Dr. Ramesh Venkatesh, V14265, Dr. Prachi A Dave, Dr. Manisha Agarwal, Dr. Shalini Singh
Introduction:
Childhood ocular trauma is the most common cause of acquired unilateral blindness1. Post-traumatic endophthalmitis (PTE) is one of the devastating complications following ocular trauma. It accounts for 2%-7% of all penetrating injuries and is a major cause of irreversible visual loss.2 PTE in children is not a common occurrence. The condition can be due to negligence of the guardian and some behavioral conditions like attention deficit hyperactivity disorder (ADHD) symptoms in children may be associated with penetrating ocular injuries3. Unlike adults, children do not complain of pain or visual problems and usually delay in seeing a doctor. Children are not adults and the treatment strategies cannot be directly applied to pediatric cases. In a study by Weinstein et al2, it was found that only 2-8% of the PTE occurred in children less than 18 years of age. There are very few reports in literature discussing about PTE in pediatric cases. In a study from the southern state of India by Rishi et al4, more than 50% of pediatric endophthalmitis cases were due to ocular trauma. In their study boys < 10 years of age were more affected and the most common source of injury was organic matter. Poor outcomes were associated with presence of corneal abscess and retinal detachments. Commonest causative organism was E. Fecalis in their study. Despite of its rare occurrence, PTE portends a poor prognosis mainly due to the infection being highly virulent and delay in the management. In our study, we intend to describe the etiology, vitrectomy and microbiological outcomes and visual outcomes of cases of traumatic endophthalmitis in the pediatric age group presenting to a tertiary eye care hospital in Northern India.
Methodology:
This was a retrospective,single centre, interventional case series of children presenting with endophthalmitis due to ocular trauma at a tertiary eye care hospital in North India from January 2011- December 2015. All patients ≤ 18 years with PTEwere included. A total of 40 children presented with PTE. Prior institutionreview board approval was obtained for this study. The study was conducted according to the tenets of the declaration of Helsinki. A written informed consent was obtained from the parent/ guardian of all participating subjects.
The following details were noted for each patient: 1) demographic data 2) type and mode of the ocular trauma as elicited by the parent/guardian 3) presenting visual acuity by either Teller’s acuity cards or Snellen’s visual acuity charts wherever possible. 4) time interval between the trauma and presentation 5) surgical intervention carried out 6) microbiological organism isolated 7) post-operative anatomical outcome and 8) post-operative visual outcome.
All patients underwent complete ophthalmic examination including slit lamp biomicroscopy and indirect ophthalmoscopy. Ultrasound B-scan was performed in all cases where primary repair was already done and in cases with suspected occult globe rupture and was deferred in cases with open globe injury at presentation. Radiological investigations like X-ray or computed tomography (CT) scan were done in cases with suspected intraocular foreign body.
Aqueous/vitreous aspirate was taken in all cases undergoing treatment under general anesthesia. The decision for aqueous or vitreous tap was based on clinical judgment of predominant focus of involvement. Eviscerated material was sent for microbiological analysis in cases where primary evisceration was advised. Aspirates were sent for microbiological analysis which included smear (Grams and KOH) and bacteriological and fungal culture and antibiotic sensitivity tests. Empirical treatment consisting of topical antibiotics and mydriatic agents along with intravitreal antibiotic injections with/ without steroids was started based on initial smear reports and was individualized in accordance with culture results, and severity of signs and symptoms.
Treatment options included topical and systemic medications, intravitreal medications, and surgical management. All patients with evidence of or clinically suspected bacterial infection were started on topical steroids and received intravitreal Vancomycin (1 mg/0.1 ml), Ceftazidime (2.25 mg/0.1 ml), and dexamethasone (0.4 mg/0.1 ml). Patients were treated with systemic steroids (1 mg/kg body weight) wherever the treating clinician felt inflammation to be significant. All patients with bacterial infections received parenteral
Cefotaxime (50 mg/kg body weight in divided doses) and Gentamicin (5–7 mg/kg body weight/day). Patients with proven fungal infections were treated with systemic ketoconazole (5-7mg/kg/day). All surgeries were performed under general anesthesia with proper aseptic conditions. All patients were reviewed on day 1, day 6 and then 6 weeks after the treatment. Follow-up intervals were individualized depending upon the clinical status of the eye and at the discretion of the treating surgeon. The details at the last follow-up visit were noted. Optimal anatomical outcome (OAO) was defined as status of eye with no retinal detachment or pthisis bulbi at the final visit. Optimal functional outcome was defined as best-corrected visual acuity > 6/60 with OAO.
