Chavakij Bhoomibunchoo

Infectious endophthalmitis: review of 420 cases

Background To characterize the causative pathogens and the visual outcomes among patients with endophthalmitis at a large referral center in northeastern Thailand. Methods All cases of infectious endophthalmitis treated between 1983 and 2007 were reviewed retrospectively. The patient data – including age, sex, history of ocular injuries, previous treatment and duration of the symptoms – were recorded. The ocular examination included affected side, anterior chamber reaction, vitreous haze, and presence of intraocular foreign bodies. Smears and cultures were prepared from anterior chamber paracentesis and/or vitreous tapping. Intraocular antibiotics were administered at the time of anterior chamber paracentesis and/or vitreous tapping. Vitrectomy and/or lensectomy were performed when indicated. Initial visual acuity before treatment and the final best-corrected vision were compared. Results A total of 420 cases of endophthalmitis were reviewed: 181 cases (43.1%) had ocular trauma before the infection; 135 (32.2%) developed endophthalmitis after intraocular surgery; and, 122 (29.1%) had a positive culture. Bacteria were isolated in 114 cases (93.4%) and fungi were noted in eight (6.6%). The common causative bacterium was Staphylococcus epidermidis. Combined vitrectomy and intraocular antibiotics were performed in 189 cases (45.0%), whereas 69 cases (16.4%) were treated with intraocular antibiotics alone. Conclusion Most of the reviewed cases were associated with trauma and intraocular surgery. The most frequently encountered bacterium causing infectious endophthalmitis was S. epidermidis. Most cases were treated with combined vitrectomy and intraocular antibiotics. The final visual outcomes seem to vary according to the type of endophthalmitis.

Blood culture bottles are superior to conventional media for vitreous culture.

To compare blood culture bottles and conventional media for the vitreous culture in patients with clinically suspected infectious endophthalmitis.

Comparing smartphone camera adapters in imaging post-operative cataract patients.

Introduction The goal of this study is to compare image quality and clinical confidence for managing post-operative cataract patients based on anterior segment smartphone images obtained in real-world settings using four types of adapters: (a) macro lens (ML), (b) ML with augmented light-emitting diode (LED) illumination (ML-LED), (c) no adapter (NA) and (d) slit lamp (SL) adapter. Methods Anterior segment images were obtained from 190 eyes after cataract surgery using an eight-megapixel iPhone 6 smartphone camera with four adapters: ML, ML-LED, NA, and SL. Smartphone images were subjectively rated by ophthalmologists as acceptable or not acceptable for: (a) image quality for evaluating the anterior segment structures and (b) reader confidence in clinically managing post-operative patients based on smartphone images. Results NA, ML-LED, and SL had the highest scores for image quality with 100%, 93.7%, and 86.3% judged as acceptable, respectively. NA, SL, and ML-LED were also rated highest in clinical confidence with 100%, 98%, and 93.2% having acceptable levels, respectively. ML was judged lowest in both image quality (61.1% acceptable) and clinical confidence (37.4% acceptable). Discussion This study represents the first effort to compare different smartphone camera adapters’ ability to image the anterior segment of the eye in a real-world setting. Our study shows that ML-LED, NA, and SL adapters were acceptable for visualizing anterior segment structures to physician readers in 86–100% of cases. When coupled with visual acuity, intro-ocular pressure and history, these images can result in acceptable clinical confidence in 93–100% of cases.

Macular sensitivity after half-dose verteporfin photodynamic therapy in central serous chorioretinopathy

Objective To study the macular sensitivity after half-dose verteporfin photodynamic therapy in patients with resolved central serous chorioretinopathy using the automated static perimeter. Methods Prospective consecutive case study of 24 patients with resolved central serous chorioretinopathy was performed. The macular sensitivity was measured using a conventional automated static perimeter with the Swedish interactive threshold algorithm 10-2 and foveal threshold. Best corrected visual acuity, intraocular pressure, fundus examination, macular thickness, and volume were also examined. The mean macular sensitivities of the affected eyes and their normal fellow eyes were calculated and compared. P<0.05 was considered statistically significant. Results The mean macular sensitivities of the affected eyes were lower than the normal fellow eyes with a statistically significant difference in all areas of the study (P<0.05). Best corrected visual acuity improved significantly from pretreatment (0.26±0.3 logMAR) to posttreatment (0.075±0.15 logMAR, P<0.05). Macular thicknesses in affected eyes were 230.66±67.34 μm and in the normal eyes were 238.33±92.26 μm (P=0.68). Macular volumes in affected eyes were 8.77±0.49 and in the normal eyes were 8.70±0.50 (P=0.60). These findings were not statistically significant. Conclusion Eyes with resolved central serous chorioretinopathy after half-dose verteporfin photodynamic therapy had lower macular sensitivity than normal fellow eyes. These findings agreed well with the previous microperimetric studies. The conventional automated static perimeter can also be used when a microperimeter is not available.

