Abstract
AIM
To explore the traumatic endophthalmitis in young children and the outcome of pars plana vitrectomy (PPV).
METHODS
Twenty-two eyes of 22 cases of young children consecutive pediatric traumatic endophthalmitis treated and followed up between September 2014 and May 2018 were included. Aqueous humor or vitreous samples were taken for bacterial culture and sensitivity tests. Intravitreal antibiotics (norvancomycin and ceftazidime) injection, combined with 23-gauge PPV, were administered in 22 eyes. Silicone oil (SO; 5000 centistoke) tamponade or perfluoropropane gas (C3F8) was used in all patients. Main outcome measures were best-corrected visual acuity (BCVA) and retinal attachment, the ratio of penetrating injury, and the existence of intraocular foreign body.
RESULTS
The mean age of patients was 6.9±2.2 (range, 3-10)y. All injured eyes suffered from penetrating ocular injury with retained intraocular foreign body in one eye. Bacterial culture was positive in only 2 eyes. The mean follow-up time was 21.1±4.7 (range, 12-30)mo. In the primary PPV, intravitreal antibiotics was administrated in all eyes, SO in 18 eyes, and C3F8 in 4 eyes. The secondary operation of SO removal and C3F8 endotamponade was performed in 16 eyes and a second SO endotamponade due to emulsification of the oil and retinal detachment (RD) was operated in 7 eyes underwent 3 to 11.5mo after primary PPV. A third operation was done in 7 eyes. The final intraocular pressure (IOP) was 8.9±1.8 (range, 6.9-11.4) mm Hg. The final BCVAs were 20/200 or better in 5, counting fingers in 2, and light perception to hand movement in 8 eyes. Whose (66.7%) had retinal injury exhibited worse BCVA (P=0.019, Fisher's exact test). Eyes underwent SO tamponade exhibited worse final BCVA than that with C3F8 in the primary PPV (P=0.026, Fisher's exact test).
CONCLUSION
Traumatic endophthalmitis in children is generally more severe and associated with more complicated surgical procedures. Most patients have retinal injury need multiple operations and the final BCVA is poor. Prevention of ocular trauma, especially in children, is still critical.
Keywords: pediatric, penetrating eye injury, traumatic endophthalmitis, pars plana vitrectomy
INTRODUCTION
Endophthalmitis is a serious eye disease that is commonly complicated by systemic infection, intraocular surgery, or penetrating eye trauma[1]–[2]. Among children, penetrating ocular trauma is the most common cause of endophthalmitis[3]–[4]. Traumatic endophthalmitis in children is generally more severe and associated with more complicated surgical procedures, longer hospitalization times, more complications, and worse visual prognoses[5]. Additionally, some studies have indicated that patients who are less than 10 years of age often exhibit worse visual outcomes, perhaps because of amblyopia[6]–[7]. Therefore, prompt diagnosis and determination of a suitable treatment is particularly important for maintenance of retinal function and visual acuity in pediatric patients with traumatic endophthalmitis. The injection of intravitreal antibiotics combined with 23-gauge pars plana vitrectomy (PPV) is reportedly effective for treatment of endophthalmitis[8]–[9]. However, in clinical settings, completion of a primary PPV procedure may not be sufficient treatment because of the complexity of pediatric endophthalmitis. Further treatment operations, such as silicone oil (SO) removal, a second SO injection, and intraocular lens (IOL) implantation are often necessary to maintain the shape of the eye and achieve better visual outcomes.
In an assessment of the published literature, we found no studies containing detailed descriptions of follow-up treatment after the primary PPV procedure. In the present study, we aimed to explore the effects of PPV and (when necessary) the next intervention (e.g., SO removal, SO injection, or IOL implantation) on the visual outcomes of pediatric patients with traumatic endophthalmitis.
