Risk Factors for Endophthalmitis Following Open Globe Injuries: A 17-Year Analysis

Figures & data

Table 1 Demographics and Summary Features of Open Globe Injuries

	Total Number	With Endophthalmitis	Without Endophthalmitis
Open Globe Injuries	586	25	561
Male	442/586 (75.4%)	20/25	422/561
Female	144/586 (24.6%)	5/25	139/561
Average age	40.7±25.1 years	42.0±29.3 years	40.7±24.9 years
Median follow-up	443 days (IQR 1293)	792 (IQR 1190.75)	430 (IQR 1293)
Total cases of suspected endophthalmitis	25/586 (4.3%)	25/25	0/561
Cases of endophthalmitis on presentation	12/586 (2.0%)	12/25	0/561
Cases of endophthalmitis post-globe closure	13/586 (2.2%)	13/25	0/561
Presenting logMAR visual acuity	2.1±1.0	2.2±0.9	2.10±1.0
Presenting Snellen equivalent visual acuity	Between count fingers and hand motion	Between count fingers and hand motion	Between count fingers and hand motion
LogMAR visual acuity at last follow-up	1.3±1.2	1.9±1.3	1.3±1.2
Snellen equivalent visual acuity at last follow-up	20/400	Between count fingers and hand motion	20/400

Table 2 Details of Open Globe Injury and Additional Procedures Performed at Time of Globe Closure

Injury Mechanism	Total Number*	With Endophthalmitis	Without Endophthalmitis
Rupture	358/586 (61.1%)	10/25 (40.0%)	348/561 (62.0%)
Perforating	118/586 (20.1%)	8/25 (32.0%)	110/561 (19.6%)
Penetrating	110/586 (18.8%)	7/25 (28.0%)	103/561 (18.4%)
Zones of injury
Zone I	268/584 (45.9%)	19/25 (76.0%)	249/559 (44.5%)
Zone II	136/584 (23.3%)	2/25 (8.0%)	134/559 (24.0%)
Zone III	180/584 (30.8%)	4/25 (16.0%)	176/559 (31.5%)
Wound length
Less than 5 mm	145/531 (27.3%)	11/24 (45.8%)	134/507 (26.4%)
Between 5 and 10 mm	135/531 (25.4%)	8/24 (33.3%)	127/507 (25.1%)
Between 11–15 mm	97/531 (18.3%)	2/24 (8.3%)	95/507 (18.7%)
Between 16–20 mm	51/531 (9.6%)	2/24 (8.3%)	49/507 (9.7%)
Greater than 20 mm	103/531 (19.4%)	1/24 (4.2%)	102/507 (20.1%)
Lens disruption	267/575 (46.4%)	11/22 (50.0%)	256/553 (46.3%)
Retinal detachment	181/586 (30.9%)	2/25 (8.0%)	179/561 (31.9%)
Uveal prolapse	401/586 (68.4%)	11/25 (44.0%)	390/561 (69.5%)
Primary lensectomy	50/586 (8.5%)	3/25 (12.0%)	47/561 (8.4%)
Vitrectomy at time of globe repair	127/586 (21.7%)	3/25 (12.0%)	124/561 (22.1%)
Manual excision of prolapsed vitreous strands	97/586 (16.6%)	0/25 (0.0%)	97/561 (17.3%)
Pars plana vitrectomy	24/586 (4.1%)	3/25 (12.0%)	21/561 (3.7%)
Anterior vitrectomy	6/586 (1.0%)	0/25 (0.0%)	6/561 (1.1%)

Note: *Denominators vary depending on availability of each available variable in the electronic medical record.

Table 3 Clinical and Microbiological Characteristics of Endophthalmitis Cases Following Open Globe Injury

Patient	Age	Injury Mechanism	Time to Presentation and Surgery	Injury	Onset of Endophthalmitis	Treatment of Endophthalmitis	Culture Results	Final Visual Acuity
1	70	Dehisced PKP from fall	< 24 hours	Dehisced PKP	5 days	Tap and injection	Candida albicans	HM
2	11	Hammering metal	< 24 hours	Corneal laceration with IOFB	1 day	PPV/PPL/IOFB removal with tap and injection	Clostridium bifermentans	Enucleated
3	48	Hammering ice	> 24 hours	Scleral laceration	On presentation	PPV/PPL/IOFB removal with tap and injection	Negative	NLP
4	59	Plastic shard hit eye	> 24 hours	Corneal laceration	On presentation	Tap and injection	Negative	20/200
5	39	Metal wire into eye	< 24 hours	Corneal laceration	1 day	PPV/PPL with tap and injection	Bacillus cereus	HM
6	43	Metal tool hit eye	< 24 hours	Corneal laceration	6 days	Tap and injection	Coagulase-negative Staphylococcus	20/30
7	86	Dehisced PKP from fall	> 24 hours	Dehisced PKP	On presentation	Tap and injection	Enterococcus faecalis	HM
8	6	Thrown pen hit eye	> 24 hours	Corneal laceration	On presentation	Tap and injection	Group-A Streptococcus	20/50
9	1	Cat scratch	> 24 hours	Scleral laceration	On presentation	Tap and injection	Negative	LP
10	9	Rupture of unclear etiology	> 24 hours	Corneal laceration	On presentation	Tap and injection	Negative	20/40
11	77	Dehisced PKP from fall	< 24 hours	Dehisced PKP	3 days	Tap and injection	Negative	20/50
12	39	Grinding metal	< 24 hours	Corneal laceration with IOFB	On presentation	PPV/PPL/IOFB removal with tap and inject	Negative	20/100
13	3	Scissor or fork into the eye	> 24 hours	Corneal laceration	On presentation	Tap and injection	Negative	20/20
14	73	Hammering chisel	> 24 hours	Corneal laceration	On presentation	Tap and injection	Negative	20/25
15	65	Fall	< 24 hours	Corneoscleral laceration	On presentation	Injection alone	No culture	Enucleated
16	20	Wood hit eye	< 24 hours	Corneoscleral laceration	8 days	Tap and injection	Negative	HM
17	32	Wire into the eye	< 24 hours	Corneal laceration	5 days	Tap and injection	Coagulase-negative Staphylococcus	NLP
18	60	High speed stone hit eye	> 24 hours	Corneoscleral laceration	On presentation	Tap and injection	Negative	20/800
19	91	Perforated PKP due to corneal ulcer	< 24 hours	Perforated PKP	1 day	Tap and injection	Haemophiles influenzae	NLP
20	91	Dehisced PKP from fall	< 24 hours	Dehisced PKP	20 days	Tap and injection	Negative	LP
21	7	Metal rod hit eye	< 24 hours	Corneal laceration	36 days	Tap and injection	Streptococcus pneumonia	NLP
22	39	Grinding non-metallic material	< 24 hours	Corneal laceration with IOFB	2 days	Primary enucleation	Bacillus cereus	Enucleated
23	10	Hammering rocks	> 24 hours	Corneoscleral laceration	On presentation	Primary enucleation	Gram-positive rods	Enucleated
24	46	Barbed wire into eye	< 24 hours	Corneal laceration	2 days	Primary enucleation	Gram-positive rods	Enucleated
25	23	Hammering metal	< 24 hours	Corneal laceration	49 days	Tap and injection	Negative	20/30

