Traumatic Endophthalmitis After Ocular Injury: Microbiologic Spectrum and Predictors of Visual Outcome in a Multicenter Retrospective 22-Year Case Series

Traumatic Endophthalmitis After Ocular Injury: Microbiologic Spectrum and Predictors of Visual Outcome in a Multicenter Retrospective 22-Year Case Series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Traumatic Endophthalmitis After Ocular Injury: Microbiologic Spectrum and Predictors of Visual Outcome in a Multicenter Retrospective 22-Year Case Series Elia de Esteban Maciñeira, Manuel Francisco Bande Rodríguez, Belén Fente-Sampayo, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8389326/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Traumatic endophthalmitis remains a vision-threatening emergency after open globe injuries. We aimed to describe epidemiology, microbiology, management patterns, and outcomes across tertiary centers, and to identify factors associated with poor final best-corrected visual acuity (BCVA). Methods Multicenter retrospective case series of consecutive eyes with traumatic endophthalmitis treated from January 2003 to January 2025 in seven tertiary hospitals. Demographics, injury details (including intraocular foreign body, IOFB), clinical findings, microbiology, and treatments (intravitreal antibiotics and pars plana vitrectomy, PPV) were analyzed. The primary outcome was final BCVA (logMAR). Results Seventy-four eyes were included (93.2% male; 95.9% penetrating injuries; 60.8% corneal; 45.9% with IOFB). Culture positivity was 58.1%, predominantly Staphylococcus epidermidis . Intravitreal antibiotics were given in 70.3% and PPV in 64.9%. Mean time from trauma to diagnosis was 1.2 ± 1.6 days; mean time from diagnosis to first intravitreal injection was 0.3 ± 1.2 days. Mean BCVA improved from 2.10 ± 0.72 to 1.06 ± 1.26 logMAR at last follow up. Final BCVA ≤ 1.0 logMAR was achieved in 43.2%, while 16.2% required evisceration. On univariate analysis, worse baseline BCVA was associated with poor final BCVA (≥ 1.0 logMAR), whereas IOFB, retinal detachment (RD), culture positivity, intravitreal therapy, and PPV were not significant predictors Conclusions Despite standardized early care, functional recovery was limited. Baseline BCVA was the strongest prognostic indicator, supporting early risk stratification and rapid source control with guideline-concordant empiric therapy adapted to the work environments and climatic conditions. traumatic endophthalmitis open‑globe injury intraocular foreign body microbiology Introduction Ocular trauma is the leading cause of monocular blindness worldwide [ 1 ]. Traumatic endophthalmitis is a vision-threatening complication of open-globe injury, with reported incidences of approximately 4–16% in prior series [ 2 ]. Prognosis remains guarded despite advances in ocular trauma care. Core management includes timely microbiologic sampling, broad-spectrum intravitreal antimicrobial therapy, and PPV in selected cases [ 1 , 2 ]. National guidance emphasizes prompt primary wound closure, adequate Gram-positive and Gram-negative intravitreal coverage, and early referral to vitreoretinal centers [ 3 ]. We conducted a multicenter study across seven tertiary hospitals in northwest Spain to characterize presentation and microbiology, quantify visual and anatomic outcomes, and identify predictors of poor vision, situating our findings alongside current evidence and guidelines. In this context, the multicenter design, which covers a considerable number of hospitals within a defined geographical region (northern Spain) with a similar climate and lifestyle, is particularly valuable. It confers great methodological and clinical relevance, allowing for the standardization of diagnostic and therapeutic protocols, thereby reducing the variability associated with local hospital practices. Methods Study design and setting We retrospectively reviewed consecutive cases of traumatic endophthalmitis managed between January 2003 and January 2025 across seven tertiary hospitals in northwest Spain. Reporting adheres to the STROBE guidelines. Data collection Collected variables included demographic data; injury mechanism and wound location; IOFBs presence and material; baseline ocular findings including initial BCVA; relevant medical history; timing variables (trauma to diagnosis; diagnosis to first intravitreal injection); microbiology and antimicrobial susceptibility; and treatment details (intravitreal, topical, and