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Anterior segment photography in patient with bleb-related endophthalmitis. BRE symptoms including hyperemia, pain, discharge, hypopyon, and loss of vision and the BRE diagnosis were identified as infectious inflammations spread to the vitreous body with white bleb.
Source publication
Purpose. To investigate clinical results on bleb-related endophthalmitis (BRE) after trabeculectomy treated with pars plana vitrectomy (PPV) and to evaluate influence factors for visual prognosis. Methods. Investigating medical records retrospectively, BRE was defined as an endophthalmitis induced by bleb infection. A total of 2018 eyes of 1225 pat...
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Purpose:
To evaluate the influence of phacoemulsification after trabeculectomy on the postoperative intraocular pressure (IOP) in eyes with uveitic glaucoma (UG).
Setting:
Kumamoto University Hospital, Kumamoto, Japan.
Design:
A retrospective cohort study.
Methods:
The medical records of patients with UG who had trabeculectomy with mitomycin...
Citations
... However, some underwent PPV or tap-and-inject more than once for inflammatory inhibition. Some studies have shown that PPV for BAE results in improved visual outcomes [26,[28][29][30]. However, Islam et al. confirmed that visual acuity and IOP control were similar after initial PPV compared with taps and injections when managing BAE [31]. ...
... were the most common pathogenic organisms found in our study (46.4%, p ≤ 0.001). Similar findings have been reported in some research [9,11,25,26,29]. Our previous study and some researchers noted that Staphylococcus species were more commonly observed [8,32]. ...
Background
This study aimed to evaluate the clinical correlative factors and outcomes of treatment of bleb-associated endophthalmitis (BAE) following glaucoma filtration surgery in a Chinese population from the year 2012 to 2022, and to compare them with the clinical course during the coronavirus disease (COVID-19) pandemic period.
Methods
This was a retrospective analysis of consecutive cases of BAE treated at the Eye & ENT Hospital of Fudan University, Shanghai, China, between January 1, 2012, and December 31, 2022. The clinical presentation, treatment modality, microbiological data, clinical course, and outcomes of visual acuity (VA) and intraocular pressure (IOP) in all BAE cases were collected and analyzed.
Results
A total of 28 eyes with BAE were examined, predominantly in male patients (71.4%, p = 0.023). Most patients underwent trabeculectomy (89.3%, p ≤ 0.001), while a smaller proportion underwent Ex-PRESS implantation (10.7%). Primary open-angle glaucoma (POAG) was the most common type of glaucoma (39.3%, p ≤ 0.001). Most patients (96.4%) presented with poor visual acuity, worse than 20/400, and IOP ranged from 3–60 mmHg. Treatment, including initial tap-and-inject procedure of antibiotics (Ceftazidime and Norvancomycin) or initial pars plana vitrectomy (PPV), was initiated 5.0 ± 7.1 days after BAE onset. Streptococcus was the most common causative organism (53.6% of cases, p ≤ 0.001). The visual acuity significantly improved from 2.58 ± 0.27 to 2.14 ± 0.85 (reported in logMAR) after treatment (p ≤ 0.001), and most patients maintained normal tension during follow-up. Poisson regression model analysis showed the annual incidence of BAE during the COVID-19 pandemic period was significantly twice greater than that of previous years.
Conclusions
BAE may cause irreversible visual impairment. POAG filtering surgery with male sex and the COVID-19 pandemic period might be potentially relevant factors for BAE. Culture positivity was closely related to BAE prognosis, with Streptococcus species being the leading pathogenic organisms. Online outpatient services, early diagnosis, and timely treatment may rescue vision and maintain IOP control in the presence of BAE.
... Die Autoren verharmlosen die Rolle des Mitomycin C: "Dauerhaft sehkraftbedrohende Komplikationen bestehen nicht. Es gibt jedoch Hinweise darauf, dass MMC das Risiko einer Katarakt erhöht." 1 Sicherlich können mithilfe des Adjuvans Mitomycin C niedrige postoperative Druckwerte erzielt werden, wahrscheinlich auch mit einer relativ geringen Quote an postoperativen Maßnahmen wie Needling [7]. ...
