Vivek Pravin Dave

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.

Endophthalmitis following pars plana vitrectomy: a literature review of incidence, causative organisms, and treatment outcomes.

Endophthalmitis following pars plana vitrectomy is a very uncommon cause of endophthalmitis. Cases reported over the last decade show a decrease in incidence over time. To optimize visual outcome, early diagnosis and treatment are essential. In this review we report a summary of the incidence of endophthalmitis following vitrectomy, various risk factors for their occurrence, the microbiological profile and the visual outcomes post treatment.

Efficacy of anti-vascular endothelial growth factor therapy in subretinal neovascularization secondary to macular telangiectasia type 2.

Purpose: To evaluate the efficacy of intravitreal anti–vascular endothelial growth factor monotherapy in the treatment of naive subretinal neovascular membrane (SRNVM) secondary to macular telangiectasia (Mactel) Type 2. Methods: A retrospective chart review of consecutive patients with naive SRNVM secondary to Mactel who were examined between January 2007 and April 2011 was performed. Eyes with diabetic retinopathy, age-related macular degeneration, or any other macular pathology were excluded. Demographic data, medical history, and ocular history were recorded. The mean change in best-corrected visual acuity at the final visit was the primary outcome measure. The mean number of intravitreal injections, retinal thickness on optical coherence tomography, and intraocular pressure were the secondary outcomes. Results: A total of 16 eyes of 16 patients were included in the study. Of 16 eyes, 4 were treated with intravitreal ranibizumab monotherapy and 12 with intravitreal bevacizumab monotherapy. The average follow-up duration was 12 months (range, 3–43 months). The mean baseline visual acuity was 0.17 ± 0.16 (Snellen equivalent 20/120) (range, 0.001–0.5), and the mean final visual acuity was 0.27 ± 0.14 (Snellen equivalent 20/70) (range, 0.05–0.66), and this difference was statistically significant (P = 0.02). The mean number of intravitreal injections was 1.9 (range, 1–3), and there were no injection-related complications. Conclusion: Intravitreal anti–vascular endothelial growth factor monotherapy appears to be effective and safe in treatment-naive SRNVM secondary to Mactel.

Pharmacokinetics of intravitreal antibiotics in endophthalmitis

Intravitreal antibiotics are the mainstay of treatment in the management of infectious endophthalmitis. Basic knowledge of the commonly used intravitreal antibiotics, which includes their pharmacokinetics, half-life, duration of action and clearance, is essential for elimination of intraocular infection without any iatrogenic adverse effect to the ocular tissue. Various drugs have been studied over the past century to achieve this goal. We performed a comprehensive review of the antibiotics which have been used for intravitreal route and the pharmacokinetic factors influencing the drug delivery and safety profile of these antibiotics. Using online resources like PubMed and Google Scholar, articles were reviewed. The articles were confined to the English language only. We present a broad overview of pharmacokinetic concepts fundamental for use of intravitreal antibiotics in endophthalmitis along with a tabulated compendium of the intravitreal antibiotics using available literature. Recent advances for increasing bioavailability of antibiotics to the posterior segment with the development of controlled drug delivery devices are also described.

Endophthalmitis and concurrent or delayed-onset rhegmatogenous retinal detachment managed with pars plana vitrectomy, intravitreal antibiotics, and silicone oil