systemic antimicrobials; corticosteroids; PPV; and adjuvant therapies). Outcomes included final BCVA, evisceration, and structural sequelae. Visual acuity (VA) BCVA was recorded in logMAR units using predefined values for low-vision categories (counting fingers (CF) = 2.00; hand motion (HM) = 2.30; light perception (LP) = 2.80; no light perception (NLP) = 3.00) [ 1 ]. Outcomes The primary outcome was final BCVA (logMAR). Poor visual outcome was defined as final BCVA ≥ 1.0 logMAR. Clinical management All patients were evaluated emergently by an ophthalmologist. Penetrating injuries underwent orbital computed tomography to assess for IOFB and prompt surgical repair of the open globe. When an IOFB was present, PPV with IOFB removal was performed. Ocular ultrasonography was performed in suspected endophthalmitis for diagnostic confirmation, and intravitreal antibiotics were administered in high‑risk presentations, consistent with national guidance [ 3 ]. Statistical analysis Continuous variables were summarized as mean ± standard deviation (SD) or median (interquartile range, IQR); categorical variables as frequencies and percentages. Two-sided p-values are reported to three decimals. Prespecified risk factors (initial BCVA thresholds, culture positivity, IOFB, retinal detachment, intravitreal therapy, and PPV) were evaluated using odds ratios (ORs) with 95% confidence intervals (CIs). Ethics The study adhered to the Declaration of Helsinki and received approval from the institutional review boards of all participating centers (coordinating center: Complejo Hospitalario Universitario de Santiago de Compostela; protocol RTP-MBR-E-2023-01, version 2.0, April 13, 2023). Informed consent was waived due to the use of de‑identified data. Results Participants and baseline characteristics Seventy-four patients (74 eyes) with traumatic endophthalmitis were included. Mean age was 53.5 ± 18.3 years (range, 1.6–91.5), and most were male (69/74, 93.2%) from rural background (67/74, 90.5%) ( Table 1 ) . Table 1 Baseline Demographic and Injury Characteristics in 74 Eyes With Traumatic Endophthalmitis Variable n (%) or Mean ± SD (range) Age (years) 53.5 ± 18.3 (1.6–91.5) Sex – male 69 (93.2%) Sex – female 5 (6.8%) Rural background 67 (90.5%) Penetrating trauma 71 (95.9%) • With IOFB 34 (45.9%) • Without IOFB 37 (50.0%) Blunt / non‑penetrating trauma 3 (4.1%) Corneal wound 45 (60.8%) Scleral wound 9 (12.2%) Combined corneal–scleral wound 2 (2.7%) Wound location not specified 20 (27.0%) Injury characteristics Penetrating trauma occurred in 71/74 cases (95.9%), whereas 3/74 (4.1%) were blunt injuries. IOFB was identified in 34/74 eyes (45.9%). Wound location was corneal in 45/74 eyes (60.8%), scleral in 9/74 (12.2%), combined corneal–scleral in 2/74 (2.7%), and not specified in 20/74 (27.0%). Metallic traumatizing material were present in 31/74 injuries (41.9%) and vegetal/organic materials in 18/74 (24.3%); the remaining cases involved inert or unknown materials ( Table 1 ) . The mean time from trauma to diagnosis was 1.2 ± 1.6 days (range, 0–8). Anatomical complications at presentation Retinal detachment (RD) was present in 23/74 eyes (31.1%). Lens involvement (traumatic cataract, dislocation, aphakia, or capsular opacity) occurred in 19/74 eyes (25.7%). Corneal alteration (edema, keratitis, or melting) was observed in 24/74 (32.4%). Hypopyon was present in 41/74 cases (55.4%) ( Table 2 ) . Table 2 Clinical Complications at Presentation in 74 Eyes With Traumatic Endophthalmitis Complication n (%) Retinal detachment 23 (31.1%) Lens involvement (traumatic cataract, aphakia, or dislocation) 19 (25.7%) Corneal alteration (edema, keratitis, or corneal melt) 24 (32.4%) Hypopyon 41 (55.4%) Microbiology and antimicrobial susceptibility Cultures were positive in 43/74 cases (58.1%). Among culture-positive cases, 86.0% of isolates were bacterial (37/43) and 16.3% were fungal (7/43). Of note, 11.6% cases (5/43) were polymicrobial; 4/43 involved multiple bacteria and 1/43 included both bacteria and fungi ( Absidia sp ., Staphylococcus warneri and Staphylococcus epidermidis) . The most frequent pathogens were Staphylococcus epidermidis (14/74, 18.9%), Staphylococcus aureus (4/74, 5.4%), Bacillus cereus (4/74, 5.4%), and Streptococcus (7/74, 9.5%). Among fungi, Fusarium oxysporum predominated (3/74, 4.1%) ( Table 3 ) . Culture positivity was higher in vitreous samples (63.9%) than aqueous humor samples (37.9%). Table 3 Microbiologic