Results:
In this study, 40 eyes of 40 patients were diagnosed with PTE. Out of the 40 patients, 25(62.5%) were boys and 15(37.5%) were girls. The average age at presentation was 7.532 years (median – 7 years; range – 1month -16 years). The average follow-up period was 272 days (median – 150 days; range 2 – 1440 days). Baseline characteristics of the patients are listed in table 1.
| Table 1: Baseline clinical characteristics of patients diagnosed with PTE. | ||
| Clinical characteristics(n=40) | Patient number (%) | |
| 1) Age distribution | ||
| 0-3 years | 10(25) | |
| >3-12 years | 25(62.5) | |
| >12-18 years | 5(12.5) | |
| 2) Sex Distribution | ||
| Boys | 25(62.5) | |
| Girls | 15(37.5) | |
| 3) Source of injury | ||
| Organic | 21(52.5) | |
| Inorganic | 19(47.5) | |
| 4) Type of injury | ||
| Penetrating trauma | 33(82.5) | |
| Occult rupture | 7(17.5) | |
| 5) Presenting VA | ||
| >6/60 | 1(2.5) | |
| <6/60 | 3(7.5) | |
| PL or less | 27(67.5) | |
| Could not be assessed | 9(22.5) | |
| 6) Mode of injury | ||
| Fruit stem | 1(2.5) | |
| Knife | 1(2.5) | |
| Fire-cracker | 1(2.5) | |
| Wooden stick | 20(50) | |
| Hypodermic needle | 8(20) | |
| Iron nail | 3(7.5) | |
| Pellet | 1(2.5) | |
| Finger nail/hand | 4(10) | |
| Stone | 1(2.5) | |
| 7) Specimen sent for microbiology | ||
| Aqueous aspirate | 8(20) | |
| Vitreous aspirate | 25(62.5) | |
| Eviscerated material | 5(12.5) | |
| Corneal scrapping | 5(12.5) | |
| Infected suture | 1(2.5) | |
| 8) Treatment procedure | ||
| Vitrectomy + intraocular antibiotics | 34(85) | |
| Primary evisceration | 5(12.5) | |
| Intraocular antibiotics alone | 1(2.5) | |
| 9) Final visual acuity | ||
| >6/60 | 11(27.5) | |
| <6/60 | 3(7.5) | |
| PL or less | 24(60) | |
| Could not be assessed | 2(5) | |
| 10) Final outcomes | ||
| Optimal anatomical outcome | 25(62.5) | |
| Adverse anatomical outcome | 15(37.5) | |
| Retinal detachment
Pthisis bulbi |
3(7.5)
12(30) |
|
Injury with wooden stick (20 eyes, 50%) was the most common source of trauma followed by hypodermic needle in 8(20%) eyes. The average interval between injury and presentation was 8.973 days (median 4 days; range 1–120 days). Visual acuity at the time of presentation was light perception or worse in 27 (67.5%) eyes, whereas only 1 (2.5%) eye had visual acuity > 6/60. Visual acuity could not be assessed accurately in 9 eyes. 5 patients presented with corneal infection, 3 cases with retinal detachment and 1 patient had an associated intraocular foreign body (IOFB).
