Bleb-related endophthalmitis: Clinical presentation, isolates, treatment and visual outcome of culture-proven cases

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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.