Treatment of Bilateral Endogenous Aspergillus Endophthalmitis with Multiple Intravitreal Voriconazole Injections with Good Visual Outcome

Endogenous endophthalmitis caused by <i>Aspergillus</i> species tends to be very aggressive, often leading to devastating visual outcomes. Historically, intravitreal amphotericin injections have played a central role in management, but with variable visual outcomes and a risk of toxicity. Limited reports suggest that use of intravitreal voriconazole is a safe and efficacious alternative, though these cases were treated with only few intravitreal injections. Here, we report a case of bilateral endogenous <i>Aspergillus</i> endophthalmitis treated with 8 intravitreal voriconazole injections in the right eye and 11 in the left eye with good best-corrected final visual outcome (20/50 right eye and 20/40 left eye).

A Case of Chorioretinitis with Retinal Angiomatous Proliferation

A 48-year-old woman had an acute blurred vision in the right eye immediately after drainage of liver abscess. Her best corrected visual acuity (BCVA) was 8/400; fundus photography suggested the diagnosis of endogenous endophthalmitis with chorioretinitis and vitritis. Due to the bad systemic condition, a systemic antibiotic combined with periocular triamcinolone (TA) was carried out first. Inflammatory cells in the vitreous cavity were decreased after treatment; however, fundus fluorescein angiography (FFA) showed abnormal dilation and leakage of the capillaries and retinal-choroidal anastomose, supporting that there was retinal angiomatous proliferation (RAP). Vitreous interleukin-6 (IL-6) was only slightly elevated; the ratio of interleukin-10 (IL-10) and IL-6 was less than 1, and the etiological test was negative. After receiving intravitreal vancomycin injection combined with periocular TA injection, the patient’s BCVA was improved from 16/400 to 20/400 with a reduction in vitreous inflammatory cells. However, the patient’s RAP was progressed and her BCVA was dramatically decreased to count finger/30 cm. After intravitreal injection of ranibizumab, the patient’s BCVA was 5/400 with a significant shrink in lesions and absorption of hemorrhage, exudation, and fluid. Thus, we suggest that early anti-inflammatory treatment in conjunction with anti-VEGF may achieve a better prognosis in patients with inflammatory retinal angiomatous proliferation (RAP).

Endogenous Endophthalmitis in COVID-19 Patients

Intrinsic endophthalmitis is indeed behavior that causes eye disease that spreads into the bloodstream from a distant primary site. The intraocular disease caused by hematogenous microbial proliferation is known as indigenous endophthalmitis. Extrinsic and intrinsic endophthalmitis are the two types of endophthalmitis that exist. The presence of an external point of entry is linked to extrinsic endophthalmitis. Intrinsic endophthalmitis is a kind of septicemia caused by a blood-borne infection. Endophthalmitis is a disease of all the inner coating of the eyeball except the sclera and cornea, which is accompanied by substantial, increasing vitreous swelling. Endophthalmitis is a severe ocular crisis with severe visual and general consequences. An exterior injury of the entrance, such as injury, operation, or an inflamed cornea, is the most prevalent route of entry for potential pathogens. Endophthalmitis has a complex etiology, with many pathogenic species and substantial regional heterogeneity. The treatment of endophthalmitis has evolved dramatically during the last century. Endophthalmitis induced by direct inoculation dissemination of pathogenic microbes is a rare occurrence that occurs most commonly in sick or disadvantaged people. Intravenous medication usage, diabetes mellitus, immunological impairment, cancer, prolonged hospitalization, or systemic antibiotic therapy have all been linked to a 0.04 percent incidence rate. Haden described metastatic endophthalmitis in a seriously sick patient with pneumococcal cerebrospinal encephalopathy treated with intravenously anti-meningococcal serum in the 1918 volume of the Journal Ophthalmology. Endogenous endophthalmitis, unlike extrinsic endophthalmitis, needs comprehensive systemic antibiotic treatment. In indigenous endophthalmitis, the illness originates not in the eye but elsewhere in the body. As a result, it is necessary to obtain comprehensive cultures. Patients are sometimes unable to carry out their functions in society or household. As a rest, the person cannot cope financially and socially in his environment. Many social and influential factors are disturbed, and the patients are often depressed. Cosmetically the surgeries are not satisfying. Artificial prosthetics can be used, but they're seldom of minimum functional importance. Such interventions can be helpful for the patient. The focus should be made to deliberately save the patients and not just the cosmetic value of the surgery. Persons with chronic endophthalmitis had more excellent eyesight than people with symptomatic or subacute endophthalmitis. Improvements in eyesight were observed in individuals with persistent or subacute keratitis several months after the surgery more frequently than in people with symptomatic endophthalmitis. Nevertheless, in 40 percent of the overall all instances with an abrupt start, there have been no improvements or even decrease in visual acuity.