Specimens sent for microbiological evaluation included aqueous aspirate in 8(20%) eyes, vitreous aspirate in 25(62.5%) eyes, eviscerated material in 5(12.5%) eyes, corneal scrapings in 5(12.5%) eyes and infected suture material in 1(2.5%) eye. Positive culture results were noted in 18(45%) eyes while culture was negative in 22(55%) eyes. Organisms identified as causative agents are listed in Table 2.
| Table 2: Microbiological profile of patients diagnosed with PTE. | ||
| Organism | Number of eyes (%) | |
| Gram positive organisms(n=13) | ||
| Staphylococcus Aureus | 5(12.5) | |
| α- hemolytic Streptococci | 3(7.5) | |
| Bacillus cereus | 3(7.5) | |
| Diptheroids | 1(2.5) | |
| Streptococcus viridians | 1(2.5) | |
| Gram negative organisms(n=5) | ||
| Klebsiella | 3(7.5) | |
| Pseudomonas | 2(5) | |
| Fungus(n=4) | ||
| Aspergillus Flavus | 1(2.5) | |
| Fusarium spp. | 3(7.5) | |
Fungi were isolated in 4 (10%) eyes. Staphylococcus Aureus was the most common Gram-positive organism, whereas Klebsiella spp. was the most common Gram-negative organism isolated in 5 (12.5%) and 3 (7.5%) eyes, respectively. Among fungi, Fusarium spp. was isolated in 3 (7.5%) eyes. 34(85%) patients underwent 3-port vitrectomy along with intraocular antibiotics, 5(12.5%) eyes underwent primary evisceration and 1(2.5%) eye underwent treatment with intraocular antibiotics alone. Only one patient had an IOFB for which IOFB removal with intraocular antibiotics was performed.
Optimal functional outcome >6/60 was noted in 11(27.5%) eyes while 24(60%) patients had post-operative visual acuity of PL or less. 15(37.5%) eyes had adverse anatomical outcome; 3(7.5%) eyes developed retinal detachment which were inoperable and 12(30%) eyes developed pthisis bulbi.
Discussion:
Our study is a retrospective, single centre, interventional case series. Out of a total of 57 children who presented with endophthalmitis in the 5-year period, 40 cases were secondary to ocular trauma. The incidence of PTE in pediatric age group as reported in the western literature is about 17%5. The same is about 51-69% in previous studies from India4, 6. PTE constituted 70% of all the cases of endophthalmitis in children in the current study. The incidence of trauma related ocular morbidity is relatively higher in the developing countries as result of less stringent laws relating to child care and increased parental negligence.
In our series, 62.5% of the patients were males. Alfaro et al7, Junejo et al8 and Rishi et al4 reported similar rates of 75%, 67% and 70% respectively in their studies. The mean of age of presentation that has been reported was 10 years7 while the same in our series was 7.532 years. Injuries with ‘broomstick’ and hypodermic needles are the most common source of injury accounting to 50% and 20 % of cases in our study. This is very peculiar for cases which are reported from the subcontinent.
Positive culture results were noted in 45 % of cases in our study similar to that reported by Rishi et al4. However, higher positive culture results are seen in previous studies from the western countries ranging from 44-75%7,9. The easy availability of antibiotics and enrolling patients who had received prior antibiotic treatment elsewhere could be the reasons for the low culture positive results in our cases.
A recent study by Rishi et al4 showed Enterococcus fecalis as the most common causative organism while Staphylococcus aureus (5 eyes) was the most common organism isolated in our series of cases. This was followed by α – haemolytic Streptococci (3 eyes), Fusarium spp. (3 eyes) and Klebsiella spp. (3 eyes). Similar studies from the western population had also reported Staphylococcus aureus as the most common causative organism in PTE 10. In our study, 85% of cases underwent early therapeutic vitrectomy along with intraocular antibiotics. This is in concordance with the recommendations of previous reports.11 Early vitrectomy reduces the microbiological load and helps in diffusion of intravitreal and systemic antibiotics within the eye. In our study more than >25 % of the cases had improvement in the visual acuity following vitrectomy and 62.5% of the patients had optimal anatomical outcome.
In conclusion, PTE among children is common in boys and most often caused by injury with organic matter. More than 50% of the cases are caused by gram positive bacteria; Staphylococcus aureus being the most common organism. Poor pre-operative vision is often associated with poor post-operative outcome. Though the prognosis is guarded, with early diagnosis, appropriate management and timely follow up, these patients can atleast be given ambulatory vision so that they are socially and economically independent.
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