.005) and less likely to receive treatment with intravenous antimicrobials (55% vs. 83%, P = 0.003). Visual acuity did not significantly differ between groups., Conclusion: Endophthalmitis related to IDU presents in younger patients with less comorbidities and frequently without positive cultures or an identifiable systemic source; therefore, a high index of suspicion is needed to identify this disease.

Importance: Since bilateral simultaneous postoperative endophthalmitis (BSPOE) after immediate sequential bilateral cataract surgery (ISBCS) can be devastating for the patient, evaluating such cases in depth is important to maintaining patient safety., Objective: To evaluate whether a systemic breach of sterility was associated with an outbreak of BSPOE after ISBCSs performed on the same day at a single community-based eye clinic., Design, Setting, and Participants: This retrospective case series included all patients diagnosed with BSPOE at ophthalmology departments in Denmark following an infectious outbreak after ISBCSs performed at a single community-based eye clinic in December 2022., Exposure: Bilateral simultaneous postoperative endophthalmitis acquired after ISBCS., Main Outcome and Measures: Patient recovery from BSPOE after ISBCS was evaluated based on clinical and microbiological reports., Results: A woman aged 71 years, a man aged 84 years, and a woman aged 79 years consecutively presented with symptoms of endophthalmitis at regional eye departments 4 to 8 days after ISBCS performed on the same date at the same eye clinic. Five of 6 infected eyes underwent vitrectomy, and all eyes received an intravitreous injection of antibiotics. The same strain of Staphylococcus epidermidis was isolated in 4 of 5 eyes that underwent vitrectomy. Contamination of viscoelastics was ruled out with repeated cultures. One eye was eviscerated due to phthisis. In another patient, the final visual acuity of the eye most severely affected was 20/63 Snellen equivalents. Visual acuity of the remaining eyes recovered to 20/25 (3 eyes in 2 patients) and 20/20 (1 eye) Snellen equivalents., Conclusions and Relevance: The finding of the same strain of S epidermidis in all patient cultures suggests a systemic breach of sterility at the clinic on the day of ISBCS. The outcome of these cases emphasizes the need to adhere to a strict surgical methodology and sterile principles during ISBCS.

Infectious endophthalmitis is a severe intraocular infection caused by bacteria, or less commonly by fungi. It can occur after penetrating eye procedures, trauma, or the spread of infection from contiguous structures or via emboli from distant organs. Because of the time-critical nature of the treatment, endophthalmitis is treated with the clinical diagnosis and modified by the microbiological report of the intraocular contents. The current strategy for managing endophthalmitis relies on pre-clinical literature, case series, and one large multi-center randomized clinical trial on post-cataract surgery endophthalmitis. Culture-susceptibility of the microorganisms from undiluted vitreous guides the definitive treatment in non-responsive cases. Strategies to reduce the incidence of endophthalmitis after penetrating eye procedures have been developed concurrently with refined means of treatment. Despite these advances, outcomes remain poor for many patients. Although consensus articles have been published on managing endophthalmitis, treatment patterns vary, and controversies remain. These include (1) the use of newer methods for early and precise microbiological diagnosis; (2) the choice of intravitreal antibiotics; (3) the need for systemic therapy; (4) early and complete vitrectomy. Here, we review the current consensus and address controversies in diagnosing and managing endophthalmitis. This review is intended to familiarize physicians and ophthalmologists with different aspects of endophthalmitis management to make informed decisions., (Copyright © 2023 Elsevier Ltd. All rights reserved.)