... In particular, a bleb-related infection that progresses to endophthalmitis is a representative longterm serious complication. [3][4][5] The adjunctive use of mitomycin C (MMC) has dramatically improved surgical success and therefore has become the standard procedure in trabeculectomy. 2,6,7 However, trabeculectomy with MMC tends to cause thin and avascular blebs. ...
Prcis:
Trabeculectomy using the Tenon advancement technique with a fornix-based conjunctival flap showed avascular bleb formation less frequently and had a significantly lower risk of developing bleb-related infections than trabeculectomy with a limbus-based conjunctival flap.
Purpose:
To determine whether the Tenon advancement technique for trabeculectomy with a fornix-based (FB) conjunctival flap is effective in preventing bleb-related infections.
Patients and methods:
This was a single-center, non-randomized retrospective cohort study of 998 eyes from 854 patients with glaucoma who underwent trabeculectomy with mitomycin C. Trabeculectomy procedures were categorized into three groups: limbus-based (LB, 296 eyes), FB without Tenon advancement (FBTA-, 167 eyes), and FB with Tenon advancement (FBTA+, 535 eyes). The cumulative incidence of bleb-related infections and the rate of surgical success during the 5-year postoperative follow-up period were analyzed using Kaplan-Meier survival analysis and Cox proportional hazards models. Intraocular pressure (IOP) reduction of <20% from baseline or additional glaucoma surgeries were deemed a surgical failure. Surgical success with or without IOP-lowering medications was evaluated according to different IOP criteria.
Results:
Ten eyes developed bleb-related infections (8 eyes in the LB group and 1 eye in both the FBTA- and FBTA+ groups each). The cumulative probability of bleb-related infections in the LB, FBTA-, and FBTA+ groups was 4.8±1.7% (± standard error), 0.8±0.8%, and 0.3±0.3%, respectively. The FBTA+ group had a significantly lower risk of bleb-related infections than the LB group (hazard ratio, 0.06; 95% confidence interval, 0.01 to 0.39; P=0.009). The FBTA+ group did not have a higher risk of surgical failure.
Conclusion:
The Tenon advancement technique for trabeculectomy using an FB conjunctival flap may be effective in preventing bleb-related infections without compromising surgical success.
... Similarly, Ohtomo et al. [21] reported a mean interval of 7.4 years (range 1-16 years) between trabeculectomy and the onset of bleb-related endophthalmitis. In other studies, the mean period between initial trabeculectomy and bleb-related infection was 3.1-5 years [22][23][24]. ...
PurposeThe spectrum of microbial infections and the pattern of their susceptibility are variable among communities. Researching these data will lead to the establishment of the most appropriate national management strategies. The purpose of this study was to analyze the epidemiological, clinical, microbial spectrum and antibiotic susceptibility of endophthalmitis cases in a tertiary referral center in Jerusalem.Methods
Retrospective review of medical charts of patients presenting with endophthalmitis over a 12-year period.ResultsA total of 74 eyes of 70 patients (males 56%) were included. Mean age ± SD at presentation was 60 ± 19.5 years. Exogenous endophthalmitis accounted for 78% of cases, of which 62% followed an intraocular surgery, 21% occurred after intravitreal injections, 10% followed infectious keratitis and 7% were posttraumatic. Endogenous cases were predominantly observed in diabetic patients. Microbial isolates were identified in 44 samples. Of them, gram-positive bacteria were the predominant microorganisms detected in 33 samples (75%); Staphylococcus epidermidis and Enterococcus faecalis were the most commonly detected pathogens.Mean presenting ± SD LogMAR visual acuity (VA) was 2.38 ± 1.21 and it improved at last follow-up to 1.7 ± 1.37 (p = 0.004, paired t test). Cases secondary to gram-positive microbes were associated with improved VA during the follow-up while cases secondary to gram-negative microbes was correlated with poor final VA (p = 0.046, r2 = 0.4). There was no evidence of bacterial resistance in the antibiograms for either vancomycin, ceftazidime, ceftriaxone or amikacin.Conclusions
Intraocular surgery remains the most common event preceding endophthalmitis with coagulase-negative staphylococci being the most frequently detected microorganisms. The microbial spectrum of endophthalmitis is similar to that in the western world.
