Endophthalmitis after intravitreal injections. Incidence, management and prognosis | Archivos de la Sociedad Española de Oftalmología (English Edition)

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(A)–(C) Color retinograph showing the clinical appearance of a stage 3 RAP. (B) Fluorescein angiography early stage and (C) late stage showing typical drusenoid staining and poorly defined intraretinal hyperfluorescence typical of RAP. (D)–(F) serial OCT explorations in (D) baseline visit; (E) at month 3 and (F) at month 12, showing complete resolution of intra-and subretinal fluid after Treat-and-Extend treatment with aflibercept. Note the changes in the serovascularized pigment epithelium detachment to the fibrovascularized type at the beginning and end of treatment." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "V. Castro-Navarro, E. Cervera-Taulet, J. Montero-Hernández, C. Navarro-Palop" "autores" => array:4 [ 0 => array:2 [ "nombre" => "V." "apellidos" => "Castro-Navarro" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Cervera-Taulet" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Montero-Hernández" ] 3 => array:2 [ "nombre" => "C." 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(B) Fundus autofluorescence evidenced a slightly diminished signal that corresponds to detachment areas associated to linear hyperfluorescence that translated hyperpigmentation. (C) No signs of choroidal neovascularization can be observed in fluorescein angiography. (D) Same with indocyanine green. (E) SD-OCT images show the presence of initial low density subretinal fluid. (F) After 9 months follow-up, 3 intravitreal injections of ranibizumab and one of triamcinolone acetonide, SD-OCT showed complete subretinal fluid resolution. Best corrected visual acuity increased from the initial 0.25–0.50 at the final visit." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Cuesta-Lasso, A. Vieira-Barros, R. Dolz-Marco, M.J. Roig-Revert, J. Badal, L. Amselem, M. Díaz-Llopis, R. Gallego-Pinazo" "autores" => array:8 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Cuesta-Lasso" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Vieira-Barros" ] 2 => array:2 [ "nombre" => "R." 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Incidence, management and prognosis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "107" "paginaFinal" => "111" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "R. Tarragó, J.L. Olea, C. Ramírez, L. Escudero" "autores" => array:4 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Tarragó" "email" => array:1 [ 0 => "Ramon.tarrago@ssib.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.L." "apellidos" => "Olea" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Ramírez" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Escudero" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oftalmología, Hospital Universitari Son Espases, Palma de Mallorca (Balearic Islands), Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Endoftalmitis tras inyecciones intravítreas. Incidencia, manejo y pronóstico" ] ] "textoCompleto" => "IntroductionEndophthalmitis caused by the use of intravitreal injections (IVI) has increased dramatically in the past 5–10 years as a consequence of the increased prescription of antiangiogenics, also known as anti-vascular endothelial growth factor (anti-VEGF).<a class="elsevierStyleCrossRef" href="#bib0120">1</a>Even though the incidence of endophthalmitis in IVI varies between 0.019 and 0.54%,<a class="elsevierStyleCrossRef" href="#bib0125">2</a> in the 2 most recent meta-analyses that analyzed large series of cases with 350,535 and 105,536 injections, incidence was 0.056 and 0.049% respectively,<a class="elsevierStyleCrossRefs" href="#bib0130">3,4</a> which is probably more in accordance with the daily clinical practice. These incidence rates are similar to those for cataract surgery, which are between 0.015 and 0.5%.<a class="elsevierStyleCrossRefs" href="#bib0125">2,5</a> However, the final prognosis in the latter is higher. On the other hand, in posterior vitrectomy, with rates between 0.011 and 0.84%, the prognosis is poorer and more similar to that published in IVI series.<a class="elsevierStyleCrossRef" href="#bib0145">6</a>The “clean room” technique increases flexibility and performance, as a higher number of IVI can be administered as well as shortening the waiting time from diagnostic to medicament administration. However, it is important to determine the actual incidence of endophthalmitis with this technique as the final prognosis in these cases is usually worse.This paper, carried out at the Son Espases University Hospital, reviews infectious endophthalmitis cases after IVI in “clean room” through a six-year period, analyzing clinical and microbiological characteristics as well as the end result in order to evaluate any differences against other infectious endophthalmitis with different etiologies.Subjects, material and methodsAn observational and retrospective study carried out at at the Son Espases University Hospital that reviews infectious endophthalmitis cases after the administration of IVI in “clean room” during the period comprised between January 1, 2010 and December 31, 2015 (6 years).The “clean room”, located within the consulting rooms and cabinets, was exclusively dedicated to said procedure: it is sterilized on a weekly basis and the entire staff of physicians and nurses in touch with patients utilized gloves and masks during the entire process.The eyes are prepared with ocular sac cleaning with 5% iodine povidone during 3min, followed by aseptic blepharostat and the injection of the medicament in the inferior temporal quadrant, avoiding contact with the palpebral edge. Finally, a povidone-impregnated swab is applied upon withdrawal of the needle. After administration, polymyxin B sulphate, neomycin and gramicidin (Oftalmowell®, UCB Pharma, S.A., Madrid, Spain) or chloramphenicol antibiotic eye drops are administered at 8-hour intervals during 3 days, as well as applying the same product 3 days before the procedure in the majority of cases.The medicaments are prepared in a sterilized room under laminar Bell flow, in the Pharmacy Department where all the specialties of the hospital are prepared. These are sent to our Dept. in a pre-charged syringe with 30G needle, with preparation and expiry date indicated as well as the flask from which it was obtained to ensure traceability. Samples for microbiological culture are extracted regularly.The 5 cases included in the study exhibited, within the first 4 weeks after IVI, clinical evidences of inflammation in the vitreous or anterior chamber with signs and symptoms such as hypopion, pain, hyperemia and diminished visual acuity, the classic endophthalmitis onset signs. All cases underwent complete exploration and anterior chamber puncture upon arrival at the Emergencies Department. In addition to the gram and microbiological culture, vancomycin or ceftazidime intravitreal administration was given and the patients were admitted to hospital for administration of systemic antibiotic and corticoid therapy, following the recommendations of the SERV guides.All patients underwent diagnostic-therapeutic posterior vitrectomy between 24 and 48h after the procedure because the primary infection loci was in the vitreous. Samples were referred to Microbiology for study and accordingly the criteria of the Endophthalmitis Vitrectomy Study (EVS) were not followed. Clinical data were recorded during follow-up until the definitive resolution of the process.The variables of the study included demographic data, associated diseases, type of IVI medication, number of previous injections and time interval to presentation, affected eye, IVI laterality, administered topical antibiotics as well as the latest visual acuity prior to endophthalmitis, at presentation and at the final evaluation. Said data are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. A descriptive study of the analyzed variables was carried out.