BACKGROUND AND OBJECTIVE The current study describes the treatment outcomes in patients with endophthalmitis and concurrent or delayed-onset retinal detachment managed with pars plana vitrectomy, intravitreal antibiotics, and silicone oil. PATIENTS AND METHODS In this noncomparative, retrospective case series, the medical records of patients diagnosed with endophthalmitis and retinal detachment from January 1991 through December 2014 at a tertiary eye care center in South India were reviewed. All patients received silicone oil for the management of retinal detachment either concurrently or during follow-up treatment. RESULTS A total of 93 patients were included in the current study. Retinal detachment was diagnosed at presentation in 20 of 93 patients (21.5%) (concurrent group: Group 1) and during follow-up in the remaining 73 of 93 patients (78.5%) (delayed-onset group: Group 2). In Group 1, the initial treatment consisted of vitrectomy, intravitreal antibiotics, and silicone oil injection in 19 of 20 patients. In Group 2, patients did not receive silicone oil during initial treatment but underwent silicone oil injection during subsequent surgery for repair of retinal detachment. Rates of complete retinal reattachment and visual acuity of 20/400 or better were 73.7% and 30.0%, respectively, in Group 1 and 98.5% and 39.7%, respectively, in Group 2. The median visual acuity at last follow-up in 44 eyes undergoing silicone oil removal was 20/100 (logMAR 0.7), whereas in the remaining 49 eyes that did not undergo silicone oil removal, median visual acuity was 20/2000 (logMAR 2.0). CONCLUSION In these patients with endophthalmitis with concurrent or delayed-onset retinal detachment, the use of silicone oil can be a useful adjunct. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:546-551.].

DIFFUSE CHOROIDAL HEMANGIOMA MASQUERADING AS CENTRAL SEROUS CHORIORETINOPATHY TREATED WITH ORAL PROPRANOLOL.

PURPOSE To describe a case of diffuse choroidal hemangioma with exudative retinal detachment treated successfully with oral propranolol. METHODS Single interventional case report of a 14-year-old boy, known case of Sturge-Weber syndrome, presented with decreased vision in the right eye since 2 months. Presenting vision was finger-counting at 3 m. Examination revealed a neurosensory detachment at the macula clinically appearing like central serous chorioretinopathy. Fundus fluorescein angiogram, B-scan ultrasound, and optical coherence tomography were consistent with an underlying diffuse choroidal hemangioma with secondary exudative macular detachment. The patient could not afford radiotherapy and thus was treated with oral propranolol. RESULTS Serial clinical examinations and optical coherence tomographies showed gradual resolution of the subretinal fluid. Vision at the last visit 4 months after treatment was 6/9 best corrected. CONCLUSION Choroidal hemangioma can be mistaken clinically to be central serous chorioretinopathy. Oral propranolol is an effective and economical treatment option in patients not affording other standard modalities of treatment.

CLINICAL PRESENTATIONS AND OUTCOMES OF RHEGMATOGENOUS RETINAL DETACHMENT IN RETINITIS PIGMENTOSA.

Purpose: To describe the clinical presentations and outcomes of rhegmatogenous retinal detachments (RRD) in eyes with retinitis pigmentosa. Methods: A retrospective review of all patients of retinitis pigmentosa with RRD from January 1990 to December 2013 at a tertiary eye care institute. Results: Of total 28,622 patients of retinitis pigmentosa over a 23-year period, 17 eyes of 17 patients had RRD. Mean age at presentation was 34.53 ± 16.42 years (median 32 years). Median duration of decreased vision attributed to RRD was 6 months. Ten eyes (59%) had cataract and 3 eyes (18%) had history of cataract surgery. Thirteen eyes (76%) had inferior retinal detachment; 9 eyes (53%) had lattice with retinal holes; and 8 eyes (47%) had atrophic retinal holes. There were no horse-shoe tears, giant retinal tears, dialysis, and macular holes related RRD. Majority (82%) of retinal breaks were in the inferotemporal quadrant. Only 3 eyes (18%) had proliferative vitreoretinopathy at presentation. Twelve eyes at presentation had best-corrected visual acuity <20/200 and 6 eyes had only light perception. The macula was involved by the detachment in all cases. Mean preoperative visual acuity was 1.4 ± 0.88 logarithm of the minimum angle of resolution (median 1.3, range 3–0.1; 20/502). Surgery was not advised in 6 eyes (35% patients); 5 eyes (30%) underwent scleral buckling and 6 eyes (35%) underwent vitrectomy. Median follow-up was 5 months. Reattachment rate at last follow-up was 91% (15 eyes). Mean postoperative best-corrected visual acuity recorded was 1.06 ± 0.8 (median 1, range 3–0.1; 20/229) (P = 0.15). Eight eyes at last visit had best-corrected visual acuity <20/200. Of the 11 eyes operated, 4 improved in vision and 7 retained the preoperative vision. Conclusion: The incidence of RRD in retinitis pigmentosa is very low. Presentation, although delayed, is at a younger age. Horse-shoe tears and proliferative vitreoretinopathy are uncommon; cataract is a common coexisting pathology. Surgical reattachment rates appear high and recurrent RRD is uncommon. However, visual gain is limited by the underlying retinal degenerative condition.