... 44 In 2015, Ohtomo et al. reported a median value for VA of 20/125 after PPV in 11 patients suffering endophthalmitis following trabeculectomy, but there was no comparative group. 45 A more recent retrospective series published by Negretti et al. reported the results after performing early PPV in several kinds of endophthalmitis. From the patients included, five cases followed glaucoma surgery: one after XEN implant, three after trabeculectomy, and one associated with the drainage tube. ...
Aim and objective:
To report the incidence of late-onset endophthalmitis following XEN45® stent implantation.
Background:
Long-term safety profile and efficacy in relation to the so-called microinvasive glaucoma surgery (MIGS) techniques are still under evaluation. The XEN45® gel stent entails a bleb formation and often requires postoperative conjunctival management, differing from the current reviewed concept of minimally invasive procedures. Endophthalmitis has been described among the complications, triggered in the majority of cases by tube extrusion.
Cases description:
From our chart of 293 eyes operated on between November 2016 and November 2019, five (1.7%) patients developed endophthalmitis, which took place in the months 3, 4, 5, 11, and 14 after surgery, respectively. Sixty percent had undergone previous needling procedures. All of them showed a previous flat bleb and developed perforation of the conjunctiva caused by the distal portion of the tube. One patient was early eviscerated due to a fateful course. Treatment consisted of intravitreal, oral, and topical antibiotics, as well as topical corticosteroids. Eighty percent underwent device withdrawal, conjunctival gap suturing, anterior chamber washout, aqueous humor (AH) tab extraction (one positive for S. epidermidis and one for Streptococcus agalactiae), and pars plana vitrectomy. A second patient was eviscerated due to phthisis bulbi. Out of three remaining patients, one underwent vitrectomy for retinal detachment, while two patients required glaucoma surgery for intraocular pressure control. The final VA was ≤20/125 in all patients.
Conclusion:
The XEN45® device appears to trigger endophthalmitis by extruding the stent or unnoticed leakage through conjunctival defects. Special attention should be paid to flat and avascular blebs.
Clinical significance:
This series shows a higher rate of endophthalmitis (1.7%) compared with previous studies with a significant sample size (0.4-1.4%).
How to cite this article:
Burggraaf-Sánchez de las Matas R, Such-Irusta L, Alfonso-Muñoz EA, et al. Late-onset Endophthalmitis after XEN45® Implantation: A Retrospective Case Series and Literature Review. J Curr Glaucoma Pract 2021;15(3):153-160.
... Potentially dangerous intraoperative and postoperative complications may occur at a frequency that cannot be ignored, including surgery-related bleb scarring, hypotony, bleb leak, and bleb infection, which are associated with a high rate of additional surgeries. [2][3][4] Although cataract extraction can deepen a crowded anterior chamber, the adhered angle can still remain. [5][6][7] Combined with goniosynechialysis (GSL), phacoemulsi cation and intraocular lens (IOL) implantation may still fail to achieve a satisfying IOP level resulted from the disabled trabecular meshwork (TM) [8][9][10] . ...