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>ResultsThe overall number of administered IVI was 9467 between January 2010 and December 2015 (6 years), of which 3302 were bevacizumab, 4473 ranibizumab, 1353 aflibercept and the remainder was other medicaments. Five endophthalmitis cases occurred, an incidence of 0.053% (0.06% of every 10,000 injections).The medicaments administered to the endophthalmitis patients were ranibizumab (2 cases), aflibercept (a further 2) and rituximab (in one case of primary intraocular lymphoma with multiple intraocular injections). Fortunately none of the cases had bevacizumab as this is an off-label medicament. The number of administered IVI was counted on the basis of the affected eye, excepting cases 1 and 2 in which administration was bilateral and simultaneous, and depended on the baseline ocular disease and the treatment guidelines followed by each physician.Diabetes and HTA were the most frequent associated systemic diseases. One of the 3 diabetes cases (#2) exhibited poor metabolic control to gather with diabetic retinopathy, a certainly poor prognosis factor. The remaining 2 were metabolically compensated and did not exhibit diabetic retinopathy. On the other hand, 3 cases presented with neoplasia and a further case with chronic renal insufficiency (CRI), diseases that cause some degree of systemic immunosuppression. As regards the clinic characteristics at the ocular level, initially endophthalmitis symptoms arose between 48 and 72h and the patients visited the emergencies department between the first and 4th day after the appearance of said symptoms.Positive cultures were obtained in all cases and the study did not exclude any case exhibiting symptoms due to negative culture. Aqueous humor produced 2 cases with positive culture (40%), whereas in vitreous the positive rate was 100%. In what concerns causative agents (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), the majority were gram-positive cocci, conjunctiva saprophytes, except in case 4 where 2 additional bacteriae presented, i.e. Acynetobacter woffi (gram-negative, environmental) and Moraxella catarrhalis (gram-negative, respiratory tract), the latter was discovered with PCR 16S (the only case in which this technique was applied). All were sensitive to vancomycin and linezolid and in addition to the tested quinolone (ciprofloxacin).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Finally, the infectious process resolved in all cases. In cases 1 and 3, visual acuity recovery was almost complete (0.9 and 0.8), case 5 partially recovered the previous visual acuity (0.05), and the 2 remaining cases evolved toward non-resolvable retina detachment, with symptomatic phthisis and evisceration in case 2, with an unfavorable prognosis of 40%.DiscussionOne of the objectives of the present study was to demonstrate the incidence of endophthalmitis after IVI in “clean room” in our hospital, which was in the area of 0.053%. A meta-analysis carried out by Fileta et al., that comprised 197 endophthalmitis cases out of 350,535 IVI, the median global incidence was 0.056% (CI 95%: 0.049–0.065%), a similar result to that of the present study.<a class="elsevierStyleCrossRef" href="#bib0125">2</a> It should be noted that the incidence in the retrospective series was 0.053%, whereas prospective series produced a slightly higher incidence of 0.068%, probably due to better recordal of this complication in said studies.At present, the administration of intravitreal agents is regarded as the most frequent procedure in ophthalmology. In the USA, the number of injections per year has increased exponentially, going from 4215 injections in 2001 to 812,413 in 2007 and reaching 2.5 million injections in 2010.<a class="elsevierStyleCrossRef" href="#bib0150">7</a> In part this is possible due to the use of high performance “clean rooms” that allow greater flexibility and speed in the administration of IVI drugs. This emphasizes the importance of analyzing the rate of endophthalmitis in said locations, which in the present case was similar to the median and reinforces the convenience of using clean rooms instead of surgical areas.<a class="elsevierStyleCrossRef" href="#bib0155">8</a>As regards prevention of endophthalmitis through IVI, a prospective cataract surgery study<a class="elsevierStyleCrossRef" href="#bib0160">9</a> demonstrated that the use of 5% topical iodine povidone in the conjunctival sac is the only method that reduces the risk of post surgery endophthalmitis as it is associated to lower bacterial culture growth of conjunctival samples taken during cataract surgery.<a class="elsevierStyleCrossRef" href="#bib0165">10</a> For this reason, conjunctival washing with 10cc of said 5% product, in addition to external cleaning of eyelids with 10%, constitutes a highly efficient preventive method in this practice. In what concerns the use of previous topical antibiotics, it has not been demonstrated to reduce the risk of endophthalmitis. Some authors suggest that antibiotics diminish the amount of bacterial flora.<a class="elsevierStyleCrossRef" href="#bib0170">11</a> On the other hand, other studies demonstrated that in addition to creating resistance to broad-spectrum antibiotics,<a class="elsevierStyleCrossRef" href="#bib0175">12</a> endophthalmitis could still occur despite the prophylactic use thereof.<a class="elsevierStyleCrossRef" href="#bib0180">13</a>The use of topical antibiotics after IVI is controversial. Proponents argue that it diminishes the number of surface bacteria and accordingly the subsequent entry thereof through the orifice produced by the intraocular injection. Opponents maintain that bacterial inoculation inside the eye takes place when the injection is placed and not after. In addition, the use of topical antibiotics would involve an additional cost as well as creating possible bacterial resistance<a class="elsevierStyleCrossRef" href="#bib0185">14</a>.In what concerns clinic characteristics, diabetes mellitus is a well-known factor that increases the incidence and severity of this complication in other ocular surgeries<a class="elsevierStyleCrossRef" href="#bib0190">15</a>: in the small series of this study, 3 out of 5 patients with diabetes (2 with AMD and EMD), and in 2of them the visual prognosis was very unfavorable. As regards the presentation of symptomatology, it appeared between the 2nd and 3rd day after the injection, a fact which establishes that any symptoms appearing in this period should be an alarming sign that both patients and physicians should be aware of.Another important analyzed data was previous visual acuity. The efficacy of these drugs allows many patients to maintain satisfactory visual acuity: 4 out of the 5 cases exhibited previous visual acuity above 0.5. Specifically, AMD cases 3 and 4 in the Treat and Extend regime, who exhibited visual acuity of 0.7 and 0.8 respectively, were given the injection in the inactive phase, a risk that cannot be ignored in these cases.The aqueous humor puncture was positive in 40% of cases and vitrectomy in 100%. These results are similar to other series, that reported values between 30 and 60%.