SUBJECTS AND METHODS
Ethical Approval
This retrospective study was conducted at Xinhua Hospital and Ninth People's Hospital, which are affiliated with the Shanghai Jiao Tong University School of Medicine, from September 2014 to May 2018. Ethics Committee approval was obtained before the study began. Patients who were less than 10 years of age and who had pediatric endophthalmitis caused by eye trauma were included in our study. The study protocol conformed to the tenets of the Declaration of Helsinki. Informed consent was obtained from all patients for surgery and for the use of their information for this retrospective study. The surgery was performed as part of routine medical care prior to writing this manuscript. The following data were extracted from medical records for each patient with pediatric endophthalmitis: inpatient number, date of birth, sex, ocular injury history, specimen (vitreous or aqueous humor) culture results, PPV surgery details, pre-/postoperative best-corrected visual acuity (BCVA), intraocular pressure (IOP), retina status and follow-up duration.
Operation Procedure
Most patients were referred from other hospitals for primary care after trauma. After the endophthalmitis diagnosis was confirmed, all patients were treated with intravitreal antibiotics (norvancomycin and ceftazidime) combined with standard 3-port 23-gauge vitrectomy. All surgeries were performed by the same experienced surgeon (Wang ZY) using the Constellation 800 CS System (Alcon Laboratories, Fort Worth, TX, USA). An SO (5000 centistoke) injection or long-acting perfluoropropane (C3F8) was used as an extended tamponade in all patients. Lensectomy was performed for patients who exhibited a lesion on the lens, such as a cataract, and for patients who exhibited dislocation of the lens. All patients underwent complete vitrectomy, and posterior hyaloid detachment was induced during surgery for all patients. Lensectomy was performed for patients who exhibited a lesion on the lens, such as a cataract, and for patients who exhibited lens subluxation and dislocation of the lens. The secondary operation of SO, C3F8, and IOL implantation were performed. In addition, a few patients underwent a third PPV. Patients were examined 1d, 1, and 3wk after vitrectomy, as well as every 1 to 2mo thereafter. At each return visit, a complete eye examination was performed, including a slit-lamp examination of BCVA with a Snellen chart, IOP measurement via applanation tonometry, B-scan ultrasonography, and a fundus examination. The mean follow-up duration was 21.1±4.7mo (range, 12-30mo).
Specimen Culture
Aqueous humor or ocular vitreous was aseptically obtained with a syringe during the operation. Our hospital was unable to perform microbiological diagnosis; thus, the samples were sent to the Eye & ENT Hospital of the Fudan University, which has a microbiology facility that could perform gram stain, bacterial culture, fungal smear and culture, and sensitivity analyses.
Statistical Analysis
Statistical analysis was performed using SPSS software version 22 (SPSS, IBM, Chicago, IL, USA). The data were tabulated and analyzed with Microsoft Excel (Microsoft Inc., Redmond, WA, USA). Data were calculated as the mean±standard deviation. Statistical analysis consisted of a Pearson Chi-squared test and Fisher's exact test. P<0.05 were considered statistically significant.
RESULTS
Subject Characteristics
Twenty-two patients with pediatric endophthalmitis were treated during the 30-month study period. Their conditions resulted from trauma; sixteen patients were boys and the other 6 patients were girls. All patients had penetrating corneal trauma, 20 patients exhibited corneal and lens lesions, 7 patients had pupil deformation, 11 patients had retinal injuries, and 2 patients had combined retinal and choroidal detachment. The etiology of penetrating ocular trauma included sharp injuries (n=13; 59.1%), blunt injuries (n=5; 22.7%) and unknown etiology (n=4; 18.2%). The mean patient age was 6.9±2.2 (range, 3-10)y. The mean duration until the first PPV operation was 4.6±2.7 (range, 1-11)d (Table 1).
