Annie Mathai

Clinical and microbiologic review of culture-proven endophthalmitis caused by multidrug-resistant bacteria in patients seen at a tertiary eye care center in southern India.

Purpose: To determine the type of bacteria and the visual outcome of culture-proven multidrug-resistant bacterial endophthalmitis in patients at a tertiary eye care center in southern India. Methods: This is a retrospective case series in which clinical and microbiologic records of culture-proven bacterial endophthalmitis between January 2000 and December 2007 were reviewed. Multidrug resistance was defined as resistance to two or more different groups of typically susceptible classes of antibiotics. Results: Of 807 patients, vitreous from 42 patients (5.2%) yielded multidrug-resistant bacteria in culture. Thirty-two (71%) of these patients had a poor visual outcome (31.6% in non–multidrug-resistant group). Multidrug resistance was more common in gram-negative bacteria (33; 78.6%) compared with gram-positive bacteria (9; 21.4%). Pseudomonas spp. (24 isolates) were the most common isolated bacteria. Fifteen (45%) of the 33 gram-negative isolates were resistant to ceftazidime, 18 (54.5%) were resistant to amikacin, and 11 (33.3%) were resistant to both amikacin and ceftazidime. Five (55.56%) of the 9 gram-positive isolates were resistant to vancomycin. Conclusion: Gram-negative bacteria, chiefly Pseudomonas, are the most common multidrug-resistant organisms, and the outcome is usually poor. Emergence of multidrug-resistant bacteria is a matter of concern. A new alternative group of drugs may be considered for the management of these isolated cases.

SHORT-TERM SAFETY PROFILE OF INTRAVITREAL ZIV-AFLIBERCEPT.

Aim: To evaluate the safety of intravitreal ziv-aflibercept (Zaltrap) in the treatment choroidal neovascularization secondary to age-related macular degeneration. Methods: Eligible eyes with choroidal neovascularization secondary to age-related macular degeneration each received a single intravitreal injection of ziv-aflibercept. Comprehensive ophthalmic examinations and detailed systemic evaluations were performed at baseline and Days 1, 7, and 30 after injection, and International Society for Clinical Electrophysiology of Vision standard electroretinography was performed at baseline and Day 30. Primary outcome measures were safety parameters that included signs of clinical and electroretinographic toxicity. Secondary outcome measures included changes in best-corrected visual acuity and central subfield thickness. Results: Twelve eyes of 12 patients were treated. None of the patients complained of blurred vision, ocular pain, or bulbar injection at any of the follow-up visits, nor was intraocular inflammation noted. There were no significant differences in implicit times, “a” and “b” wave amplitudes, or b/a ratios at 1 month when compared with baseline (P = 0.4). None of the patients experienced serious ocular or systemic adverse events. Mean best-corrected visual acuity improved only slightly at 30 days (LogMAR 0.45 ± 0.31 [Snellen equivalent: 20/60]) compared with baseline (LogMAR 0.37 ± 0.24 [Snellen equivalent: 20/50]; P = 0.51). Conclusion: Single intravitreal injections of ziv-aflibercept into eyes with neovascular age-related macular degeneration appear to be safe through 1 month. Ziv-aflibercept could become a safe, low-cost therapy for macular diseases in developing countries and in those where intravitreal aflibercept (Eylea) is not available.

Vancomycin-resistant Gram-positive bacterial endophthalmitis: epidemiology, treatment options, and outcomes

BackgroundThe purpose of this study is to evaluate the microbiological profile and treatment outcomes of vancomycin-resistant Gram-positive bacterial endophthalmitis. Medical records of all patients with Gram-positive bacterial endophthalmitis resistant to vancomycin presenting between 1 January 2005 and 31 December 2010 were reviewed in this noncomparative, consecutive, retrospective case series. Favorable outcome was defined as a best-corrected visual acuity of ≥20/200.ResultsOut of 682 culture-positive endophthalmitis isolates, 448/682 (65.6%) were associated with Gram-positive bacteria. In vitro resistance to vancomycin was noted in 7/448 (1.56%). Three cases were posttraumatic, three were postoperative, and one was endogenous in origin. Four Bacillus isolates, two Staphylococcus isolates, and an Enterococcus isolate were resistant. Isolates resistant to vancomycin were sensitive in vitro to ciprofloxacin in 6/7 (86%) patients. Presenting visual acuity was light perception in all seven cases. Favorable outcome was achieved in only 1/7 (14.3%) cases.ConclusionsVancomycin-resistant endophthalmitis is uncommon and usually associated with poor visual outcome. Bacillus sp. is the most frequent Gram-positive bacteria resistant to vancomycin. Fluoroquinolones like ciprofloxacin may be considered as a useful alternative in vancomycin-resistant endophthalmitis.