Spectrum in 74 Eyes With Traumatic Endophthalmitis Pathogen n (%) of total eyes (N = 74) Any positive culture 43 (58.1%) GRAM- POSITIVE BACTERIA 40 (54.1%) • Staphylococcus epidermidis 14 (18.9%) • Other coagulase-negative Staphylococci ( S. lugdunensis, S. hominis, S. warneri, S. cohnii, S. capitis ) 6 (8.1%) • Staphylococcus aureus 4 (5.4%) • Streptococcus agalactiae 4 (5.4%) • Oral viridans Streptococci ( Streptococcus parasanguis, Streptococcus mitis, Viridans Group Streptococcus ) 3 (4.1%) • Bacillus cereus 4 (5.4%) • Enterococcus faecalis 2 (2.7%) • Micrococcus sp. 1 (1.4%) • Clostridium sp. 1 (1.4%) • Cutibacterium acnes 1 (1.4%) GRAM- NEGATIVE BACTERIA 3 (4.1%) • Proteus mirabilis 1 (1.4%) • Escherichia coli 1 (1.4%) • Citrobacter freundii 1 (1.4%) FUNGI 7 (9.5%) • Fusarium oxysporum 3 (4.1%) • Scedosporium apiospermum 2 (2.7%) • Candida parapsilosis 1 (1.4%) • Absidia sp. (Lictheimia) 1 (1.4%) POLYMICROBIAL 5 (6.8%) Bacterial isolates showed frequent resistance to macrolides and lincosamides. In Staphylococcus spp., resistance to erythromycin and clindamycin was 28.3% and 10.9%, respectively; resistance to gentamicin was 10.9% and to oxacillin 6.5%. In Streptococcus spp., resistance to penicillin, ampicillin, and amoxicillin–clavulanate was 13.0%, 8.7%, and 4.3%, respectively. Although Gram-negative organisms were less common, multidrug-resistant isolates were identified, including Citrobacter freundii and Proteus mirabilis . Quinolone resistance was low in our series (2.2% to ciprofloxacin; none to moxifloxacin). Aminoglycoside resistance was 10.9%. One Fusarium oxysporum isolate showed broad resistance across polyenes, azoles, and echinocandins; the remaining fungal isolates were susceptible. ( Table 3 ) . Treatment Initial management included PPV in 48/74 eyes (64.9%). Intravitreal antimicrobials were administered in 52/74 eyes (70.3%), with 20/74 (27.0%) receiving two or more injections. Vancomycin plus ceftazidime was the most common intravitreal regimen; intravitreal voriconazole or dexamethasone were used selectively. Systemic antibiotics were administered to 61/74 patients (82.4%), and systemic corticosteroids to 22/74 (29.7%). Hospital admission was required in 55/74 cases (74.3%), with a mean stay of 7.8 ± 5.7 days (median, 7). The first intravitreal injection occurred at 0.3 ± 1.2 days from diagnosis ( Table 4 ) . Table 4 Treatment Modalities in 74 Eyes With Traumatic Endophthalmiti Intervention n (%) of eyes (N = 74) Pars plana vitrectomy (PPV) 48 (64.9%) Intravitreal antimicrobial injections (IVI) 52 (70.3%) ≥ 2 IVI 20 (27.0%) Time from diagnosis to first IVI 0.3 ± 1.2 (mean ± SD, days) Systemic antimicrobial treatment 61 (82.4%) Systemic corticosteroids 22 (29.7%) Hospital admission 55 (74.3%) Visual and anatomic outcomes Baseline BCVA was 2.10 ± 0.72 logMAR (median, 2.3), improving to 1.06 ± 1.26 logMAR at final follow-up. Overall, 43.2% achieved final BCVA ≤ 1.0 logMAR and anatomical loss (phthisis bulbi or evisceration) occurred in 18 eyes (24.3%) ( Table 5 ) . Evisceration occurred in 12/74 eyes (16.2%). Table 5 Visual and Anatomical Outcomes in 74 Eyes With Traumatic Endophthalmitis Outcome n (%) or Mean ± SD (median) Baseline BCVA (logMAR) 2.10 ± 0.72 (2.3) Final BCVA (logMAR) 1.06 ± 1.26 (1.6) BCVA improvement from baseline 33 (41.2%) Final BCVA ≤ 1.0 logMAR 32 (43.2%) Final BCVA > 1.0 logMAR 31 (41.9%) Severe visual outcomes: LP 7 (9.5%) Severe visual outcomes: HM 4 (5.4%) Severe visual outcomes: NLP 15 (20.3%) Final BCVA not registered 11 (14.9%) Evisceration 12 (16.2%) Phthisis bulbi 6 (8.1%) Globe preservation 56 (75.7%) Factors associated with poor visual prognosis On univariate analysis, baseline BCVA was the only significant predictor of poor final BCVA (≥ 1.0 logMAR). Thresholds of 2.3 logMAR and 2.0 logMAR yielded ORs of 8.59 (95% CI 1.85–39.79; p = 0.004) and 7.15 (95% CI 1.53–33.45; p = 0.010), respectively. IOFB presence, IOFB material, wound location, hypopyon, anterior chamber fibrin, flat anterior chamber, lens involvement, age ≥ 70 years, fungal vs bacterial etiology, and Gram-positive vs Gram-negative organisms were not significantly associated with outcome ( Table 6 ) . Since only baseline BCVA demonstrated a significant association in univariate analysis, a multivariable model was not constructed. Though it was not statistically significant, we observed final BCVA (median) varied by pathogen: 2.00 logMAR for Gram positives, 2.50 logMAR for Gram