Abbreviations: PKP, penetrating keratoplasty; IOFB, intraocular foreign body; PPV, pars plana vitrectomy; PPL, pars plana lensectomy; HM, hand motion; LP, light perception; NLP, no light perception.

Table 4 Univariable and Multivariable Models for Risk Factors for the Development of Endophthalmitis Following Open Globe Injury

Univariate Analysis
Risk Factor	Odds Ratio	P-value
IOFB (yes vs no)	2.934	0.0158
Injury mechanism (penetrating versus rupture)	2.375	0.0871
Injury mechanism (perforating versus rupture)	2.516	0.0580
Time to repair (>24 hours versus <24 hours)	4.833	0.0002
Zone of injury (1 versus 3)	3.385	0.0291
Zone of injury (2 versus 3)	0.662	0.6364
Wound length (5–10 mm vs <5 mm)	0.767	0.5819
Wound length (11–15 mm vs <5 mm)	0.256	0.0812
Wound length (16–20 mm vs <5 mm)	0.497	0.3744
Wound length (>20 mm vs < 5 mm)	0.122	0.0455
Uveal prolapse (yes vs no)	0.338	0.0087
IV antibiotics (yes vs no)	0.544	0.1403
IV antibiotic duration (one-time versus none)	0.470	0.0841
IV antibiotic duration (<24 hours but more than one dose versus none)	2.679	0.1588
IV antibiotic duration (>24 hours versus none)	<0.001	0.9792
Age	1.002	0.7829
Gender	0.761	0.5919
Laterality of injury (OD vs OS)	1.144	0.7431
Previous ocular surgery (yes vs no)	1.457	0.3925
Time to presentation (>24 hours vs <24 hours)	4.940	0.0002
LogMAR presenting VA	1.125	0.6063
RAPD (yes vs no)	1.640	0.3523
Foreign body location (vitreous vs anterior chamber)	4.000	0.2106
Foreign body location (other vs anterior chamber)	3.500	0.3941
Lens status (pseudophakic vs phakic)	1.278	0.6352
Lens status (aphakic vs phakic)	4.176	0.1964
Lens disruption (yes vs no)	1.157	0.7376
Vitreous hemorrhage (yes vs no)	0.681	0.4015
Intraocular inflammation (yes vs no)	10.931	<0.0001
Retinal detachment (yes vs no)	0.230	0.0478
Days to treatment of RD	0.072	0.6755
Time to antibiotics (>24 hours vs <24 hours)	5.700	<0.0001
PO antibiotics (yes vs no)	2.149	0.0622
PO antibiotics duration in days	1.115	0.3436
Intraocular antibiotics (yes vs no)	18.061	<0.0001
Subconjunctival antibiotics (yes vs no)	0.286	0.0024
Topical antibiotics (yes vs no)	0.387	0.1417
Subconjunctival steroids (yes vs no)	0.534	0.1290
Topical steroid (yes vs no)	0.675	0.5356
Cycloplegic (yes vs no)	1.621	0.3119
Vitrectomy (Weck-Cel vs none)	<0.001	0.9524
Vitrectomy (Anterior vs none)	<0.001	0.9882
Vitrectomy (Posterior vs none)	2.946	0.0998
Primary lensectomy (yes vs no)	1.544	0.4944
Additional surgeries (yes vs no)	3.786	0.0323
Enucleation (yes vs no)	1.545	0.3421
Multivariable Analysis
Risk factor	Odds Ratio	P-value
Delay in Globe Closure	OR = 4.5 (95% CI 1.9–10.7)	0.0008
Zone I vs Zone III Injury	OR = 3.6 (95% CI 1.1–11.0)	0.0282
Zone II vs Zone III Injury	OR = 1.0 (95% CI 0.2–5.7)	0.9940
Need for Additional Surgery	OR = 5.5 (95% CI 1.5–19.7)	0.0092
Subconjunctival Antibiotics	OR = 0.3 (95% CI 0.1–0.7)	0.0036

Note: Bolded rows within table denote risk factors and their associated odds ratio and p-value that were statistically significant in univariate modeling.