Comparison of Conventional Pattern and Novel Navigated Panretinal Photocoagulation in Proliferative Diabetic Retinopathy

PURPOSE To compare the laser spot quality between the conventional slit lamp pattern laser (PASCAL) and the navigated pattern laser (NAVILAS) for panretinal photocoagulation (PRP). METHODS Prospective randomized interventional trial of 73 eyes (51 patients) with high-risk proliferative diabetic retinopathy. Eyes underwent PRP using 30-ms pulse duration with either PASCAL (16 eyes) or NAVILAS laser (21 eyes), or 100-ms pulse duration with either PASCAL (16 eyes) or NAVILAS laser (20 eyes). Fundus color images of all quadrants were taken 5 minutes after treatment. Laser burn size (major and minor diameter and area) and ellipticity (ratio of minor to major axis) were analyzed across the retina. Treatment time and pain were compared between both groups. RESULTS The burn size variation in navigated laser 30 ms, 100 ms, and conventional pattern 30 ms and single-spot 100 ms laser was 22%, 24%, 21%, and 35%, respectively. The variation of the laser burn area near the arcade for NAVILAS and for PASCAL was 29% and 22%, respectively (P < 0.01). Closer to the equator, burns from the NAVILAS showed even smaller variation of 15% compared with 25% with PASCAL (P < 0.005). Laser spots from PASCAL exhibited an increasing elliptical shape toward the periphery, whereas NAVILAS laser spots tended to be more uniform all over the retina. Average treatment duration and pain experience was less with navigated laser compared with pattern laser (P ≤ 0.05). CONCLUSIONS Navigated laser treatment achieves more uniform laser burns with less pain during shorter treatment duration in comparison with conventional pattern laser.

Combined ceftazidime and amikacin resistance among Gram-negative isolates in acute-onset postoperative endophthalmitis: prevalence, antimicrobial susceptibilities, and visual acuity outcome

BackgroundThe purpose of this study is to evaluate the prevalence, antimicrobial susceptibilities, and visual acuity outcome of acute-onset postoperative Gram-negative bacterial endophthalmitis cases resistant to both ceftazidime and amikacin seen between 2005 and 2010 at L. V. Prasad Eye Institute, a tertiary care ophthalmic Centre in South India. Medical records of all patients with Gram-negative bacterial endophthalmitis resistant to both amikacin and ceftazidime between 1 January 2005 and 31 December 2010 were reviewed in this non-comparative, consecutive, retrospective case series. Favorable outcome was defined as a best-corrected visual acuity of ≥20/200.ResultsSixty five (39.6%) of 164 culture-positive postoperative endophthalmitis were caused by Gram-negative organisms. Among these 65 isolates, 32 (49%; 95% confidence interval (CI) 37% to 61%) were resistant to ceftazidime, 17 (26%; 95% CI 15% to 37%) to amikacin, and 12 (18.5%; 95% CI 9% to 27%) to both ceftazidime and amikacin. Eight Pseudomonas isolates, three Enterobacter isolates, and one Haemophilus isolate were resistant to both ceftazidime and amikacin. The isolates were sensitive to fluoroquinolones (42%) and imipenem (50%). Presenting visual acuity was light perception in 10 (83.3%) cases. A final visual acuity ≥20/200 was achieved in 5/12 (41.7%) of these patients.ConclusionIn the current study, Pseudomonas was the most common Gram-negative bacteria resistant to both amikacin and ceftazidime. The emergence of multidrug-resistant bacteria causing endophthalmitis is a matter of concern in India. Alternative antibiotics like imipenem or fluoroquinolones may be considered for the management of these resistant organisms.

An outbreak of acute post-cataract surgery Pseudomonas sp. endophthalmitis caused by contaminated hydrophilic intraocular lens solution

OBJECTIVE To report the investigation for the source of infection and the clinical course and treatment response of 11 cases of acute post-cataract surgery endophthalmitis that developed during an outbreak. DESIGN Retrospective, consecutive, interventional case series. PARTICIPANTS Eleven patients who developed acute postoperative endophthalmitis after an uneventful cataract surgery with intraocular lens implantation from September 6 to 29, 2010, at a tertiary eye care center in South India. METHODS Aqueous aspirates, vitreous aspirates, and environmental surveillance specimens were sampled. All specimens were subjected to smear and culture. Positive cultures were subjected to antibiotic susceptibility. Genotypic diversity was determined by polymerase chain reaction (PCR) with enterobacterial repetitive intergenic consensus (ERIC) primers of each strain and was used to establish the clonal relationship between clinical and environmental isolates. The clinical patterns were analyzed. MAIN OUTCOME MEASURES Positive microbiology, molecular diagnostic similarity among the culture positive endophthalmitis cases, and surveillance specimens. RESULTS Aqueous and vitreous samples showed gram-negative bacilli in the smears of 8 of 11 eyes, and cultures grew Pseudomonas aeruginosa in 5 of 11 eyes. Among the samples from various surveillance specimens cultured, only the hydrophilic acrylic intraocular lenses and their solution grew P. aeruginosa, with antibiotic susceptibility pattern identical to the clinical isolates. The isolates from the patients and the intraocular lens solution revealed matching patterns similar to an American Type Culture Collection (ATCC) strain of P. aeruginosa on ERIC-PCR. The intraocular lenses of the same make were discontinued at our hospital, and the endophthalmitis did not recur. The final visual acuity improved to ≥ 20/50 in 8 of 11 patients (72.7%). One patient developed retinal detachment, but was treated successfully, and 2 other patients progressed to phthisis bulbi. CONCLUSIONS Positive microbiology and the ERIC-PCR results proved that contamination of hydrophilic intraocular lenses and the preservative solution was the source of infection in this outbreak. Early detection and a planned approach during the outbreak helped us to achieve good visual and anatomic outcomes, even though the offending organism was identified as P. aeruginosa.