We evaluated the efficacy and safety of combined phacoemulsification, intraocular lens implantation, goniosynechialysis (GSL), and trabectome in patients with primary angle-closure glaucoma (PACG). In this prospective interventional study, twenty patients (22 eyes) of PACG treated with combined phacoemulsification, intraocular lens implantation, GSL, and trabectome between September 2017 to September 2020 were recruited. The intraocular pressure (IOP), the number of glaucoma medications, and best-corrected visual acuity (BCVA) were recorded at baseline, 1, 3, 6, 12, and 24 months after operation. IOP was decreased significantly from 20.69±6.90 mmHg at baseline to 15.83±2.79mmHg at 24 months’ follow-up (P=0.043). The number of glaucoma medications reduced from 2.76±1.14 preoperatively to 0.73±0.77 at 24 months’ follow-up (P=0.026). The qualified success rate was 86.8% at 2 years. The reduction of IOP showed a positive correlation with baseline IOP (p<0.001) and the reduction of the number of glaucoma medications was positively correlated with baseline number of glaucoma medications (p<0.001). There was no vision-threatening complication during and after operation. The combined procedure of phacoemulsification, IOL implantation, GSL, and trabectome was effective and safe for PACG patients. It may provide a new method for PACG patients especially those with long term and extensive goniosynechia.
... Since intravitreal antibiotics injection and follow-up are difficult in the non-mydriatic eye, one treatment option is to perform simultaneous cataract surgery and vitrectomy for stage III bleb-related endophthalmitis. When bleb-related endophthalmitis occurs in a phakic eye, some ophthalmologists perform lensectomy [5] . The rationale is to remove bacteria and biofilm attached to the lens [6] , aiming to prevent recurrence of endophthalmitis. ...
... One of the most serious complications is bleb-associated endophthalmitis. 1 The reported incidence of bleb-associated endophthalmitis (BAE) varies between 0.2% and 3.8%. 2,3 Although rare, the visual acuity outcomes can be poor and are often irreversible. ...
... A study performed in Tokyo reported that pars plana vitrectomy as primary treatment produced better visual outcomes when compared to intravitreal administration of antibiotics alone. 1 However, Busbee et al did not show a statistically significant difference in final visual outcome between groups treated with PPV and tap and injection alone. 14 Our study found no difference in visual outcome between eyes treated with vitrectomy compared to those treated with tap and inject alone. ...
Importance
Bleb‐associated endophthalmitis is a potentially vision‐threatening complication of trabeculectomy. With improvements in surgical technique and changing patterns of intraoperative antimetabolite use, a re‐evaluation of the incidence of bleb‐associated endophthalmitis is warranted.
Background
To investigate changes in the incidence, presentation, management and outcomes of bleb‐associated endophthalmitis between 1997 and 2015 in Victoria, Australia.
Design
A retrospective cohort analysis.
Participants
Consecutive cases of bleb‐associated endophthalmitis managed at the Royal Victorian Eye and Ear Hospital (RVEEH) between 1997 and 2015.
Methods
Medical record review of consecutive cases of bleb‐associated endophthalmitis and statistical analysis were performed.
Main Outcome Measures
Visual acuity, including loss of light perception, intraocular pressure, and need for further surgery.
Results
Sixty‐seven eyes with bleb‐associated endophthalmitis (BAE) were identified. Of these, 41 had trabeculectomy performed in Victoria during the study period, over which time 11,129 trabeculectomies were performed. The proportion of BAE was stable over time (0.4%). The mean age at presentation was 73.7 ± 12.1 years old and the majority of patients were Caucasian (79.1%). The mean duration between glaucoma filtration surgery and the development of bleb‐associated endophthalmitis was 3 years (Interquartile Range = 0.4‐6.0 years). The cultures were positive in 71.6 % of cases. Approximately 1 in 8 patients required enucleation. The final visual acuity was poor with a Snellen Visual Acuity (VA) of 6/60 or worse in two‐thirds of patients.
Conclusion and Relevance
Bleb‐associated endophthalmitis is an uncommon complication following glaucoma filtration surgery. The proportion has remained stable over time. Visual outcomes remain poor.
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... Treatment of significant bleb leaks in the setting of BAE poses serious problems. The most common approach consisting of bleb excision, debridement of necrotic tissue, and conjunctival advancement flap to cover the trabeculectomy site can be technically difficult and may result in bleb failure [10]. ...
