Pathogen-Associated Visual Outcomes Following Postprocedure Endophthalmitis

Abstract

Objective: To report the anatomic and functional outcomes of a large, multicenter series of postprocedure acute endophthalmitis, stratified by pathogen virulence.

Design: Retrospective, interventional case series.

Participants: Two hundred forty adult patients diagnosed with postprocedural acute endophthalmitis from 2012 to 2022 at four tertiary, university-based care centers. Of these, 208 patients had adequate follow-up data for comparative analyses.

Methods: Medical records were reviewed for demographics, microbiology, treatment, and visual outcomes of patients that developed endophthalmitis following any intraocular procedure. Organisms were categorized into surface commensals (coagulase-negative Staphylococcus sp.) and nonsurface commensals (eg, Streptococcus, Enterococcus sp.) as a proxy for virulence. Visual acuity (VA) outcomes and complication rates were compared across groups using Fisher's exact test and regression models adjusting for age, sex (male or female), comorbidities, and treatment modality for postinjection endophthalmitis.

Main outcome measures: Final VA, number of interventions, and rates of vision-threatening complications, including phthisis, retinal detachment, enucleation/evisceration.

Results: Among culture-positive cases, patients infected with nonsurface commensal organisms had significantly worse final VA than those with coagulase-negative Staphylococcus (mean logMAR 2.14 vs 0.77, P < .0001), as well as higher rates of third interventions (27.5% vs 10.1%, P = .017), phthisis (15.4% vs 1.1%, P = .0032), and enucleation/evisceration (12.8% vs 0%, P = .0022). In multivariable regression of postinjection endophthalmitis, virulent, nonsurface commensal organisms remained independently associated with poorer visual outcomes (P = .0005). Complication patterns were consistent whether culture-negative cases were included or not in the nonvirulent group. Most patients were initially treated with intravitreal injections (92.1%). An initial vitrectomy was uncommon and not significantly associated with better outcomes when performed.

Conclusions: Infections with virulent, nonsurface commensal organisms such as Streptococcus and Enterococcus are associated with significantly worse outcomes in postprocedure endophthalmitis, independent of presenting vision or treatment delay. These findings support a shift toward pathogen-informed management and underscore the need for timely identification of virulent organisms in postprocedural acute endophthalmitis.