Optical coherence tomographic angiography in type 1 idiopathic macular telangiectasia: OCT-angiography in idiopathic macular telangiectasia Pappuru, Peguda and Dave

Optical coherence tomographic angiography (OCTA) is a novel non-invasive imaging modality, which uses motion contrast imaging to high-resolution volumetric blood flow information and thus instantly generates angiographic images. Splitspectrum amplitude-decorrelation angiography (SSADA) is an algorithm used in OCTA that detects motion in blood vessels by the variation in reflected OCT signal amplitude between consecutive crosssection scans. The novelty of SSADA lies in how the OCT signal is processed to enhance flow detection and reject axial bulk motion noise. Specifically, the algorithm splits the OCT image into narrow spectral bands, thereby increasing the number of cross-sectional image frames that could be used to compute variation (decorrelation) in the speckle pattern caused by the motion of blood cells. Each spectral band provides different speckle contrast from the interference of blood cells and surrounding structures and therefore, independent information on speckle variance due to blood flow. Averaging the decorrelation values from multiple spectral bands enhances the flow signal and creates the final image. In comparison, fundus fluorescein angiography (FFA) is an invasive modality for studying retinal pathology. It also has hazards associated with Figure 1. Fundus photograph showing hard exudates and cystic macula in a case of type 1 idiopathic macular telangiectasia

Clinical presentations, risk factors and outcomes of ceftazidime-resistant Gram-negative endophthalmitis

To describe the clinical features and outcomes of patients diagnosed with ceftazidime‐resistant Gram‐negative endophthalmitis and the role of intravitreal imipenem in these cases.

Comparison of clinico-microbiological profile and treatment outcome of in-house and referred post cataract surgery endophthalmitis in a tertiary care center in South India

BackgroundThe purpose of the study is to compare the clinico-microbiological profile and treatment outcome of in-house vs referred cases of post cataract surgery endophthalmitis in a tertiary eye care facility in South India.MethodsThe clinical records of 50 culture-positive cases each of in-house (group A) and referred (group B) post cataract surgery endophthalmitis were analyzed. The management protocol was similar in both groups.ResultsThe time to report to the institute was longer in group B (group B 13.63 [±11.67; 95% CI, 9.95–17.31] days; group A 6.83 [±7.61; 95% CI, 4.57–9.09] days; P = 0.002). The average inflammatory scores in presentation were comparable (group A 17.85 ± 5.83; group B 18.18 ± 7.35; P = 0.243). The final visual outcome was clinically superior in group A (≥20/200-group A 60.42% and group B 44%, P = 0.11; ≤20/400-group A 37.5% and group B 52%, P = 0.62), but statistically not significant. There were more gram-positive organisms in group A (62% vs 38%; P = 0.027) and more gram-negative organisms in group B (52% vs 24%; P = 0.007). Gram-positive bacteria were mostly sensitive to vancomycin (95.24% to 96.67%), but gram-negative bacteria were partly sensitive to ceftazidime (58.33% to 64%).ConclusionsOne could suspect gram-negative infection more often in the referred cases of endophthalmitis. While vancomycin could continue to be the antibiotic of choice in gram-positive bacteria, specific antibiotic following due sensitivity for gram-negative bacteria should replace the empiric use of ceftazidime.