Background and Objectives
To report a case of delayed-onset bleb-associated endophthalmitis (BAE) with bleb leak successfully managed with pars plana vitrectomy, intravitreal antibiotics, intracameral air, and fibrin glue.
Patient and Methods
A 66-year-old pseudophakic female presented with BAE and bleb leak. A 25-gauge pars plana vitrectomy, cultures, and intravitreal antibiotics and steroid injections were performed. The infusion was switched to air filling the anterior chamber and bleb with air. Fibrin glue (Tisseel®) was applied over the leaking bleb.
Results
BAE and bleb leak resolved with return of visual acuity to 20/25 and a functioning bleb with no recurrence of bleb leak after 1 year of follow-up.
Conclusion
The combination of intracameral air and fibrin glue may have a role in the management of bleb leaks.
... 1,4 Intravitreal antibiotics with or without pars plana vitrectomy (PPV) are the mainstay of treatment. 1,4,5 Visual prognosis despite prompt treatment is guarded, with endophthalmitis patients often having both poor visual outcomes and intraocular pressure (IOP) control. 6 In this study, we describe the demographics, risk factors, presenting signs, diagnostic workup, treatment, complications, and visual outcomes of eyes with BRE at a US tertiary care facility over a 15year period. ...
... Our study demonstrated a high rate of poor visual outcomes even with aggressive and prompt antibiotic treatment, which is congruent with previous reports. 1,[3][4][5]8,[11][12][13] In our cohort of 36 eyes, 86% of eyes were blind with vision less than 20/200, and 80% with less than 20/400 at resolution of infection. The longterm visual outcomes were very limited in this cohort of patients, but the 6-month follow-up data mirrored those at the time of infection resolution, with an average vision of HM. ...
Purpose
The purpose of this study is to describe the patient characteristics, management, and outcomes of bleb-related endophthalmitis (BRE).
Methods
A retrospective chart review was conducted of patients who presented to a tertiary care facility from 2001 to 2016 with BRE. Collected data included demographics, medical and ocular history, visual acuity (VA), intraocular pressure (IOP), presence of hypopyon, treatment, microbiology, visual outcomes particularly of VA and IOP, and complications.
Results
Thirty-six eyes (36 patients: 21 females, mean 66.8 years old, 78% with primary open-angle glaucoma) presented an average of 4.5 years (range, 2 days-33 years) after glaucoma surgery (30 trabeculectomies with mitomycin C, 6 tube shunts) with endophthalmitis. Mean VA and IOP at presentation were hand motion (HM; logMAR 2.1) and 19.9 mmHg, respectively, with 82% displaying hypopyon and 87% with purulent blebitis. Eighteen (50%) eyes (mean VA HM) underwent vitreous tap and injection (T/I) of intravitreal antibiotics (vancomycin 1 mg/0.1 cc and ceftazidime 2.25 mg/0.1 cc), and 18 (50%) eyes (mean VA HM) underwent pars plana vitrectomy (PPV) with intravitreal antibiotic injection. Eight (45%) eyes initially treated with T/I required a subsequent PPV, and 5 (28%) eyes treated initially with PPV underwent a second PPV. All patients also received systemic antibiotics (33 intravenous [IV] and 3 oral) and topical medications. Average time to documented resolution was 15 days, with mean VA of HM and IOP of 13.6 mmHg. Thirty-one (86%) eyes had vision worse than 20/200 at resolution, and those presenting with light perception or no light perception (NLP) vision (n = 6) had worse vision final VA (logMAR 2.6) than those with initial vision of HM or better (final VA logMAR 1.7). Three (8.6%) eyes were enucleated, with 4 worsening to NLP during the course of the infection.
Conclusions
BRE is a visually devastating infection requiring prompt diagnosis and management. Despite aggressive treatment with antibiotics, visual prognosis is poor.