<a class="elsevierStyleCrossRefs" href="#bib0195">16–18</a>The most frequent isolated causing agent was S. epidermidis, that probably proceeded from sac fundus or ocular adnexes. For this reason local asepsis is crucial. Only M. catarrhalis, found in co-infection with S. epidermidis in case number 4, could originate in a respiratory contamination. Other series have emphasized the importance of oral contamination, which would account for poor visual prognosis.<a class="elsevierStyleCrossRef" href="#bib0125">2</a> For these reasons the use of a mask is recommended in addition to refrain from speaking during the injection process to reduce the likelihood of contamination by oral germs.As in cataract surgery, gram-positive bacteria are the most frequently isolated microorganisms.<a class="elsevierStyleCrossRefs" href="#bib0200">17,19</a> Fortunately, in the present series the patients responded not only to vancomycin, which is becoming the first line intravitreal antibiotic in these cases, but also to quinolones. Even though ciprofloxacin is usually assayed in microbiological antibiograms, moxifloxacin (a fourth-generation quinolone) could be equally or more efficient due to the advantage of systemical and topical existence with very good intraocular penetration.<a class="elsevierStyleCrossRef" href="#bib0215">20</a>As regards the use of vancomycin at the IVI level, it must be taken into account that recent studies have linked it with the occlusive retinal vasculitis hemorrhagic syndrome, an extremely rare and potentially devastating disease that can occur after cataract surgery without other complications. Even though the exact cause of said syndrome remains unknown, it could be a delayed immune reaction similar to the leukocyteclastic vasculitis induced by vancomycin.<a class="elsevierStyleCrossRef" href="#bib0220">21</a>Unfortunately, the reported prognosis of endophthalmitis after IVI is poor<a class="elsevierStyleCrossRefs" href="#bib0125">2,22,23</a>: in the present series, 2 out of 5 subjects ended up with no perception of light due to irreducible retina detachment despite the fact that the infectious component was positively resolved.In summary, the rate of endophthalmitis after IVI is in the area of 0.05% despite the standard prophylactic measures recommended in the guides, where gram-positive cocci are the predominant agents. Even though it is a rare occurrence, the presentation of endophthalmitis in these cases courses with a poor prognosis and it is expected to increase due to the extended use of IVI and the appearance of new pharmacological agents for treating the most prevalent retinal diseases.Conflict of interestsNo conflict of interests was declared by the authors." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres807358" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec805256" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres807359" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec805255" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Subjects, material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-07-21" "fechaAceptado" => "2016-09-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec805256" "palabras" => array:6 [ 0 => "Endophthalmitis" 1 => "Intravitreal injection" 2 => "Anti-vascular endothelial growth factor" 3 => "Staphylococcus" 4 => "Vancomycin" 5 => "Vitrectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec805255" "palabras" => array:6 [ 0 => "Endoftalmitis" 1 => "Inyección intravítrea" 2 => "Antivascular Endothelial Growth Factor" 3 => "Staphylococcus" 4 => "Vancomicina" 5 => "Vitrectomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo assess the rate of endophthalmitis after intravitreal injection (IVI) in a “clean room” of a single health center, following the guidelines of the Spanish Vitreo-Retinal Society (SERV). An analysis was performed on the culture specimens, response to treatment, and final outcomes (guidelines). Material and methodsA retrospective, observational study was conducted on a consecutive case series of patients diagnosed with infectious endophthalmitis after IVI in a single health center between 2010 and 2015. Intravitreal and systemic treatment was given following the SERV guidelines. The patients were followed up the case was resolved. ResultsThere were 5 cases of endophthalmitis out of 9467 IVI (incidence 0.053%). Positive cultures were obtained in aqueous and/or vitreous fluid in all cases, with Staphylococcus epidermidis being involved in 4 out of 5 cases. In 2 cases, final visual acuity was non-light perception due to intractable retinal detachments after resolution of the infectious process. ConclusionsIVI performed in a “clean room” have a low incidence of endophthalmitis. The most common infectious agent was Staphylococcus species. In 2 cases the functional prognosis was poor." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoAveriguar la incidencia de la endoftalmitis tras inyecciones intravítreas (IVT) en «sala limpia» de un centro terciario, siguiendo los protocolos de la Sociedad Española de Retina y Vítreo (SERV). Identificar agentes causales, observar la respuesta al tratamiento y el resultado funcional final. Material y métodosEstudio retrospectivo, observacional, en una serie de casos clínicos, de las endoftalmitis tras IVT realizadas en nuestro centro entre 2010 y 2015. En estos casos, se efectuó tratamiento intravítreo y sistémico, siguiendo las pautas de la SERV, así como una vitrectomía diagnóstico-terapéutica, con seguimiento hasta la resolución definitiva del caso. ResultadosSe produjeron 5 casos de endoftalmitis en 9.467 IVT (incidencia 0,053%). Se obtuvieron muestras de acuoso o vítreo, con cultivo positivo en todos los casos: Staphylococcus epidermidis fue el principal agente causal en 4 de los 5 casos. En 2 casos la agudeza visual fue de no percepción luminosa por desprendimiento de retina irreductible tras la resolución del proceso infeccioso. ConclusionesLas IVT realizadas en «sala limpia» tiene una baja incidencia de endoftalmitis: la especie Staphylococcus es la responsable más frecuente. Dos de los casos acabaron con un mal pronóstico funcional." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Tarragó R, Olea JL, Ramírez C, Escudero L. Endoftalmitis tras inyecciones intravítreas. Incidencia, manejo y pronóstico. Arch Soc Esp Oftalmol. 2017;92:107–111." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AFL: aflibercept; ATB: antibiotic; FC: finger counting; CLF: chloramphenicol; DM: diabetes mellitus; AMD: age-related macular degeneration; DME: diabetes macular edema; F: female; AHT: arterial hypertension; CRI: chronic renal insufficiency; PIOL: primary intraocular lymphoma; M: male; HM: hands movement; NPL: no perception of light; RE: right eye; OFW: Oftalmowell; LE: left eye; PL: perception of light; RIT: rituximab; RNZ: ranibizumab." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Gender \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Indication \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Associated pathology \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Agent \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">#Of previous IVI \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">IVI laterality \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Affected eye \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Days to presentation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Topical ATB</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VA</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Previous \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Posterior \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Previous \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Present \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Final \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PIOL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SNC lymphoma Anemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RIT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CLF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CLF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DME \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DM II AHT Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RNZ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NPL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AMD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DM II AHT Neo colon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RNZ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CLF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FC 1m \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NPL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AMD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neo breast Neo lung arthrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AFL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OFW \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FC 1m \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AMD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DM II AHT Dyslipidemia Anemia CRI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AFL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FC 1m \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1354802.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic and visual acuity (VA) data." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "–: Resistant; +: sensitive; AMK: amikacin; CFZ: ceftazidime; CLN: clindamycin; CPX: ciprofloxacin; ERT: erythromycin; GNT: gentamicin; IMP: imipenem; LNZ: linezolid; MUP: mupirocin; NT: not tested; PEN: penicillin; TBR: tobramycin; VNC: vancomycin." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Sample aqueous \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Sample vitreous \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="10" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiogram</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Bacterian identification \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Bacterian identification \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VNC \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">TBR \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">GNT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AMK \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CPX \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CLN \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">IMP \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">LNZ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">PEN \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">MUP \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. epidermidis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Micrococcus spp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Micrococcus spp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. epidermidis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. epidermidis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Acynetobacter woffi \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Moraxella catarrhalis<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">*** \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">*** \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">*** \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">*** \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">*** \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">*** \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">*** \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">*** \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">*** \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">*** \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. epidermidis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. saprophyticus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1354803.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Germ identified with PCR in vitreous (not antibiogram)." ] ] ] "descripcion" => array:1 [ "en" => "Microbiological results." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intravitreal injection of therapeutic agents" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G.A. Peyman" 1 => "E.M. Lad" 2 => "D.M. Moshfeghi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/IAE.0b013e3181a94f01" "Revista" => array:6 [ "tituloSerie" => "Retina" "fecha" => "2009" "volumen" => "29" "paginaInicial" => "875" "paginaFinal" => "912" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19584648" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0125" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Microbial spestrum and outcomes of endophthalmitis after intravitreal injection versus pars plana vitrectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.J. Garg" 1 => "M. Dollin" 2 => "P. Storey" 3 => "J.D. Pitcher" 4 => "N.H. Fagn-Yen" 5 => "J. 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Endophthalmitis after intravitreal injections. Incidence, management and prognosis

Endoftalmitis tras inyecciones intravítreas. Incidencia, manejo y pronóstico

R. Tarragó

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Ramon.tarrago@ssib.es

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, J.L. Olea, C. Ramírez, L. Escudero