negatives, and 1.25 logMAR for Fungi (Table 6 ). Polymicrobial infections had uniformly poor outcomes (final BCVA 3.0 logMAR) (Table 6 ). Final BCVA (median) also varied by the nature of the traumatizing material: 3.00 logMAR for blunt organic injuries, which caused keratitis with poor evolution, 0.80 logMAR for metallic penetrating injuries with IOFB, and 0.30 logMAR for penetrating organic injuries without IOFB (Table 7 ). Table 6 Final BCVA by Microorganism group Microbiological Group n Final BCVA (logMAR), median (IQR) Gram positives 40 2.00 (0.40–2.80) Gram negatives 3 2.50 (2.25–2.75) Fungi 7 1.25 (0.20–2.83) Polymicrobial 5 3.00 (2.00–3.00) Negative culture / Not registered 31 0.40 (0.10–2.30) Gram positives included Staphylococcus spp. ( S. epidermidis, S. aureus, S. hominis, S. capitis, S. cohnii, S. lugdunensis, S. warneri ), Streptococcus spp. ( S. viridans, S. mitis, S. parasanguis, S. agalactiae ), Bacillus spp., Enterococcus faecalis, Micrococcus spp. and Cutibacterium acnes . Gram negatives included Escherichia coli, Proteus mirabilis and Citrobacter freundii . Fungi included Fusarium oxysporum , Candida parapsilosis, Scedosporium apiospermum and Absidia sp . Polymicrobial was defined as the isolation of ≥ 2 microorganisms in the same episode. Table 7 Final BCVA by Traumatizing Material Trauma IOFB Nature (grouped) n Final BCVA (logMAR), median (IQR) Blunt No Vegetal 3 3.00 (2.50–3.00) Penetrating Yes Metallic 25 0.80 (0.15–2.30) Vegetal 2 1.00 (—) Other / Unknown 8 2.30 (0.30–3.00) No Metallic 6 0.20 (0.10–3.00) Vegetal 13 0.30 (0.20–3.00) Other / Unknown 17 2.80 (0.00–3.00) Treatment-specific outcomes Poor final BCVA (≥ 1.0 logMAR) occurred in 58.8% of eyes receiving intravitreal therapy vs 40.0% of those without intravitreal therapy. PPV was not significantly associated with final BCVA (49.0% vs 34.5%; p = 0.211). Similar outcomes were observed regardless of systemic antibiotic or corticosteroid use ( Table 4 ) . Discussion The study population was predominantly rural, reflecting the socioeconomic context of Galicia and Asturias, where agricultural, livestock, and industrial activities are common and inherently increase the risk of ocular trauma from metallic and organic debris. The northwest of Spain has a temperate oceanic climate characterized by mild temperatures, high humidity, and frequent rainfall throughout much of the year. These environmental conditions—together with rural occupational exposures—may shape the local microbiological landscape of traumatic endophthalmitis, with a potentially higher burden of soil- and plant-associated organisms compared with drier or urban regions. Male predominance observed in our study, associated with a wide range of ages, is consistent with previous reports and appears to be related to the greater exposure of males to higher-risk work environments (industrial, agricultural, or involving the use of tools) [ 4 , 5 ]. The nature of the trauma played a critical role in the etiology of the endophthalmitis cases analyzed. In our study, IOFB was identified in 45.9% of cases, with metallic objects being the most frequently implicated (41.9%), followed by organic materials in 24.3%. Zhuang et al. reported comparable rates of IOFB identification in cases of traumatic endophthalmitis (33.9%) [ 6 ]. Other authors, consistent with our observations, have also documented a predominance of metallic IOFBs among those identified [ 7 , 8 ]. Nonetheless, it is important to emphasize that although the presence of an IOFB substantially increases both severity and infection risk, it is not a prerequisite for the development of post-traumatic endophthalmitis. Functional recovery following traumatic endophthalmitis remained markedly limited. Although most eyes maintained anatomical integrity, only 43.2% achieved a final BCVA ≤ 1.0 logMAR, underscoring the substantial visual morbidity associated with these injuries. These findings are consistent with aggregated evidence from large cohorts assessing prognostic determinants and surgical timing in open-globe trauma [ 1 , 2 ]. The ocular manifestations documented in our study align with previous reports and are indicative of a marked and often abrupt inflammatory response [ 4 , 5 ]. Corneal perforation, identified in 60.8% of cases, was most strongly associated with poor baseline VA and the subsequent need for complex, highly invasive reconstructive procedures. In our series, baseline VA was the only variable significantly