Abstract
Purpose :
In the context of a historic opioid crisis, ophthalmologists can impact the care of persons with substance use disorders (SUDs) through the diagnosis and management of injection drug use-associated endogenous endophthalmitis (IDU-EE) and collaboration with an addiction consult service (ACS). We aimed to update SUD care and visual outcomes in the context of IDU-EE.
Methods :
We reviewed cases of endophthalmitis from 2015-2021. Among patients with IDU-EE, the clinical features, treatment and outcomes of SUDs and IDU-EE were analyzed.
Results :
Of 627 endophthalmitis cases, 62 subjects (9.9%; 65 eyes) with IDU-EE were included. Reported injected drugs included heroin (74.2%), cocaine (19.4%), and fentanyl (17.7%). Among 54 subjects who were inpatient, 37 (68.5%) were seen by the ACS. Of the 32 patients eligible for a new medication for opioid use disorder (MOUD) prescription, 25 (78.1%) were offered one (24 with ACS consult) and 13 (40.6%) accepted (12 with ACS consult). None of the 8 patients treated as outpatients were prescribed MOUD.
Initial ophthalmic treatments were tap and inject (TAI) in 51 (78.5%) eyes and pars plana vitrectomy (PPV) in 9 (13.8%) eyes. Subsequent TAI was performed in 21 eyes (32.3%) and PPV in 30 eyes (46.2%). Intraocular cultures were positive in 34 (54.8%) eyes and systemic cultures were positive in 10 (16.1%) subjects. Organisms were identified in 44 (67.7%) eyes with 28 (43.1%) growing fungus and 20 (30.8%) growing bacteria, of which 8 were considered contaminants. Candida albicans was the most prevalent organism (17 eyes). TAI was less likely to yield a positive culture (11/52) compared with PPV (26/39; p<0.0001). Median visual acuity (VA) improved from 1.5 (20/640 Snellen) to 1.3 logMAR (20/400) at most recent follow-up (p=0.0003); VA improved in 43 (68.2%) eyes. Retinal detachment occurred in 15 (23.1%) eyes. Initial TAI versus PPV did not influence final VA (p>0.8). Fentanyl use increased the odds of poor (≤counting fingers) VA outcome (OR 5.0, 95% CI 1.3-22.8).
Conclusions :
This is the largest case series of IDU-EE to date (Modjtahedi BS, et al. Ophthalmol Retina. 2017) and spans the current fentanyl crisis. Hospitalization and ACS collaboration resulted in a 4x increased likelihood of MOUD initiation. Initial PPV did not statistically improve visual outcomes over TAI but did facilitate pathogen identification. Fentanyl use conferred greater odds of poor visual outcomes.
This abstract was presented at the 2023 ARVO Annual Meeting, held in New Orleans, LA, April 23-27, 2023.