|Year : 2009 | Volume
| Issue : 1 | Page : 20-24
Bleb-related endophthalmitis: Clinical presentation, isolates, treatment and visual outcome of culture-proven cases
Basel T Ba’arah, William E Smiddy
Department of Ophthalmology, University of Miami, Bascom Palmer Eye Institute, Miami, Florida, United States of America
Basel T Ba’arah
PO Box 2327, Amman 11181, Jordan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Purpose: To investigate clinical features, causative organisms and their antibiotic sensitivity, management, and visual acuity outcomes of eyes with bleb-related endophthalmitis (BRE).
Design: Retrospective, noncomparative, consecutive eye series.
Methods: Clinical and microbiological records of patients with culture positive bleb-related endophthalmitis treated at a single institution between April 1995 and February 2002 were revised retrospectively.
Main Outcome Measures: Final visual acuity, loss of eye and complications.
Results: There were 34 cases with presenting visual acuities ranging from 20/200 to light perception. Decrease of visual acuity was the most frequent sign (94%) followed by pain (79%) and hypopyon (53%). Associated features included pseudophakia (79%), vitreous wick (29%), and wound leak (12%). The most frequent organisms isolated from vitreous specimens, were streptococcus species (55%) and gram positive coagulase negative staphylococci (20%). Polymicrobial growth was noted in 27% of cases. The cultured organisms were sensitive to antibiotics used in 94% of cases. Treatment modality used was vitreous tap with antibiotic injection without (65%) or with vitrectomy (35%). The most common intravitreal antibiotics combination was vancomycin with ceftazidime, Intravitreal dexamethsone was administered in 56% of cases. Final visual outcome of 20/400 or better was noticed in 50% of cases without and 33% with vitrectomy, but this was not statistically significant (p=0.45). The difference in final visual acuity of cases infected by gram-positive coagulase-negative staphylococci and streptococcus species were not statistically significant (p= 0.18). Overall, final visual outcome of 20/400 or better was noticed in 47% of cases, while no light perception was recorded in 8 (24%) cases. Of no light perception cases 7 underwent evisceration or enucleation. Overall, 32% of the cases experienced other complications like retinal detachment with dislocated intraocular lens, phthisis bulbi, and epiretinal membrane formation.
Conclusion: BRE is associated with substantial visual morbidity. Prompt treatment of BRE with intravitreal vancomycin and broad spectrum antibiotics recommended while culture results are pending. Neither tap-injection with vitrectomy nor tap-injection without vitrectomy proved superior in the management of this condition.
Keywords: Bleb-related Endophthalmitis, Antibiotics, Vitrectomy
|How to cite this article:|
Ba’arah BT, Smiddy WE. Bleb-related endophthalmitis: Clinical presentation, isolates, treatment and visual outcome of culture-proven cases. Middle East Afr J Ophthalmol 2009;16:20-4
|How to cite this URL:|
Ba’arah BT, Smiddy WE. Bleb-related endophthalmitis: Clinical presentation, isolates, treatment and visual outcome of culture-proven cases. Middle East Afr J Ophthalmol [serial online] 2009 [cited 2019 Sep 15];16:20-4. Available from: http://www.meajo.org/text.asp?2009/16/1/20/48862
Bleb-related endophthalmitis (BRE) is the second most frequent (16.7%) cause of postoperative endophthalmitis after acute and chronic post-cataract surgery endophthalmitis.  It's incidence is reported to be between 0.2% to 1.3%, , and is more common with the use of antiproliferative agent (up to 3%) and even higher when the bleb is placed inferiorly (up to 9.4%). ,,, Like other forms of endophthalmitis, BRE usually presents with decreased visual acuity, redness, pain, diffuse conjunctival congestion, opalescent blebs with intense fibrin and/or hypopyon in the anterior chamber, and florid vitritis. , These signs may be influenced by different variables and factors such as time to initial treatment, causative organism, wound leak and the presence of a vitreous wick. The most commonly reported microorganisms cultured from the vitreous of eyes with BRE are staphylococcal species , and streptococcal species. , The Endophthalmitis Vitrectomy Study (EVS) compared the results of two different management approaches for post-cataract surgery endophthalmitis, but did not address BRE which has specific features that may require alterations in management. 
The purpose of the current study is to analyze the clinical features, causative organisms with their antibiotic sensitivity, management and visual acuity outcomes of eyes treated for BRE.
| Methods|| |
This study protocol was approved by the institutional review board of the University of Miami School of Medicine. Medical and microbiological records of patients with culture positive BRE treated at Bascom Palmer Eye Institute between April 1995 and February 2002 were reviewed retrospectively. Patients were included in the study if they had clinical signs of endophthalmitis, positive intraocular bacteriological culture and visual acuity of light perception or better at the initial examination.