Table 1. Characteristics of patients with pediatric endophthalmitis in this study.
| Cases | Sex | Age (y) | Eye | Etiology | Treatment time (d) | Lesion | Pre BCVA//logMAR |
| 1 | F | 8 | Right | Pencil | 11 | Cornea/lens/retina | NLP/NLP |
| 2 | M | 5 | Left | Unknown | 5 | Cornea/lens | HM/3.0 |
| 3 | M | 6 | Left | Bamboo stick | 4 | Cornea/lens | LP/LP |
| 4 | F | 3 | Right | Plastic ball | 3 | Cornea/lens | NA/NA |
| 5 | M | 6 | Right | Scissor | 4 | Cornea/lens/retina | LP/LP |
| 6 | M | 4 | Left | Branch | 8 | Cornea/lens | NA/NA |
| 7 | M | 6 | Left | Wood stick | 4 | Corneas | LP/LP |
| 8 | M | 8 | Left | Unknown | 3 | Cornea/lens | CF/2.0 |
| 9 | M | 3 | Left | Unknown | 9 | Cornea/lens/retina | NA/NA |
| 10 | F | 8 | Right | Copper wire | 2 | Cornea/lens | LP/LP |
| 11 | M | 9 | Left | Wood stick | 1 | Cornea/lens | LP/LP |
| 12 | F | 8 | Left | Iron | 5 | Cornea/lens/retina/choroid | HM/3.0 |
| 13 | M | 7 | Left | Cement nail | 2 | Cornea/lens/retina | HM/3.0 |
| 14 | M | 9 | Left | Wood stick | 2 | Cornea/lens | CF/2.0 |
| 15 | F | 4 | Right | Plastic ball | 4 | Cornea/lens/retina | LP/LP |
| 16 | M | 4 | Left | Wood stick | 3 | Cornea/lens | CF/2.0 |
| 17 | M | 10 | Right | Explosion | 5 | Cornea/lens/retina | NLP/NLP |
| 18 | M | 7 | Left | Impact | 3 | Cornea/lens/retina | LP/LP |
| 19 | M | 9 | Right | Impact | 9 | Cornea/lens/retina | LP/LP |
| 20 | F | 9 | Left | Explosion | 7 | Cornea/lens/retina/choroid | LP/LP |
| 21 | M | 10 | Left | Iron | 4 | Cornea/lens/retina | LP/LP |
| 22 | M | 8 | Right | Unknown | 2 | Cornea/lens/retina | NLP/NLP |
Pre: Preoperative; BCVA: Best-corrected visual acuity; LP: Light perception; HM: Hand movement; NLP: No light perception; CF: Counting fingers.
Culture Results
In all patients, we performed an intraoperative aqueous humor or vitreous biopsy using syringes, and the culture results are summarized in Table 1. Only two eyes (9.1%) had positive vitreous cultures: one showed signs of fungus and the other was Pneumoniae.
Surgical Results
The clinical onset of post-trauma endophthalmitis occurred within 2wk of injury. All patients were referred from other hospitals for primary care at 1-2d after trauma, with perforation wound closure and without PPV treatment. Only one patient was diagnosed and treated by standard vitrectomy within 1d. During surgery, we observed the formation of a ciliary body exudative membrane in all patients. All patients with pediatric endophthalmitis achieved successful infection control. Eighteen patients (81.8%) underwent more than 2 PPV. In the primary PPV, all patients received intravitreal antibiotics; eighteen children (81.8%) of the patients underwent SO injection and four (18.2%) of the patients underwent C3F8 application. Of the patients who underwent SO injection in the primary operation, after a mean follow-up duration of 5.1±2.4 (range, 3-11.5)mo, seven children underwent a second SO removal combined with C3F8 endotamponade, seven eyes underwent a second SO endotamponade due to emulsification of the oil, and seven patients required a third operation. Of the 4 patients who underwent C3F8 application in the primary operation, secondary IOL implantation was needed for 2 patients. In our study, only 5 patients had retinal detachment (RD) within 3-4d of initial presentation, which likely resulted from trauma. In addition, 4 patients had traction RD after the second PPV, which was regarded as a complication of surgery. Four patients exhibited band-shaped degeneration of the cornea during follow-up after the third operation. The final IOP was 8.9±1.8 mm Hg. As shown in Tables 1 and 2, at the preoperative baseline, twelve patients had BCVA of light perception, three patients had no light perception, three patients could detect hand movement, and one patient could count fingers. The final BCVAs were 20/200 or better in five patients, two patients could count fingers, eight patients could detect hand movement, one patient had light perception and one patient had no light perception. Final BCVAs were not available for three patients. As shown in Table 3, multiple factors (e.g., sex, age, eye, etiology, onset of PPV, and lesions) were not associated with the final visual outcomes. However, BCVA worse than counting fingers was present in seven children who underwent PPV+SO in the primary PPV operation, whereas this poor BCVA was not observed in children who underwent PPV+C3F8 in the primary PPV operation (P=0.026, Table 3). Twelve patients had retinal injury exhibited worse BCVA (P=0.019, Table 3).