Servicio de Oftalmología, Hospital Universitari Son Espases, Palma de Mallorca (Balearic Islands), Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Endophthalmitis caused by the use of intravitreal injections &#40;IVI&#41; has increased dramatically in the past 5&#8211;10 years as a consequence of the increased prescription of antiangiogenics&#44; also known as <span class="elsevierStyleItalic">anti-vascular endothelial growth factor</span> &#40;anti-VEGF&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Even though the incidence of endophthalmitis in IVI varies between 0&#46;019 and 0&#46;54&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> in the 2 most recent meta-analyses that analyzed large series of cases with 350&#44;535 and 105&#44;536 injections&#44; incidence was 0&#46;056 and 0&#46;049&#37; respectively&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#44;4</span></a> which is probably more in accordance with the daily clinical practice&#46; These incidence rates are similar to those for cataract surgery&#44; which are between 0&#46;015 and 0&#46;5&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2&#44;5</span></a> However&#44; the final prognosis in the latter is higher&#46; On the other hand&#44; in posterior vitrectomy&#44; with rates between 0&#46;011 and 0&#46;84&#37;&#44; the prognosis is poorer and more similar to that published in IVI series&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The &#8220;clean room&#8221; technique increases flexibility and performance&#44; as a higher number of IVI can be administered as well as shortening the waiting time from diagnostic to medicament administration&#46; However&#44; it is important to determine the actual incidence of endophthalmitis with this technique as the final prognosis in these cases is usually worse&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This paper&#44; carried out at the Son Espases University Hospital&#44; reviews infectious endophthalmitis cases after IVI in &#8220;clean room&#8221; through a six-year period&#44; analyzing clinical and microbiological characteristics as well as the end result in order to evaluate any differences against other infectious endophthalmitis with different etiologies&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Subjects&#44; material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">An observational and retrospective study carried out at at the Son Espases University Hospital that reviews infectious endophthalmitis cases after the administration of IVI in &#8220;clean room&#8221; during the period comprised between January 1&#44; 2010 and December 31&#44; 2015 &#40;6 years&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The &#8220;clean room&#8221;&#44; located within the consulting rooms and cabinets&#44; was exclusively dedicated to said procedure&#58; it is sterilized on a weekly basis and the entire staff of physicians and nurses in touch with patients utilized gloves and masks during the entire process&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The eyes are prepared with ocular sac cleaning with 5&#37; iodine povidone during 3<span class="elsevierStyleHsp" style=""></span>min&#44; followed by aseptic blepharostat and the injection of the medicament in the inferior temporal quadrant&#44; avoiding contact with the palpebral edge&#46; Finally&#44; a povidone-impregnated swab is applied upon withdrawal of the needle&#46; After administration&#44; polymyxin B sulphate&#44; neomycin and gramicidin &#40;Oftalmowell<span class="elsevierStyleSup">&#174;</span>&#44; UCB Pharma&#44; S&#46;A&#46;&#44; Madrid&#44; Spain&#41; or chloramphenicol antibiotic eye drops are administered at 8-hour intervals during 3 days&#44; as well as applying the same product 3 days before the procedure in the majority of cases&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The medicaments are prepared in a sterilized room under laminar Bell flow&#44; in the Pharmacy Department where all the specialties of the hospital are prepared&#46; These are sent to our Dept&#46; in a pre-charged syringe with 30<span class="elsevierStyleHsp" style=""></span>G needle&#44; with preparation and expiry date indicated as well as the flask from which it was obtained to ensure traceability&#46; Samples for microbiological culture are extracted regularly&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The 5 cases included in the study exhibited&#44; within the first 4 weeks after IVI&#44; clinical evidences of inflammation in the vitreous or anterior chamber with signs and symptoms such as hypopion&#44; pain&#44; hyperemia and diminished visual acuity&#44; the classic endophthalmitis onset signs&#46; All cases underwent complete exploration and anterior chamber puncture upon arrival at the Emergencies Department&#46; In addition to the gram and microbiological culture&#44; vancomycin or ceftazidime intravitreal administration was given and the patients were admitted to hospital for administration of systemic antibiotic and corticoid therapy&#44; following the recommendations of the SERV guides&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">All patients underwent diagnostic-therapeutic posterior vitrectomy between 24 and 48<span class="elsevierStyleHsp" style=""></span>h after the procedure because the primary infection loci was in the vitreous&#46; Samples were referred to Microbiology for study and accordingly the criteria of the <span class="elsevierStyleItalic">Endophthalmitis Vitrectomy Study</span> &#40;EVS&#41; were not followed&#46; Clinical data were recorded during follow-up until the definitive resolution of the process&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The variables of the study included demographic data&#44; associated diseases&#44; type of IVI medication&#44; number of previous injections and time interval to presentation&#44; affected eye&#44; IVI laterality&#44; administered topical antibiotics as well as the latest visual acuity prior to endophthalmitis&#44; at presentation and at the final evaluation&#46; Said data are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; A descriptive study of the analyzed variables was carried out&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">The overall number of administered IVI was 9467 between January 2010 and December 2015 &#40;6 years&#41;&#44; of which 3302 were bevacizumab&#44; 4473 ranibizumab&#44; 1353 aflibercept and the remainder was other medicaments&#46; Five endophthalmitis cases occurred&#44; an incidence of 0&#46;053&#37; &#40;0&#46;06&#37; of every 10&#44;000 injections&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The medicaments administered to the endophthalmitis patients were ranibizumab &#40;2 cases&#41;&#44; aflibercept &#40;a further 2&#41; and rituximab &#40;in one case of primary intraocular lymphoma with multiple intraocular injections&#41;&#46; Fortunately none of the cases had bevacizumab as this is an off-label medicament&#46; The number of administered IVI was counted on the basis of the affected eye&#44; excepting cases 1 and 2 in which administration was bilateral and simultaneous&#44; and depended on the baseline ocular disease and the treatment guidelines followed by each physician&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Diabetes and HTA were the most frequent