The data recorded at clinical presentation included age, gender, best corrected visual acuity (BCVA), interval from previous surgery, timing of initial treatment, and ocular symptoms of pain, time to decrease of vision, surgical wound complication, intraocular lens style (if present), pupillary reaction, or hypopyon presence and its size.
Intraoperative data included type of procedure; vitreous tap and intravitreal injection with (tap-PPV-injection group) or without vitrectomy (tap-injection group), intravitreal, subconjunctival, systemic or topical agent used and treatment setting (outpatient vs. Inpatient).
Post-procedure data included the results of vitreous and aqueous cultures growth, sensitivity for used antibiotics, vitreous re-injection, re-operation (especially enucleation or evisceration), final BCVA, complications, and duration (if any) of inpatient stay were noted.
Cultured organisms were grouped into 5 categories including; gram-positive coagulase negative staphylococcus species, gram-positive coagulase positive staphylococcus, gram-positive streptococcus species, gram-positive bacilli, and gram-negative species.
Intravitreal agents included: vancomycin (1mg), ceftazidime (2.25mg), gentamicin (0.1mg), or decadron (0.4mg) delivered in a 0.1ml volume. Subconjunctival agents (when used) were administered in 0.5ml volume of vancomycin (50mg), ceftazidime (50mg), gentamicin (20mg), or dexamethasone (4.0mg). Systemic intravenous antibiotics (when used) included ceftazidime 1.0g Q12 hours, vancomycin 500mg Q8 hours, and oral ciprofloxacin 500mg Q 12hr. Topical antibiotics included vancomycin (50mg/ml), ceftazidime (50mg/ml), tobramycin (14mg/ml), or gentamicin (14mg/ml) and prednisolone acetate 1%.
Statistical analyses for proportional data were done with two-tailed Fisher's exact test to detect group differences.
The main outcome measures included loss of eye (enucleation or evisceration), severe loss of vision (no light perception), complications, and final BCVA > 20/400.
| Results|| |
One hundred and two cases of culture positive bacterial endophthalmitis of all types were recovered from the microbiological records including pseudophakia (51%, 52 cases), bleb-related (BRE) (34%, 35cases), trauma, and other categories (6%, 9% respectively). The 35 BRE culture positive cases constituted the cohort for the current study. One case was excluded because of no light perception vision at initial examination.
Patient characteristics at presentation are summarized in [Table 1]. BRE developed at a mean of 51.5 ± 58 months after filtration surgery (range, 0.03 -249.3). Acute or early BRE (< 2weeks) observed in 15% of cases. Decreased vision (94%) and pain (79%) were the most common symptoms. Most were pseudophakic (79%), including posterior chamber IOLs (77%) and anterior chamber IOLs 2%. Wound complications were present in 23 (68%) of cases, included fibrinous reaction (56%), vitreous wick (29%), and wound leak (12%). An afferent pupillary defect was present in 21% and a hypopyon in 53% with a mean size of 0.57±0.7mm. The initial BCVA ranged from 20/200 to light perception and was•e5/200 in 12%, between 5/200 and hand motion in 35% and hand motion in 53% of all patients.
All patients had a positive vitreous culture by inclusion criteria [Table 2].
An anterior chamber culture was obtained in 44% of cases; 67% were positive. Organisms from the anterior chamber differed from that from the vitreous in 20% of cases. Streptococcus species were the most common vitreous isolates (55%), Str. viridans and faecalis were the most frequently isolated strains, 18.2% each.
Gram-positive, coagulase negative staphylococcus (most commonly S. epidermidis) was the second most commonly isolated vitreous microorganisms (20%). Organisms recovered from A/C cultures had a similar frequency of distribution [Table 2]. Of all anterior chamber and vitreous cultures, polymicrobial growth was noted in 9 of 34 cases (27%): two organisms were isolated in eight of them and three organisms were isolated in one case. Organisms recovered from the specimens were sensitive to the administered antibiotics in 32 (94%) cases.
Initially, 12 (35%) cases underwent tap-injection with vitrectomy while the remaining 22(65%) had tap-injection alone. Later PPV was done for 11(32%) more cases, 8 of them were from the tap-injection group. Overall PPV was done in 20(59%) cases. All three cases that underwent reinjection were from the tap-injection group.
Eighteen patients (53%) were treated as inpatients with a mean stay 1.56 ± 1.9 days.
Antimicrobials and corticosteroid usage [Table 3].
Intravitreal agents used included vancomycin (100%), ceftazidime (94%) and dexamethason (56%). Subcojunctival injections were used in 21 (62%) cases and included vancomycin, ceftazidime and dexamethason (50%, 35%, and 50% respectively). Topical agents included vancomycin, ceftazidime and prednisolone acetate. Oral or intravenous antibiotics were used in14%. Systemic corticosteroids were not administered to any patient.