Table 2. The pars plana vitrectomy results of children with endophthalmitis.
| Cases | Final IOP | Final BCVA/logMAR | Retina status | PPV operation |
Culture (organism) | Follow-up (mo) | ||||
| First | Interval time (mo) | Second | Interval time (mo) | Third | ||||||
| 1 | 9.1 | HM/3.0 | Attachment | Lensectomy+PPV+SOE | 5 | SOR+PPV+C3F8 | 6 | CT | V (fungus) | 30 |
| 2 | 8.3 | 20/40+0.3 | Attachment | Lensectomy+PPV+C3F8 | - | - | - | - | V(-) | 20 |
| 3 | 11.4 | HM/3.0 | Attachment | Lensectomy+PPV+SOE | 4 | SOR+PPV+C3F8 | - | - | V(-) | 24 |
| 4 | 13.2 | NA/NA | Attachment | Lensectomy+PPV+SOE | 6 | SOR+PPV+C3F8 | - | - | V(-) | 20 |
| 5 | 7.6 | NLP/NLP | Attachment | Lensctomy+PPV+SOE | 11.5 | SOR+PPV+C3F8 | 2 | PPV+SOE | V (Pneumoniae) | 24 |
| 6 | 9.7 | NA/NA | Reattachment | Lensectomy+PPV+SOE | 4 | SOR+PPV+SOE | - | - | V(-) | 26 |
| 7 | 7.5 | HM/3.0 | Attachment | PPV+SOE | 9 | SOR+PPV+SOE | 0.5 | Partial SOR+PPV | V(-) | 26 |
| 8 | 14.1 | 20/200/1.0 | Attachment | Lensectomy+PPV+C3F8 | - | - | - | - | V(-) | 25 |
| 9 | 8.3 | NA/NA | Attachment | Lensectomy+PPV+C3F8 | 3.5 | IOLs+PR+PPV | 0.5 | IOLs+PR+PPV | V(-) | 28 |
| 10 | 10.2 | CF/2.0 | Attachment | Lensectomy+PPV+SOE | 11 | SOR+PPV+C3F8 | - | - | V(-) | 25 |
| 11 | 7.7 | CF/2.0 | Attachment | Lensectomy+PPV+C3F8 | 5 | IOLs | - | - | V(-) | 22 |
| 12 | 6.9 | HM/3.0 | Reattachment | Lensectomy+PPV+SOE | 4 | SOR+PPV+C3F8 | 3 | PPV+SOE | V(-) | 20 |
| 13 | 8.3 | HM/3.0 | Attachment | Lensectomy+PPV+SOE | 3 | SOR+PPV+C3F8 | - | - | V(-) | 21 |
| 14 | 9.6 | 20/200/1.0 | Attachment | Lensectomy+PPV+SOE | 4 | - | 2.5 | IOLs | V(-) | 20 |
| 15 | 7.8 | HM/3.0 | Attachment | Lensectomy+PPV+SOE | 4 | - | - | - | V(-) | 17 |
| 16 | 8.1 | 20/200/1.0 | Attachment | Lensectomy+PPV+PR+SOE | 6 | SOR+PPV+SOE | - | - | V(-) | 18 |
| 17 | 8.4 | LP/LP | Reattachment | Lensectomy+PPV+SOE | 4.5 | SOR+PPV+SOE | 6 | SOR+PPV+SOE | V(-) | 19 |
| 18 | 7.3 | HM/3.0 | Attachment | PPV+PR+SOE | 7 | SOR+PPV+SOE | - | - | V(-) | 20 |
| 19 | 9.2 | HM/3.0 | Attachment | Lensectomy+PPV+SOE | 5 | - | - | - | V(-) | 21 |
| 20 | 7.7 | NLP/NLP | Attachment | Lensectomy+PPV+SOE | 3.5 | SOR+PPV+SOE | - | - | V(-) | 14 |
| 21 | 8.5 | HM/3.0 | Attachment | Lensectomy+PPV+SOE | 5 | - | - | - | V(-) | 12.5 |
| 22 | 7.3 | 20/200/1.0 | Reattachment | Lensectomy+PPV+SOE | 8 | SOR+PPV+SOE | - | - | V(-) | 12 |