associated with poor visual outcome, while culture positivity, IOFB, and RD showed trends aligned with published literature but did not reach statistical significance. The unadjusted association between intravitreal therapy and poorer visual outcomes likely reflects confounding by indication: eyes with greater baseline severity (e.g., dense vitritis, IOFB, or media opacity) were preferentially treated more intensively; therefore, this correlation should not be inferred as causal [ 2 – 3 , 9 – 16 ]. Prospective capture of injection number and timing, alongside standardized severity metrics and multivariable methods to adjust for baseline imbalances, would help clarify this relationship in future studies. Microbiologically, Gram-positive bacteria predominated, accounting for 93.0% of positive cultures (40/43), with Staphylococcus species being the most frequently isolated organisms (55.8% of positive cultures, 24/43). Among these, coagulase-negative Staphylococcus represented 46.5% of positive samples (20/43). Bacillus cereus constituted 9.3% of positive samples (4/43) and has traditionally been associated with rapidly progressive post-traumatic presentations and infections related to intraocular foreign bodies (IOFBs), particularly in reports from rural or industrial settings where such microorganisms are common contaminants of open-globe injuries [ 8 ]. This profile supports empirical intravitreal coverage targeting Gram-positive and Gram-negative organisms, in line with national guidance from the Spanish Vitreo-Retinal Society (SERV), which advocates empirical intravitreal treatment combining vancomycin with a third-generation cephalosporin (or equivalent Gram-negative coverage), and aligns with recently published reviews on traumatic endophthalmitis [ 3 – 6 ]. Fungal infections were less common in our series (16.3% of positive cultures, 7/43) but remained clinically relevant—particularly in injuries involving vegetative material—consistent with published traumatic series [ 6 , 10 ]. Nevertheless, they occurred at a slightly higher rate than that reported in other series (5%–15%) [ 7 , 8 ]. This increased incidence may be related to local climatic conditions—specifically a humid and temperate environment—as well as greater agricultural and livestock activity in the region, factors that heighten the risk of trauma involving vegetative material, a well-recognized vector for fungal inoculation. Most of the microorganisms isolated in our series demonstrated good susceptibility to the antimicrobial regimens commonly used for empirical intravitreal therapy. However, over the course of more than 20 years, some cases exhibited resistance patterns, particularly to macrolides and lincosamides among Staphylococcus , and although Gram-negative organisms were less common, multidrug-resistant isolates were identified during this period, especially Citrobacter freundii and Proteus mirabilis . These findings underscore the need to adjust the therapeutic regimen once antimicrobial susceptibility results became available. Given that initial treatment in most cases of endophthalmitis is administered empirically, the availability of local antimicrobial susceptibility data is essential to guide the selection of first-line therapy and optimize clinical outcomes. Regarding prophylaxis after open-globe injury, recent meta-analytic data shows no benefit to extending systemic antibiotics beyond 24 hours and no superiority of intravenous or intraocular routes over oral administration; ciprofloxacin monotherapy underperforms versus vancomycin plus a third-generation cephalosporin [ 16 ]. These results support concise, risk-adapted prophylaxis—particularly in patients with IOFB, rural injuries, or lens rupture—and reinforce our cohort’s empirical Gram-positive/Gram-negative approach, in harmony with SERV recommendations [ 1 – 3 , 6 , 16 ]. Because management is initiated empirically, rapid diagnostics can complement culture-based testing. Polymerase chain reaction (PCR) can refine early treatment decisions and support diagnosis when initial cultures are negative [ 17 ]. Among host-response biomarkers, vitreous soluble Triggering Receptor Expressed on Myeloid cells-1 (sTREM-1) may help discriminate infectious from non-infectious presentations; elevations have been reported in both culture-positive and culture-negative traumatic cases, supporting escalation when clinical suspicion remains high despite negative cultures [ 18 ]. The