The final BCVA was 5/200 or better in 50% compared to 12% at initial examination (p=0.001).A final BCVA of 20/400 resulted in 16 (47%) of 34 patients. There was no light perception (NLP) in 8 (24%) patients. The 14 cases managed without PPV included 7 (50%) had visual acuity of 20/400; 4 (33%) of the 12 eyes managed with a PPV had BCVA of ≥20/400 (p= 0.45). [Table 4]. Final BCVA of 20/400 resulted in 5 (83%) gram-positive, coagulase-negative staphylococcal species cases, and 7 (47%) streptococcal species cases (P=0.18).
Inadequate response to therapy necessitated further surgery of evisceration or enucleation in 7 (21%) cases. Culture results of those cases were Gram negative organisms in three cases ( H.influenzae , Serattia marcescens and pseudomonas aeruginosa), gram positive organisms (streptococcus salivaris, sanguinis and beta-hemolytic) three cases, and both Str. mitis with S. epidermidis in one case.
At final follow up one case had dislocated intraocular lens with retinal detachment, two cases had epiretinal membranes and one case left with a phthitic eye.
| Discussion|| |
The results of this study are consistent with other reports finding BRE as the second most common form of infectious endophthalmitis, after acute and chronic post-cataract surgery Endophthalmitis.  BRE usually develop late (>1month) but in our series 15% of the cases had BRE earlier (< 2weeks). Possible reasons for an earlier onset might be a high frequency of polymicrobial growth of virulent bacteria. In addition, pseudophakia, vitreous wick, and bleb leakage have been reported as potential risk factors that may contribute in the development of BRE ,, and these factors were present in our cases (79%, 29%, and 12% respectively). As reported in cases of endophthalmitis following cataract surgery ; hypopyon present in a surprisingly low proportion (53%) and, therefore, the significance of its absence must not be overemphasized.
The study results are also consistent with previous reports that streptococcus species (55%) and coagulase negative staphylococci (20%) are the most common infecting organisms in BRE. , Our results coincide with the findings in EVS that vitreous is a richer source of positive cultures than the aqueous  . The frequency of polymicrobial growth (27%) was higher in the current study than that reported by the EVS for post-cataract surgery endophthalmitis cases (9.3%)  and may have played a role in the visual end results were NLP vision was higher (24%) in BRE cases compared to EVS (5%). A high rate of NLP vision (18%) after post-operative endophthalmitis was reported by others. 
Successful management of infectious bacterial endophthalmitis depends on timely diagnosis and prompt institution of appropriate therapy.  No single antibiotic provided coverage for all of the microbes isolated from eyes with endophthalmitis,  but cultured microorganisms were sensitive to the antibiotics used in 94% of cases in the current study. Accordingly, empiric, broad spectrum intravitreal antibiotic therapy appears to be justified without awaiting culture results. Intravenous antibiotics were uncommonly used and most were managed in outpatient setting; when admitted, the stay was brief (1.6 ± 1.9 days).
The initial treatment regimen most commonly used was vitreous tap-injection without PPV (65%). Later PPV was performed in 8 (36%) cases; meaning 59% of the studied cases underwent PPV. Busbee BG et al reported that BRE cases treated with tap-injection had significantly worse final visual acuity and higher rate of NLP vision than patients treated with tap-PPV-injection,  but in the current report the difference in final BCVA of the two groups was not statistically significant. The visual outcome of endophthalmitis cases occurring after cataract surgery has been reported to be worse with growth of streptococcal species than with growth of staphylococcal ones,  but the current study of BRE did not find a significant difference (p=0.18).
Complications are common with BRE, as 21% of cases underwent evisceration or enucleation secondary to phthisis, pain and/or poor vision (LP to NLP), and only 47% of the cases had visual acuity of 20/400 or better. The observed frequent polymicrobial growth of more virulent infecting organisms and recorded potential risk factors (pseudophakia, vitreous wick and bleb leak) may contribute in BRE clinical progression and severity that result's in poor visual outcome.
| Conclusion|| |
Despite prompt and intensive treatment of patients with BRE the end result remains disappointing. In BRE Streptococcal species are the most common causative organism. Based on culture and antibiotic susceptibility results, initial treatment of BRE with intravitreal vancomycin and broad spectrum antibiotic like ceftazidime appears to be justified until culture results are obtained. Neither tap-injection with PPV nor tap-injection without PPV proved superior in the management of this condition.