BCVA: Best-corrected visual acuity; LP: Light perception; HM: Hand movement; NLP: No light perception; CF: Counting fingers; IOP: Intraocular pressure; PPV: Pars plana vitrectomy; SOE: Silicone oil endotamponade; S OR: Silicone oil removal; PR: Pupil reformation; CT: Corneal transplant; IOL: Intraocular lens implantation; IOLs: Intraocular lens suspension; V: Vitreous.
Table 3. Predictors of final visual outcomes.
| Variable | Final BCVA |
P (Fisher's exact test) | |
| ≥CF | <CF | ||
| Sex | |||
| M | 6 | 8 | 0.603 |
| F | 1 | 4 | |
| Age (y) | |||
| ≥5 | 6 | 11 | 0.999 |
| <5 | 1 | 1 | |
| Eye | |||
| Left | 5 | 7 | 0.656 |
| Right | 2 | 5 | |
| Etiology | |||
| Sharp | 4 | 7 | 0.999 |
| 0 | 2 | 5 | |
| Onset of PPV (d) | |||
| ≥5 | 1 | 5 | 0.333 |
| <5 | 6 | 7 | |
| Lesion | |||
| Retinal injury | 2 | 10 | 0.019 |
| No retinal injury | 6 | 2 | |
| First operation | |||
| PPV+C3F8 (n=4) | 3 | 0 | 0.026 |
| PPV+SO (n=18) | 4 | 14 | |
BCVA: Best-corrected visual acuity; CF: Counting fingers; PPV: Pars plana vitrectomy; C3F8: C3F8 endotamponade; SO: Silicone oil endotamponade. P<0.05 means the difference is statistically significant.
DISCUSSION
The diagnosis of traumatic endophthalmitis is based on a history of injury and an ophthalmic examination. However, early diagnosis and immediate treatment for endophthalmitis is challenging in pediatric patients, especially in young children, because they may not be able to describe reduced BCVA or pain symptoms[10]–[12]; moreover, they are often uncooperative during clinical examinations, which causes delayed diagnosis[13]–[14]. In the present study, we conducted a retrospective analysis of children with endophthalmitis; we identified a total of twenty-two patients who exhibited endophthalmitis after penetrating eye trauma during a 12 to 30mo period. Notably, of the twenty-two patients, only 1 was diagnosed with endophthalmitis and treated with standard vitrectomy within 1d. This low rate of early diagnosis and treatment was likely related to the high incidence of traumatic endophthalmitis and the low proportion of timely consultations, which may have occurred because most pediatric patients in our study were from rural areas and experienced delays in primary diagnosis and treatment. Other studies have also found that patients injured in a rural setting exhibited an increased risk of post traumatic endophthalmitis[15]–[16].