Effect of Eyelid Margin Cleaning on Conjunctival and Eyelid Bacterial Flora Before Intraocular Surgery

ABSTRACT Purpose: To compare the bacterial cultures of the lower eyelid margins and lower fornices between ocular irrigations with and without eyelid margin cleaning before intraocular surgery. Methods: A prospective study was carried out that included 102 eyes from 51 patients undergoing intraocular surgery between December 2016 and April 2017. In each patient, the surgical eye (control group) only received ocular irrigation and the opposite eye (study group) received ocular irrigation with eyelid margin cleaning. Normal saline solution was used in all procedures. In each group, samples from the lower eyelid margins and lower fornices were cultured before and after cleaning. Povidone iodine and antibiotic eye drops were instilled after specimen collection. Results: The most common bacterial isolate of all groups was Staphylococcus spp. There were no statistically significant differences of positive cultures between the control and study groups in either lower eyelid margins (Odds ratio [OR], 2.19; 95% CI, 0.84–5.72) nor lower fornices (OR, 0.93; 95% CI, 0.43–2.00). In addition, there were no statistically significant differences of positive cultures between before and after eyelid cleanings from both lower eyelid margins (OR, 2.74; 95% CI, 0.53–14.24) and lower fornices (OR, 0.73; 95% CI, 0.21–2.57). Conclusions: Eyelid margin cleaning with normal saline solution immediately before intraocular surgery did not help to decrease microbial loading on the ocular surfaces. The rate of bacterial contamination, however, was not increased which could be due to not performing eyelid compression.

Predictive factors in the treatment of streptococcal endophthalmitis

Objective To evaluate visual outcomes and possible predictive factors in the treatment of infectious endophthalmitis caused by Streptococcus species during 2012–2016 at a large referral eye center in northeastern Thailand. Methods A retrospective medical record chart review of patients with culture-positive endophthalmitis caused by Streptococcus species was conducted. Demographic data including age, gender, occupation, duration of symptoms, time to surgery, surgical procedures, initial visual acuity at presentation, and final visual acuity after treatment were collected and analyzed. Possible predictive factors associated with improved visual outcomes were also studied. Results Forty-five eyes of 45 patients were recruited for the study. The 3 most common types of endophthalmitis were postoperative (35.56%), posttraumatic (20%), and endogenous (15.56%). At presentation, most patients (95.56%) had visual acuity of hand motion (55.56%), light perception (28.89%), or no light perception (11.11%). The 3 most common isolates were Streptococcus pneumoniae (44.44%), Group B β-hemolytic Streptococcus (26.68%), and Streptococcus viridans (20%). Most patients (62.22%) were treated with surgical interventions, either pars plana vitrectomy with intravitreal antibiotics or pars plana vitrectomy with intravitreal antibiotics and silicone oil tamponade. After treatment, improved visual outcome was noted in only 9 patients (20%), and no visual improvement was seen in 36 patients (80%). Evisceration and enucleation were performed in 15 patients (33.33%). The only possible predictive factor associated with improved visual outcomes was early vitrectomy, performed within 3 days. Conclusion Streptococcal endophthalmitis is often associated with poor visual prognosis. Only 9 patients (20%) had improved vision after treatment. The only possible predictive factor associated with improved visual outcomes was vitrectomy within 3 days. Early diagnosis and early vitrectomy are therefore recommended.

Factors affecting visual outcomes after treatment of infectious endophthalmitis in northeastern Thailand

Objective To determine factors affecting visual outcomes after treatment of infectious endophthalmitis during 2012–2016 at a large referral eye center in northeastern Thailand. Patients and methods Medical charts of patients with a diagnosis of infectious endophthalmitis including demographic data, types of endophthalmitis, causative organisms, methods of treatment, anatomical, and functional outcomes were retrospectively reviewed. Factors associated with improved visual outcomes were analyzed. Results Four hundred and eleven patients (417 eyes) were recruited for the study. The three most common types were post-traumatic (44.53%), post-operative (31.87%), and endogenous endophthalmitis (17.52%). Vitreous cultures revealed causative organisms in 41.25%. Most common Gram-positive organisms were coagulase-negative Staphylococcus 30% (36/120), Bacillus spp. 20% (24/120), and Streptococcus pneumoniae 18.33% (20/120). Most common Gram-negatives were Pseudomonas spp. 24.32% (9/37), Klebsiella spp. 24.32% (9/37), and Enterobacter spp. 16.21% (6/37). Methods of treatment were medical treatment (18.71%) and surgical treatment (81.29%), including pars plana vitrectomy with or without silicone oil tamponade (62.59%) and destructive surgery (18.71%). After treatment, visual improvement was noted in 44.6%, stable vision in 18.47%, and worse vision in 36.93%. Factors associated with improved visual outcomes were post-operative endophthalmitis (P<0.001), coagulase-negative Staphylococcus (P=0.003), and initial visual acuity before treatment of hand motion or better (P=0.017). Conclusion Most infectious endophthalmitis patients were post-traumatic, post-operative, and endogenous. The most common method of treatment was pars plana vitrectomy. Treatment could improve visual outcomes and at least stabilize the vision in 63.07%. Factors associated with improved visual outcomes were types of endophthalmitis, causative organisms, and initial visual acuity before treatment.