associated systemic diseases&#46; One of the 3 diabetes cases &#40;&#35;2&#41; exhibited poor metabolic control to gather with diabetic retinopathy&#44; a certainly poor prognosis factor&#46; The remaining 2 were metabolically compensated and did not exhibit diabetic retinopathy&#46; On the other hand&#44; 3 cases presented with neoplasia and a further case with chronic renal insufficiency &#40;CRI&#41;&#44; diseases that cause some degree of systemic immunosuppression&#46; As regards the clinic characteristics at the ocular level&#44; initially endophthalmitis symptoms arose between 48 and 72<span class="elsevierStyleHsp" style=""></span>h and the patients visited the emergencies department between the first and 4th day after the appearance of said symptoms&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Positive cultures were obtained in all cases and the study did not exclude any case exhibiting symptoms due to negative culture&#46; Aqueous humor produced 2 cases with positive culture &#40;40&#37;&#41;&#44; whereas in vitreous the positive rate was 100&#37;&#46; In what concerns causative agents &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; the majority were gram-positive cocci&#44; conjunctiva saprophytes&#44; except in case 4 where 2 additional bacteriae presented&#44; i&#46;e&#46; <span class="elsevierStyleItalic">Acynetobacter woffi</span> &#40;gram-negative&#44; environmental&#41; and <span class="elsevierStyleItalic">Moraxella catarrhalis</span> &#40;gram-negative&#44; respiratory tract&#41;&#44; the latter was discovered with PCR 16S &#40;the only case in which this technique was applied&#41;&#46; All were sensitive to vancomycin and linezolid and in addition to the tested quinolone &#40;ciprofloxacin&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Finally&#44; the infectious process resolved in all cases&#46; In cases 1 and 3&#44; visual acuity recovery was almost complete &#40;0&#46;9 and 0&#46;8&#41;&#44; case 5 partially recovered the previous visual acuity &#40;0&#46;05&#41;&#44; and the 2 remaining cases evolved toward non-resolvable retina detachment&#44; with symptomatic phthisis and evisceration in case 2&#44; with an unfavorable prognosis of 40&#37;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">One of the objectives of the present study was to demonstrate the incidence of endophthalmitis after IVI in &#8220;clean room&#8221; in our hospital&#44; which was in the area of 0&#46;053&#37;&#46; A meta-analysis carried out by Fileta et al&#46;&#44; that comprised 197 endophthalmitis cases out of 350&#44;535 IVI&#44; the median global incidence was 0&#46;056&#37; &#40;CI 95&#37;&#58; 0&#46;049&#8211;0&#46;065&#37;&#41;&#44; a similar result to that of the present study&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> It should be noted that the incidence in the retrospective series was 0&#46;053&#37;&#44; whereas prospective series produced a slightly higher incidence of 0&#46;068&#37;&#44; probably due to better recordal of this complication in said studies&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">At present&#44; the administration of intravitreal agents is regarded as the most frequent procedure in ophthalmology&#46; In the USA&#44; the number of injections per year has increased exponentially&#44; going from 4215 injections in 2001 to 812&#44;413 in 2007 and reaching 2&#46;5 million injections in 2010&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> In part this is possible due to the use of high performance &#8220;clean rooms&#8221; that allow greater flexibility and speed in the administration of IVI drugs&#46; This emphasizes the importance of analyzing the rate of endophthalmitis in said locations&#44; which in the present case was similar to the median and reinforces the convenience of using clean rooms instead of surgical areas&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">As regards prevention of endophthalmitis through IVI&#44; a prospective cataract surgery study<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> demonstrated that the use of 5&#37; topical iodine povidone in the conjunctival sac is the only method that reduces the risk of post surgery endophthalmitis as it is associated to lower bacterial culture growth of conjunctival samples taken during cataract surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> For this reason&#44; conjunctival washing with 10<span class="elsevierStyleHsp" style=""></span>cc of said 5&#37; product&#44; in addition to external cleaning of eyelids with 10&#37;&#44; constitutes a highly efficient preventive method in this practice&#46; In what concerns the use of previous topical antibiotics&#44; it has not been demonstrated to reduce the risk of endophthalmitis&#46; Some authors suggest that antibiotics diminish the amount of bacterial flora&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> On the other hand&#44; other studies demonstrated that in addition to creating resistance to broad-spectrum antibiotics&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> endophthalmitis could still occur despite the prophylactic use thereof&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The use of topical antibiotics after IVI is controversial&#46; Proponents argue that it diminishes the number of surface bacteria and accordingly the subsequent entry thereof through the orifice produced by the intraocular injection&#46; Opponents maintain that bacterial inoculation inside the eye takes place when the injection is placed and not after&#46; In addition&#44; the use of topical antibiotics would involve an additional cost as well as creating possible bacterial resistance<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In what concerns clinic characteristics&#44; diabetes mellitus is a well-known factor that increases the incidence and severity of this complication in other ocular surgeries<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a>&#58; in the small series of this study&#44; 3 out of 5 patients with diabetes &#40;2 with AMD and EMD&#41;&#44; and in 2<span class="elsevierStyleHsp" style=""></span>of them the visual prognosis was very unfavorable&#46; As regards the presentation of symptomatology&#44; it appeared between the 2nd and 3rd day after the injection&#44; a fact which establishes that any symptoms appearing in this period should be an alarming sign that both patients and physicians should be aware of&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Another important analyzed data was previous visual acuity&#46; The efficacy of these drugs allows many patients to maintain satisfactory visual acuity&#58; 4 out of the 5 cases exhibited previous visual acuity above 0&#46;5&#46; Specifically&#44; AMD cases 3 and 4 in the Treat and Extend regime&#44; who exhibited visual acuity of 0&#46;7 and 0&#46;8 respectively&#44; were given the injection in the inactive phase&#44; a risk that cannot be ignored in these cases&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The aqueous humor puncture was positive in 40&#37; of cases and vitrectomy in 100&#37;&#46; These results are similar to other series&#44; that reported values between 30 