Paediatric Traumatic Endophthalmitis in Western India: A Study of Clinical Presentation, Management and Treatment Outcomes

Shreya Shah^1*, Mehul Shah¹, Raj Vador¹, Vedant Rajoria¹, Riddhi Shah¹, Bhoomi Chadarana¹, Deepak Tiwari¹

¹Drashti Netralaya, Dahod, Gujarat, India

*Correspondence author: Shreya Shah, Drashti Netralaya, Dahod, Gujarat, India; Email: [email protected]

Citation: Shah S, et al. Paediatric Traumatic Endophthalmitis in Western India: A Study of Clinical Presentation, Management and Treatment Outcomes. J Ophthalmol Adv Res. 2025;6(1):1-8.

Copyright^© 2025 by Shah S, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Table 2: Comparative study of visual outcome.

Table 3: Comparative study of variables with visual outcome.

Discussion

Posttraumatic endophthalmitis is one of the major complications after the repair of OGI in children [25,26]. In this study, we aimed to investigate the incidence and the risk factors of endophthalmitis in children to make the correct decision in the management of such clinical challenges in cases with larger wounds and contaminated objects to   decrease the incidence and the consequences of this devastating event.

Next, we reported an endophthalmitis rate of 4.6 % in the eyes with OGI, which was consistent with the previously reported rates between 0.9% and 17.0% these variations because of different settings, geographical locations and habitats of injuries [2-12]. Our protocol for OGI emphasizes no systemic antibiotics in contrast to previous reports [2]. All of the 32 cases of endophthalmitis were diagnosed on presentation;the rate of endophthalmitis developing following globe closure was nil in 1751 cases in contrast to that report by Durrani, et al. [2]. On the other hand, the incidence rate of endophthalmitis was reported to be 3.4% by the United States eye registry in 2002 and 5.1% in an Iranian study in children with OGI [28,29]. Some studies reported a low incidence of endophthalmitis (1-7%) and attributed this to the use of systemic antibiotics [2,31]. The current study identified several risk factors associated with the development of endophthalmitis. Especially, the presence of zone I injury as a risk factor for the development of endophthalmitis has only been previously reported in another study sample size of 117 eyes with open globe injury which did not differ significantly from that in the current study [6]. This phenomenon could be attributed to zone 1 injury wherein organisms are not directly inoculated in the vitreous cavity.

Thompson, et al., demonstrated that the eyes repaired after 24 Hours have a high incidence of endophthalmitis [32,33]. Durrani et al. also found that the time to globe repair >24 h after injury was a risk factor for the development of endophthalmitis, as described previously [2,6,7,14,16]. We did not find an association between the interval between injuries because the object of injury is the wooden stick and the major plants were alocia nilotica which has anti-bacterial and anti-fungal properties. However, we hypothesized that the anti-bacterial and anti-fungal properties of alocia nilotica in these cases could explain this difference [2,4,6,7,16,35-37].

Tyler, et al., reported incidence of endophthalmitis 9% following open globe injury by wood [38]. The management of OGI is controversial and there is limited consensus on the best practices to prevent endophthalmitis. One controversy is the role of systemic antibiotic prophylaxis.

Only the use of subconjunctival antibiotics at the time of globe closure was associated with decreased risk of endophthalmitis following globe closure. Thus, subconjunctival antibiotics protect against endophthalmitis as they decrease the microbial load at the site of injury.

Systemic vancomycin and ceftazidime is a potent combination that provides coverage of all Gram-positive and Gram-negative organisms, but their penetration into the vitreous under different anatomic states is debatable [19,20,27]. At our institution, we did not use any prophylaxis as all endophthalmitis cases are presented as full-flagged cases and receive intravitreal injections. We  did not find significant difference in visual outcome with  the number of intravitreal injections.

The current study reported that pars plana vitrectomy with or without silicone oil tamponade helps in vision improvement, which is in agreement with the finding by Azad, et al. [38].

While the use of systemic antibiotic prophylaxis is a common practice for OGI, intravitreal antibiotic prophylaxis and the timing of IOFB removal are debatable. Several studies demonstrated that the presence of an IOFB alone, irrespective of the time of removal, is an independent risk factor for the development of endophthalmitis [3,4,6,7,16]. The current study had IOFB in 15.6% cases. In support of this practice, a multicentre, randomized, control trial found a benefit of prophylactic intravitreal gentamicin and clindamycin in cases of IOFB [12]. Taken together, these findings propose that delayed IOFB removal within a few days of globe closure (the median time to removal was 2 days in our study) with intravitreal antibiotic injection at the time of closure may be an acceptable practice in the management of OGI involving IOFBs, especially if it would be unsafe to remove the IOFB at the time of closure. In addition to the use of intravitreal antibiotics in cases of IOFBs, intravitreal antibiotics are recommended in cases of delayed presentation even without IOFB because the delay might be a risk factor for the development of endophthalmitis.

Notably, no eyes with endophthalmitis required enucleation in our study, which was contradictory to the previous studies [2]. Given the speciation we encountered in this study, vancomycin and ceftazidime, are a potent combination of intravitreal antibiotics to treat suspected cases of endophthalmitis [28,33].

The limitations of this study include those inherent to any retrospective study;especially, observer bias and incomplete records for some children. The rate of endophthalmitis may be higher in our cohort than that treated at other centres. Since we are a tertiary referral center in a rural tribal area, the interval between injury and intervention is long;the median is 5 days and delays are inevitable as children first present elsewhere prior to transferring to our center.

Our findings may not be generalizable as they are based on a diverse cohort of children presenting various injuries, including those from urban or remote rural areas. Another potential bias source is that many children diagnosed with OGI during the study period did not meet the inclusion criteria, primarily due to the lack of a 30-day follow-up. All charts of these children were reviewed and none were found to develop any endophthalmitis. Given our large catchment area, many of these children choose to return to their local ophthalmologists for follow-up after the postoperative day one appointment.

The rate of endophthalmitis following OGI has declined over the past 30 years as prompt diagnosis and closure of the globe has become the standard of care worldwide [3-12]. Our rate of endophthalmitis, 4.6 %, is similar to that reported in studies across large academic centres [3-12]. All our cases of endophthalmitis were diagnosed at presentation, which is because of late presentation. Owing to the poor visual outcomes in OGI complicated by endophthalmitis, the identification of eyes at maximal risk is critical;hence, close monitoring and prophylactic treatment are essential. Herein, we found that delayed globe closure and zone I injury were not risk factors for the development of endophthalmitis as reported previously [2,41-43]. Thus, it could be speculated that a standardized protocol is a one-time dose of intravitreal fluoroquinolone antibiotics, globe closure within 24 h whenever possible and prophylactic intravitreal antibiotics for prophylaxis.

Zhang, et al., reported poor outcome in post OGI poor outcome in childen in china(ref china) Wang, et al., reported 18.9% endophthalmitis in cases of pediatric traumatic cataract [25,26].

We could not find many other studies to compare outcome in the pediatric age group  but displayed severe inflammatory changes [29,43-47]. The current study revealed that vitreous opacities have a significant impact on visual outcomes. Sub-groups of OGI, according to BETTS, did not have any significant difference in current study but large wooden foreign bodies have poor impact [38]. Wound size in OGI does not have an impact on the visual outcome, which was consistent with that reported by Durrani, et al., [1].

Conclusion

Post trauma endophthalmitis is a devastating condition with poor visual outcomes. Careful and aggressive management can cause a significant improve visual outcomes.

Conflict of Interest

The authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding Details

No funding was received for this review. No other financial disclosures of all authors.

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