Successful treatment of Chrysosporium keratitis with voriconazole

Objective To report a patient with severe Chrysosporium keratitis successfully treated by voriconazole. Method Case report. Results A 37-year-old healthy male presented with irritation, pain and reduced vision in his left eye after mud contamination. Examination demonstrated corneal stromal infiltration, endothelial plaque and hypopyon. Corneal scrapings demonstrated numerous septate hyphae, and specimen cultures were positive for Chrysosporium sp. The lesion did not respond to aggressive topical 5% natamycin, 0.15% topical amphotericin B and oral itraconazole. The patient was then treated by topical 1% voriconazole every hour. Intracameral and intrastromal voriconazole injections (50 μg/0.1 mL) were also undertaken. The keratitis was significantly improved after voriconazole. Conclusion To the best of the authors’ knowledge, this is the first report on the use of voriconazole for Chrysosporium keratitis. Voriconazole may be an effective alternative to conventional antifungal agents in some cases of fungal keratitis. It should be considered before shifting to therapeutic keratoplasty.

Idiopathic polypoidal choroidal vasculopathy in Thai patients with clinical and angiographic choroidal neovascularization

Objective This study aimed to study the prevalence and characteristics of idiopathic polypoidal choroidal vasculopathy (IPCV) in Thai patients with clinical and angiographic choroidal neovascularization (CNV). Patients and methods A consecutive case study of 140 patients presenting with CNV was conducted in nine large referral eye centers throughout Thailand. The demographic data, fundus photographs, fundus fluorescein angiography and indocyanine green angiography of the patients were analyzed. Results Of 129 patients with clinical and angiographic CNV, IPCV was diagnosed in 100 patients (77.52%), idiopathic CNVs in 16 patients (12.40%) and age-related macular degeneration (AMD) in 12 patients (9.30%). Of the 107 eyes with IPCV, 90 eyes (84.11%) had both branching venous networks (BVNs) and polypoidal lesions. Most IPCV patients (93%) had unilateral involvement and were at a younger age than AMD patients. In all, 79 eyes (73.83%) had lesions found in the macular area, 14 eyes (13.08%) in the temporal to vascular arcades, ten eyes (9.35%) in the peripapillary area and four eyes (3.74%) in both macular and peripapillary areas. The clinical manifestations of IPCV at presentation were categorized into two patterns. There were 95 eyes (88.79%) of a hemorrhagic pattern and 12 eyes (11.21%) of an exudative pattern. Conclusion IPCV is the most common macular disease in Thai patients with CNV. Most IPCVs have both BVNs and polypoidal lesions located in the macular area and present with a hemorrhagic pattern.

Incidence of and risk factors for chloroquine and hydroxychloroquine retinopathy in Thai rheumatologic patients

Objective To study the incidences of and risk factors for chloroquine (CQ) and hydroxychloroquine (HCQ) retinopathy in Thai rheumatologic patients. Methods A retrospective cohort study of 234 rheumatologic patients receiving either CQ or HCQ was conducted. Patients were divided based on whether or not they developed retinopathy as retinopathy-positive or negative groups. Medical records giving details regarding age, gender, body weight, underlying diseases, daily doses, and cumulative doses of CQ or HCQ were reviewed. CQ and HCQ retinopathy were diagnosed by indirect ophthalmoscopy, Humphrey visual field test, and optical coherence tomography. The main outcome measures were incidences and risk factors of CQ and HCQ retinopathy. Results The CQ retinopathy was detected in 14 of 173 patients (8.09%) who received CQ for 139–2,033 days, cumulative doses from 14.3 to 325.1 g, and daily doses from 0.8 to 18.5 mg/kg/d. Their ages ranged from 27 to 65 years. When compared to the CQ retinopathy-negative group, only age, body weight, and cumulative dose showed statistically significant differences. The HCQ retinopathy-positive group was comprised of 2 of 61 patients (3.28%) who received HCQ for 660–828 days, cumulative doses from 80 to 130 g, and daily dose from 1.9 to 4.4 mg/kg/d. Their ages were 36 and 39 years. Compared to the HCQ retinopathy-negative group, there were no statistically significant differences in studied risk factors. Conclusion Incidences of and risk factors for CQ and HCQ retinopathy were reported. Since most patients developed retinopathy earlier than 5 years, it is suggested that patients taking long-term CQ or HCQ should undergo ophthalmologic screening annually after the baseline examination.