Elsevier

Ophthalmology Retina

Volume 1, Issue 3, May–June 2017, Pages 192-199
Ophthalmology Retina

Original article
Intravenous Drug Use–Associated Endophthalmitis

https://doi.org/10.1016/j.oret.2016.10.013Get rights and content

Purpose

To characterize features and outcomes of intravenous drug use (IVDU)-associated endophthalmitis.

Design

Retrospective cross-sectional study.

Methods

A retrospective chart review of all cases of endophthalmitis seen between September 2006 and November 2014 at a single academic referral center was performed. All cases of IVDU-associated endophthalmitis were identified and characterized.

Main Outcome Measures

Ophthalmic examination findings, microbial results, visual outcomes, and secondary ocular sequelae.

Results

Thirty patients (32 eyes) with IVDU-associated endophthalmitis were identified, which represented 9% of all endophthalmitis patients (n = 338) and 44% of all endogenous endophthalmitis patients (n = 68). Mean follow-up was 11 months. All eyes had vitritis, 6 had hypopyon, and 2 had subretinal abscesses. Twenty eyes had macular involvement, 8 eyes had no macular involvement, and media opacities precluded macular assessment in 4 eyes. Initial treatment was needle vitreous biopsy with intravitreal antibiotics (“tap and inject”) in 25 eyes (78%) and pars plana vitrectomy (PPV) in 6 eyes (19%); 1 patient refused ocular treatment. An organism was identified from at least 1 source in 75% of eyes (24/32): 59% fungal, 16% bacterial, 22% negative cultures, and 3% refused ocular cultures. Mean visual acuity improved significantly between initial examination and final follow-up (1.64 logMAR to 0.91 logMAR, P < 0.0001). At final follow-up, 90% of eyes had improved vision compared with presentation, 31% of eyes had 20/40 or better vision, and 25% of eyes had 20/200 or worse vision. Twenty-one eyes (66%) required PPV for their infection—6 initially and 15 secondarily after tap and inject. Sixty-nine percent of eyes (9/13) that had cultures sent from a secondary PPV had positive cultures, despite almost all receiving appropriate intravitreal antibiotic therapy at the time of the tap and inject. Eight patients (27%) had extraocular signs of infection. Twenty eyes (63%) suffered secondary ocular sequelae.

Conclusions

This represents the largest series of IVDU-associated endophthalmitis. Bacterial etiologies constitute an important share of cases. A majority of patients eventually required PPV and there was frequent culture positivity even after tap and inject with appropriate antibiotics; therefore, early PPV may have an important role in management.

Section snippets

Methods

Institutional Review Board approval was obtained by the Human Studies Committee and the study protocol adhered to the Declaration of Helsinki. International Classification of Diseases 9 (ICD-9) billing codes were used to identify cases of endophthalmitis at the Massachusetts Eye and Ear Infirmary (MEEI) from September 2006 until November 2014. Every medical record was reviewed and patients with a preceding history of IVDU were identified.

Inclusion criteria included a history of endophthalmitis,

Patient Characteristics

A total of 338 patients with endophthalmitis were seen during the study period, of which 68 had endogenous endophthalmitis (20%), and 30 patients (32 eyes) were identified as having IVDU-associated endophthalmitis (9% of total, 44% of endogenous cases). There were 36 patients (36 eyes) with non-IVDU endogenous endophthalmitis. One patient did not have visual acuity data available for analysis because presentation preceded electronic medical records. Mean follow-up time was 11 months (range, 1

Discussion

This is the largest series of IVDU-associated endophthalmitis to date. IVDU-associated endophthalmitis is a significant source of ophthalmic morbidity, accounting for 9% of all cases of endophthalmitis at our academic referral center. Ten patients were initially misdiagnosed before presentation. Patients with IVDU-associated endophthalmitis are typically young and with minimal systemic complaints. These patients may be initially reluctant to volunteer a history of drug use; however, clinicians

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  • Cited by (0)

    Financial Disclosure(s): The author(s) have made the following disclosure(s): There were no funding sources for this project. The authors have no conflicts of interest to report. B.S.M., A.V.F., T.D.P., M.D., D.H.: No financial disclosures. D.E.: Consultant — Alcon, Alimera, Allergan, Arctic, Avalanche, Dutch Ophthalmic, Ophthotech, MacuLogix, Santen, and Thrombogenics; Research grants — Neurotech and Ocata Therapeutics.

    Author Contributions:

    Research design: Modjtahedi, Finn, Papakostas, Husain, Eliott

    Data analysis and/or interpretation: All authors (Modjtahedi, Finn, Papakostas, Durand, Husain, Eliott)

    Data acquisition and/or research execution: All authors (Modjtahedi, Finn, Papakostas, Durand, Husain, Eliott)

    Manuscript preparation: All authors (Modjtahedi, Finn, Papakostas, Durand, Husain, Eliott)

    Drs Modjtahedi and Finn contributed equally to this work.

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