and 60&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">16&#8211;18</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The most frequent isolated causing agent was <span class="elsevierStyleItalic">S&#46; epidermidis</span>&#44; that probably proceeded from sac fundus or ocular adnexes&#46; For this reason local asepsis is crucial&#46; Only <span class="elsevierStyleItalic">M&#46; catarrhalis</span>&#44; found in co-infection with <span class="elsevierStyleItalic">S&#46; epidermidis</span> in case number 4&#44; could originate in a respiratory contamination&#46; Other series have emphasized the importance of oral contamination&#44; which would account for poor visual prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> For these reasons the use of a mask is recommended in addition to refrain from speaking during the injection process to reduce the likelihood of contamination by oral germs&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">As in cataract surgery&#44; gram-positive bacteria are the most frequently isolated microorganisms&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">17&#44;19</span></a> Fortunately&#44; in the present series the patients responded not only to vancomycin&#44; which is becoming the first line intravitreal antibiotic in these cases&#44; but also to quinolones&#46; Even though ciprofloxacin is usually assayed in microbiological antibiograms&#44; moxifloxacin &#40;a fourth-generation quinolone&#41; could be equally or more efficient due to the advantage of systemical and topical existence with very good intraocular penetration&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">As regards the use of vancomycin at the IVI level&#44; it must be taken into account that recent studies have linked it with the occlusive retinal vasculitis hemorrhagic syndrome&#44; an extremely rare and potentially devastating disease that can occur after cataract surgery without other complications&#46; Even though the exact cause of said syndrome remains unknown&#44; it could be a delayed immune reaction similar to the leukocyteclastic vasculitis induced by vancomycin&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Unfortunately&#44; the reported prognosis of endophthalmitis after IVI is poor<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2&#44;22&#44;23</span></a>&#58; in the present series&#44; 2 out of 5 subjects ended up with no perception of light due to irreducible retina detachment despite the fact that the infectious component was positively resolved&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In summary&#44; the rate of endophthalmitis after IVI is in the area of 0&#46;05&#37; despite the standard prophylactic measures recommended in the guides&#44; where gram-positive cocci are the predominant agents&#46; Even though it is a rare occurrence&#44; the presentation of endophthalmitis in these cases courses with a poor prognosis and it is expected to increase due to the extended use of IVI and the appearance of new pharmacological agents for treating the most prevalent retinal diseases&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0145" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "identificador" => "xres807358"
          "titulo" => "Abstract"
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              "identificador" => "abst0005"
              "titulo" => "Objective"
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          "titulo" => "Keywords"
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          "titulo" => "Resumen"
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              "titulo" => "Material y m&#233;todos"
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              "titulo" => "Resultados"
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              "identificador" => "abst0040"
              "titulo" => "Conclusiones"
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          "titulo" => "Palabras clave"
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          "titulo" => "Introduction"
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          "titulo" => "Subjects&#44; material and methods"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-07-21"
    "fechaAceptado" => "2016-09-27"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec805256"
          "palabras" => array:6 [
            0 => "Endophthalmitis"
            1 => "Intravitreal injection"
            2 => "Anti-vascular endothelial growth factor"
            3 => "Staphylococcus"
            4 => "Vancomycin"
            5 => "Vitrectomy"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec805255"
          "palabras" => array:6 [
            0 => "Endoftalmitis"
            1 => "Inyecci&#243;n intrav&#237;trea"
            2 => "Antivascular Endothelial Growth Factor"
            3 => "Staphylococcus"
            4 => "Vancomicina"
            5 => "Vitrectom&#237;a"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the rate of endophthalmitis after intravitreal injection &#40;IVI&#41; in a &#8220;clean room&#8221; of a single health center&#44; following the guidelines of the Spanish Vitreo-Retinal Society &#40;SERV&#41;&#46; An analysis was performed on the culture specimens&#44; response to treatment&#44; and final outcomes &#40;guidelines&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective&#44; observational study was conducted on a consecutive case series of patients diagnosed with infectious endophthalmitis after IVI in a single health center between 2010 and 2015&#46; Intravitreal and systemic treatment was given following the SERV guidelines&#46; The patients were followed up the case was resolved&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There were 5 cases of endophthalmitis out of 9467 IVI &#40;incidence 0&#46;053&#37;&#41;&#46; Positive cultures were obtained in aqueous and&#47;or vitreous fluid in all cases&#44; with <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> being involved in 4 out of 5 cases&#46; In 2 cases&#44; final visual acuity was non-light perception due to intractable retinal detachments after resolution of the infectious process&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">IVI performed in a &#8220;clean room&#8221; have a low incidence of endophthalmitis&#46; The most common infectious agent was <span class="elsevierStyleItalic">Staphylococcus</span> species&#46; In 2 cases the functional prognosis was poor&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Averiguar la incidencia de la endoftalmitis tras inyecciones intrav&#237;treas &#40;IVT&#41; en &#171;sala limpia&#187; de un centro terciario&#44; siguiendo los protocolos de la Sociedad Espa&#241;ola de Retina y V&#237;treo &#40;SERV&#41;&#46; Identificar agentes causales&#44; observar la respuesta al tratamiento y el resultado funcional final&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo&#44; observacional&#44; en una serie de casos cl&#237;nicos&#44; de las endoftalmitis tras IVT realizadas en nuestro centro entre 2010 y 2015&#46; En estos casos&#44; se efectu&#243; tratamiento intrav&#237;treo y sist&#233;mico&#44; siguiendo las pautas de la SERV&#44; as&#237; como una vitrectom&#237;a diagn&#243;stico-terap&#233;utica&#44; con seguimiento hasta la resoluci&#243;n definitiva del caso&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se produjeron 5 casos de endoftalmitis en 9&#46;467 IVT &#40;incidencia 0&#44;053&#37;&#41;&#46; Se obtuvieron muestras de acuoso o v&#237;treo&#44; con cultivo positivo en todos los casos&#58; <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> fue el principal agente causal en 4 de los 5 casos&#46; En 2 casos la agudeza visual fue de no percepci&#243;n luminosa por desprendimiento de retina irreductible tras la resoluci&#243;n del proceso infeccioso&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las IVT realizadas en &#171;sala limpia&#187; tiene una baja incidencia de endoftalmitis&#58; la especie <span class="elsevierStyleItalic">Staphylococcus</span> es la responsable m&#225;s frecuente&#46; Dos de los casos acabaron con un mal pron&#243;stico funcional&#46;</p></span>"