Microbiologic spectrum and susceptibility of isolates in acute postcataract surgery endophthalmitis: are they same as they were more than a decade ago?

Endophthalmitis is a severe and vision-threatening complication of intraocular surgeries like cataract surgery. Treatment of endophthalmitis includes vitreous tap/biopsy to identify the etiologic organisms and prompt initiation of broad-spectrum intravitreal antibiotics. The choice of initial broad-spectrum antibiotics is based on the susceptibility patterns of micro-organisms in a particular region. The purpose of the current study was to investigate the spectrum of organisms causing culture-proven acute postcataract surgery endophthalmitis and their antimicrobial susceptibilities at our centre between 2006 and 2013, and to compare the results with the previously published data from the same centre.1 This was a retrospective, non-comparative, consecutive case series. Microbiology records were reviewed of all the culture-proven, acute postcataract surgery endophthalmitis cases treated at L V Prasad Eye Institute, Hyderabad, India, between January 2006 and March 2013. Bacterial isolates were identified using Analytical Profile Index (API, Bio Meriux, France). The susceptibility was determined by the Kirby–Bauer disk diffusion method. …

High-resolution genotyping of Pseudomonas aeruginosa strains linked to acute post cataract surgery endophthalmitis outbreaks in India

BackgroundInvestigation of two independent outbreaks of post cataract surgery endophthalmitis identified the reservoir of epidemic strains of P. aeruginosa.MethodsPatient isolates cultured from vitreous fluid of all the nine cases and from the peripheral devices of phacoemulsification machine were subjected to high-resolution Fluorescent Amplified Fragment Length Polymorphism (FAFLP) analysis.ResultsFAFLP based genotyping of the isolates confirmed nosocomial transmission. Although biochemical characterization and antibiotic susceptibility profiles grouped all the isolates together, FAFLP based genotyping revealed that, all the outbreak isolates were derived from 2 different strains, with independent origins. One group of isolates was traced to phacoprobe and the second one to the internal tubing system of the phacoemulsification machine used in cataract surgery. In silico analysis indicated possible evolution in both the clusters of P. aeruginosa isolates due to genetic polymorphisms. The polymorphisms were mapped to gene products (cell envelope, outer membrane proteins) possibly having significant role in pathogenesis.ConclusionThe present study is probably the first one to apply FAFLP typing successfully to investigate outbreaks of postoperative endophthalmitis (POE) in an ophthalmic setting, which was able to identify the source, and helped to make rational decisions on sterilization procedures that halted more cases of infection in these hospitals.

Stenotrophomonas maltophilia endogenous endophthalmitis: clinical presentation, sensitivity spectrum and management.

Stenotrophomonas maltophilia is gaining importance as a community-acquired pathogen, after becoming firmly established as a nosocomial pathogen. Here we report a case of endogenous endophthalmitis due to S. maltophilia. Antibiotic-susceptibility testing of the isolate was performed by the Kirby-Bauer disc diffusion method. The organism was resistant to aminoglycosides, imipenem, ticarcillin and cotrimoxazole and was sensitive to ceftazidime and chloramphenicol. The patient was successfully treated with a sensitivity-based intravitreal antibiotic regimen.

Spontaneous bilateral peripapillary, subhyaloid and vitreous hemorrhage with severe anemia secondary to idiopathic thrombocytopenic purpura.

A 42-year-old female presented to us with a complaint of sudden painless loss of vision in both eyes of three days duration. Visual acuity was 20/100 for distance in both eyes. Fundus examination showed bilateral peripapillary hemorrhages, with subhyaloid and vitreous hemorrhage in both eyes. Hematological investigations revealed hemoglobin (HB 7 gm %) and severe thrombocytopenia (12,000/ ul). She was referred to a hematologist where a diagnosis of idiopathic thrombocytopenic purpura (ITP) was made. She was treated for systemic condition with regular ophthalmic follow-up. Over the next nine months, retinal hemorrhages completely resolved and the patient regained her visual acuity. The purpose of this case report is to highlight the clinical presentation of severe anemia, which is different from previous reports and the role of an ophthalmologist in first detecting the Idiopathic thrombocytopenic purpura (ITP), which led to successful recovery.