The most common etiology of penetrating ocular trauma was sharp injuries (n=13; 59.1%), such as those from pencils, sticks, scissors, metal wires, wood stick and cement nails. Both Bayar et al[16] and Dehghani et al[17] reported similar findings. Regarding microbial culture results in our study, only two of the 22 patients (9.1%) were culture-positive (one fungus and one Pneumoniae). Importantly, most hospitals do not have adequate microbiology facilities to test for pathogenic bacteria. In previous studies, culture-positive rates were 44%-75%[18]–[19]; thus, many patients were culture-negative. Regardless of positive or negative microbiological test results, improved visual outcomes may be achieved by providing the best initial management strategy using intravitreal antibiotics combined with vitrectomy, as soon as possible[20]–[21]. However, completion of a single PPV procedure was typically not sufficient treatment. Further treatment operations, such as SO removal, SO endotamponade, and IOL implantation, were often implemented to maintain the shape of the eye and ensure better visual outcomes. In the present study, all patients with pediatric endophthalmitis achieved successful infection control. Bayar et al[16] reported similar results. As shown in Tables 1 and 2, the final BCVAs were 20/200 or better in five patients. This proportion was smaller than the 40% observed in a previous study[13]. As shown in Table 2, patients who underwent PPV+SO injection in the primary PPV operation (81.8%) had worse visual recovery than those who underwent PPV+C3F8 in the first PPV operation (18.2%; P=0.026, Fisher's exact test). Patients who underwent SO might have had worse outcomes because traumatic endophthalmitis resulted in serious ocular damage that limited overall visual recovery.
The rate of RD as a complication of pediatric endophthalmitis was reportedly 38% in previous studies[4]. However, in our study, only two patients exhibited RD within 3-4d of presentation, which was a common result of trauma. In addition, two patients had traction RD after the second PPV operation, which was likely a complication of surgery; these patients received a third PPV operation with SO and both achieved retinal stability. The final IOP was 8.9±1.8 mm Hg. Four patients exhibited band-shaped degeneration of the cornea during follow-up after their third PPV operation, which influenced final vision recovery.
There were some limitations in the present study. First, the sample size was limited to 22 patients, which precluded some statistical analyses. Additionally, the data were all from a hospital and may not be representative of patients who are treated in other settings, thus limiting the generalizability of the findings. Second, because the primary treatments were performed by different surgeons, patients experienced variable delays in treatment; moreover, the primary BCVA and other data were not be collected in a consistent manner. Third, for microbial cultures, only two eyes had positive vitreous cultures (fungus and Pneumoniae). Thus, we were unable to determine any associations between these organisms and the final BCVA in our patients.
In conclusion, traumatic endophthalmitis in children is generally more severe and associated with more complicated surgical procedures. Most patients underwent SO endotamponade in the primary PPV operation had more serious ocular damage that resulted in worse visual recovery, compared with patients who underwent C3F8 in the first PPV operation. Despite advanced management of intravitreal antibiotics combined with vitrectomy for all patients in this study, most patients need multiple operations and the final BCVA is poor. Prevention of ocular trauma, especially in children, is still critical.
Acknowledgments
We thank Ryan Chastain-Gross, Ph.D., from Liwen Bianji, Edanz Group China (www.liwenbianji.cn/ac), for editing the English text of a draft of this manuscript.
Authors' contributions: Wang ZY and Zhou YL conceived and designed the study. Zhou YL, Wang ZY collected the data. Yao TT performed the data statics and analysis. Zhou YL wrote the paper. Wang YX and Yang Y reviewed and edited the manuscript.
Foundations: Supported by the National Natural Science Foundation of China (No.81770934); Shanghai Municipal Education Commission-Gaofeng Clinical Medicine Grant Support (No.20181810).
Conflicts of Interest: Zhou YL, None; Wang YX, None; Yao TT, None; Yang Y, None; Wang ZY, None.
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