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            "identificador" => "abst0025"
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            "titulo" => "Material y m&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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    "NotaPie" => array:1 [
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Tarrag&#243; R&#44; Olea JL&#44; Ram&#237;rez C&#44; Escudero L&#46; Endoftalmitis tras inyecciones intrav&#237;treas&#46; Incidencia&#44; manejo y pron&#243;stico&#46; Arch Soc Esp Oftalmol&#46; 2017&#59;92&#58;107&#8211;111&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">AFL&#58; aflibercept&#59; ATB&#58; antibiotic&#59; FC&#58; finger counting&#59; CLF&#58; chloramphenicol&#59; DM&#58; diabetes mellitus&#59; AMD&#58; age-related macular degeneration&#59; DME&#58; diabetes macular edema&#59; F&#58; female&#59; AHT&#58; arterial hypertension&#59; CRI&#58; chronic renal insufficiency&#59; PIOL&#58; primary intraocular lymphoma&#59; M&#58; male&#59; HM&#58; hands movement&#59; NPL&#58; no perception of light&#59; RE&#58; right eye&#59; OFW&#58; Oftalmowell&#59; LE&#58; left eye&#59; PL&#58; perception of light&#59; RIT&#58; rituximab&#59; RNZ&#58; ranibizumab&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Indication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Associated pathology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Agent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">&#35;Of previous IVI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">IVI laterality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Affected eye&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Days to presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Topical ATB</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VA</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Previous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Posterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Previous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Final&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PIOL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SNC lymphoma<br>Anemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RIT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CLF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CLF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DME&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DM II<br>AHT<br>Dyslipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RNZ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NPL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AMD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DM II<br>AHT<br>Neo colon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RNZ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CLF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FC 1<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NPL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AMD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neo breast<br>Neo lung<br>arthrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AFL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OFW&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FC 1<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AMD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DM II<br>AHT<br>Dyslipidemia<br>Anemia<br>CRI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AFL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FC 1<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Demographic and visual acuity &#40;VA&#41; data&#46;</p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">&#8211;&#58; Resistant&#59; &#43;&#58; sensitive&#59; AMK&#58; amikacin&#59; CFZ&#58; ceftazidime&#59; CLN&#58; clindamycin&#59; CPX&#58; ciprofloxacin&#59; ERT&#58; erythromycin&#59; GNT&#58; gentamicin&#59; IMP&#58; imipenem&#59; LNZ&#58; linezolid&#59; MUP&#58; mupirocin&#59; NT&#58; not tested&#59; PEN&#58; penicillin&#59; TBR&#58; tobramycin&#59; VNC&#58; vancomycin&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Sample aqueous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Sample vitreous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="10" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiogram</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Bacterian identification&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Bacterian identification&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VNC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">TBR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">GNT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AMK&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CPX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CLN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">IMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">LNZ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">PEN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">MUP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; epidermidis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Micrococcus</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Micrococcus</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; epidermidis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; epidermidis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">&#8722;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Effect of topical ciprofloxacin 0&#46;3&#37; and ofloxacin 0&#46;3&#37; on the reduction of bacterial flora on the human conjunctiva"
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                        0 => array:2 [
                          "etal" => false
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                        "tituloSerie" => "J Cataract Refract Surg"
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                            0 => "D&#46; Miller"
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Article information

ISSN: 21735794
Original language: English

DOI:10.1016/j.oftale.2016.09.019

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