| References|| |
|1.||Kent DG.Endophthalmitis in Auckland 1983-1991. Aust N Z J Ophthalmol1993 Nov;21(4):227-236. |
|2.||Mochizuki K, Jikihara S, Ando Y, et al. Incidence of delayed onset infection after trabeculectomy with adjunctive mitomycin C or 5-fluorouracil treatment. Br J Ophthalmol 1997 Oct;81(10):877-83. |
|3.||Collignon-Brach J. Surgery for glaucoma and endophthalmitis. Bull Soc Belge Ophtalmol 1996;260:73-77. [PUBMED] |
|4.||Wolner B, Liebmann JM, Sassani JW, et al. Late bleb-related endophthalmitis after trabeculectomy with adjunctive 5-fluorouracil. Ophthalmology 1991 Jul; 98(7):1053-1060. |
|5.||DeBry PW, Perkins TW, Heatley G, et al. Incidence of late-onset bleb-related complications following trabeculectomy with mitomycin. Arch Ophthalmol 2002 Mar;120(3):297-300. |
|6.||Greenfield DS, Suner IJ, Miller MP, et al. Endophthalmitis after filtering surgery with mitomycin. Arch Ophthalmol 1996 Aug;114(8):943-949. |
|7.||Higginbotham EJ, Stevens RK, Musch DC, et al. Bleb-related endophthalmitis after trabeculectomy with mitomycin C. Ophthalmology. 1996 Apr;103(4):650-656. |
|8.||Soltau JB, Rothman RF, Budenz DL, et al. Risk factors for glaucoma filtering bleb infections. Arch Ophthalmol 2000 Mar;118(3):338-342. |
|9.||Ayyala RS, Bellows AR, Thomas JV, Hutchinson BT. Bleb infections: clinically different courses of "blebitis" and endophthalmitis. J Ophthalmic Nurs Technol 1997 Nov-Dec;16(6):292-300. |
|10.||Phillips WB, Wong TP, Bergern RL, et al. Late onset endophthalmitis associated with filtering blebs. Ophthalmic Surg 1994;25:88-91. |
|11.||Waheed S, Ritterband DC, Greenfield DS, et al. New patterns of infecting organisms in late bleb-related endophthalmitis: a ten year review. Eye.1998;12 (Pt 6):910-915. |
|12.||Kangas TA, Greenfield DS, Flynn HW Jr, et al. Delayed-onset endophthalmitis associated with conjunctival filtering blebs. Ophthalmology. 1997 May;104(5): 746-752. |
|13.||Beck AD, Grossniklaus HF, Hubbard B, et al. Pathologic findings in late endophthalmitis after glaucoma filtering surgery. Ophthalmology 2000 Nov;107(11):2111-2114. |
|14.||Ciulla TA, Beck AD, Topping TM, Baker AS. Blebitis, early endophthalmitis, and late endophthalmitis after glaucoma-filtering surgery. Ophthalmology 1997 Jun;104(6):986-995. |
|15.||Poulsen EJ, Allingham RR. Characteristics and risk factors of infections after glaucoma filtering surgery. J Glaucoma 2000 Dec; 9(6):438-443. |
|16.||Mac I, Soltau JB. Glaucoma-filtering bleb infections. Curr Opin Ophthalmol 2003 Apr;14(2):91-94. |
|17.||Khan RI, Kennedy S, Barry P. Incidence of presumed postoperative endophthalmitis in Dublin for 5-year period (1997-2001). Ophthalmology 2005 Aug;31(8): 1575-1581. |
|18.||Mandelbaum S, Forster RK, Gelender H, Culbertson W. Late onset endophthalmitis associated with filtering belbs.Ophthalmology 1985 July;92(7):964-972. |
|19.||Song A, Scott IU, Flynn HW Jr, Budenz DL. Delayed-onset bleb-associated endophthalmitis: clinical features and visual acuity outcomes. Ophthalmology 2002 May;109(5):985-991. |
|20.||Barza M, Pavan PR, Doft BH, et al. Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study. Arch ophthalmol1997;115:1142-1150. [PUBMED] |
|21.||Han DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic isolates in the endophthalmitis vitrectomy study. Am J Ophthalmol 1996 July;122 (1):1-17. |
|22.||Somani S, Grinbaum A, Slomovic AR. Postoperative endophthalmitis: incidence, predisposing surgery, clinical course and outcome. Can J Ophthalmol 1997 Aug;32(5):303-310. |
|23.||Kresloff MS, Castellann AA, Zarbin MA. Endophthalmitis. Survey of Ophthalmology 1998 Nov;43(3):193-224. |
|24.||Benz MS, Scott IU, Flynn HW Jr, et al. Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of culture-proven cases. Am J Ophthalmol 2004 Jan;137(1):38-42. |
|25.||Busbee BG, Recchia FM, Kaiser R, et al. Bleb-associated endophthalmitis: clinical characteristics and visual outcomes. Ophthalmology 2004 Aug;111(8):1495-1503. |
|26.||Kejll U. Sandvig, Lise Dannevig. Postoperative endophthalmitis: establishment and results of a national registry. Ophthalmology July 2003;29(7):1273- 1280. |
[Table 1], [Table 2], [Table 3], [Table 4]