A painful red eye in an intravenous drug abuser: When not everything is what it seems

Introduction Endogenous endophthalmitis is a rare but devastating ocular infection, resulting from microbial seeding of the eye during bacteremia or fungemia. Among other sources of septicemia, intravenous drug abuse is a significant risk factor, and endogenous endophthalmitis should always be thought of in any patient with a history of injectable drug use, presenting with a painful vision loss and a red inflamed eye. Case Description We report the case of a 47-year-old male, with a history of injectable drug consumption, who presented to our emergency department complaining of a painful red eye and recent deterioration of visual acuity. After the first clinical hypothesis of endogenous endophthalmitis being considered, the final diagnosis of Human Leukocyte Antigen (HLA) B27-associated acute anterior uveitis was established. Conclusion Ocular inflammation is one of the most challenging fields in all ophthalmology. Several inflammatory disorders, ranging from a wide variety of infectious and non-infectious conditions, can present themselves with the same clinical signs and symptoms, making their diagnosis extremely defiant.

Ocular Sporotrichosis

Sporotrichosis is a subacute or chronic mycosis predominant in tropical and subtropical regions. It is an infection of subcutaneous tissue caused by Sporothrix fungus species, but occasionally resulting in an extracutaneous condition, including osteoarticular, pulmonary, nervous central system, and ocular disease. Cases of ocular sporotrichosis are rare, but reports have been increasing in recent decades. Ocular infections usually occur in hyperendemic areas of sporotrichosis. For its classification, anatomic criteria are used. The clinical presentation is the infection in the ocular adnexal and intraocular infection. Ocular adnexa infections include palpebral, conjunctivitis, and infections of the lacrimal sac. Intraocular infection includes exogenous or endogenous endophthalmitis. Most infections in the ocular adnexal have been reported in Brazil, China and Peru, and intraocular infections are limited to the USA and Brazil. Diagnosis is performed from Sporothrix isolation in the mycological examination from ocular or skin samples. Both sporotrichosis in the ocular adnexa and intraocular infection can mimic several infectious and non-infectious medical conditions. Ocular adnexa infections are treated with potassium iodide and itraconazole. The intraocular infection is treated with amphotericin B. This review describes the clinical findings and epidemiological, diagnosis, and treatment of ocular sporotrichosis.

269. A Review of Gram Negative Endogenous Endophthalmitis at University Hospital in Newark

Background Endophthalmitis (EO) is an ocular emergency characterized by intraocular inflammation, usually in response to infection. While most cases are exogenous, gram negative (GN) EO account for 10-24% of all cases, and endogenous EO (EEO) account for 2-8% of all cases. Risk factors for EEO include diabetes mellitus (DM), IV drug use, and indwelling catheters. Major sources of infection are urinary tract infections (UTI), liver abscesses, pneumonia, and bacteremia. Common pathogens include K. pneumoniae, P. aeruginosa, and H. influenzae. Outcomes are poor, with only 20% of patients achieving improved visual acuity, and 30-40% requiring enucleation. Methods Retrospective analysis was performed on patients diagnosed with EO (n=89) at University Hospital in Newark from January 2016 to December 2020 using ICD-10 codes H44.0-H44.009, H44.1, and H44.19. Patients included were 18 years of age or older with culture proven GN endogenous EO (GNEEO) (n=7). Outcomes included anatomical success, functional success, and mortality at 28 days and 3 months. Results 7 of 89 patients met criteria for GNEEO (median age 67, 4 males, 71.4% Hispanic/Latino). Comorbidities included hepatobiliary disease (57.1%) and DM (42.9%). All 7 patients presented with ocular symptoms and 3 had non-ocular symptoms. Primary sources of infection included UTI, prostate abscess, and pneumonia/empyema. Eye cultures identified Pseudomonas in 4 patients and Klebsiella in 3 patients. Mean antibiotic length was 17.7 days with 6 patients receiving intravitreal antibiotics. Enucleation was performed in 3 patients. 2 patients had functional success and 4 had anatomical success, with 0 mortality at 28 days and 3 months. Table 1. Ocular symptoms on presentation of cases of gram negative endogenous endophthalmitis Table 2. Positives cultures obtained from cases of gram negative endogenous endophthalmitis Conclusion Although rare, GNEEO causes significant morbidity, with only 2 recovering visual acuity and 3 requiring enucleation. Risk factors, sources of infection, and microbes were all consistent with those in previous reports. Hepatobiliary disease and DM were the most prominent risk factors while sources of infection included UTI and empyema. Eye cultures were positive for K. pneumoniae and P. aeruginosa, two common pathogens previously identified. This case series highlights the importance of prompt recognition and initial treatment of GNEEO with empiric coverage that includes vancomycin and ceftazidime. Disclosures All Authors: No reported disclosures