traditional Endophthalmitis Vitrectomy Study (EVS) paradigm is frequently challenged in the context of traumatic endophthalmitis. The role and timing of PPV should be individualized. In our series, PPV was performed early in 64.9% of cases and was not independently associated with worse visual outcomes. When IOFB, dense vitritis, or media opacity are present, early PPV facilitates source control, direct sampling, and removal of necrotic/toxic material—though definitions of “early” vary across studies [ 1 , 9 – 11 ]. Notably, PPV serves both therapeutic and diagnostic purposes by enabling removal of inflamed and infected vitreous, enhancing intravitreal antibiotic penetration, and providing samples for culture. In eyes with total media opacity where a temporary keratoprosthesis is not feasible, ultrasound-guided PPV (USG‑PPV) can enable safer debulking under intraoperative imaging [ 19 ]. Recently, the complementary use of intravitreal injections or low-concentration diluted povidone–iodine irrigation (0.025%–1.25%) has been recommended, as it has demonstrated bactericidal, fungicidal, and virucidal activity in infections associated with intraocular foreign bodies, without inducing inflammation or retinal toxicity; however, the overall quality of evidence remains limited [ 20 , 21 ]. Broader epidemiologic experience similarly emphasizes the ongoing burden of trauma-related endophthalmitis and the importance of coordinated regional care networks, consistent with our multicenter experience in Asturias and Galicia [ 3 , 12 – 15 ]. Strengths of this study include its multicenter design, standardized VA conversion, and comprehensive capture of microbiology, treatment, and outcomes across two decades. Limitations inherent to retrospective analyses include potential selection/referral bias, incomplete timing data, and residual confounding by indication (notably for intravitreal therapy and PPV). Inter-hospital variability in practice, small fungal and Gram-negative subgroups, and possible misclassification of IOFB material may limit generalizability. Future prospective studies should incorporate prespecified, penalized multivariable analyses, standardized time-to-intervention metrics, and systematic handling of missing data. Conclusions In this multicenter series of traumatic endophthalmitis, infection control and globe preservation were high, yet functional recovery remained limited. The long study period of over 20 years allowed for the demonstration of stability in the spectrum of causative microorganisms, although resistance to certain antibiotics (macrolides and lincosamides) and multidrug-resistant Gram-negative organisms was observed. Epidemiological experience from a specific region of northern Spain, characterized by specific climatic conditions and occupational activities, can inform the development of empirically tailored therapeutic strategies aligned with the local microbial profile and resistance patterns. Early risk stratification, primarily based on initial visual acuity, combined with careful assessment of injury severity, IOFB status, and RD, may assist in patient classification and treatment planning, thereby facilitating prompt source control and management of trauma-associated endophthalmitis. Abbreviations BCVA best-corrected visual acuity VA visual acuity IOFB intraocular foreign body PPV pars plana vitrectomy RD retinal detachment CF Counting fingers HM hand motion LP light perception NLP no light perception logMAR logarithm of the minimum angle of resolution SD Standard deviation IQR interquartile range OR odds ratio CI confidence interval SERV Spanish Vitreo-Retinal Society EVS Endophthalmitis Vitrectomy Study sTREM-1 Triggering Receptor Expressed on Myeloid cells-1 PCR Polymerase chain reaction USG‑PPV ultrasound‑guided pars plana vitrectomy. Declarations Ethics approval and consent to participate: The study adhered to the tenets of the Declaration of Helsinki and was approved by the Institutional Review Boards of all participating centers (coordinating center: Complejo Hospitalario Universitario de Santiago de Compostela; protocol RTP-MBR-E-2023-01, v2.0, April 13, 2023). The requirement for individual informed consent was waived for de‑identified data. Consent for publication: Not applicable (aggregated, de‑identified data). Funding: None. Author Contribution E.d.E.M. conceived the study, curated data, and drafted the manuscript. M.F.B.R. performed data analysis/interpretation and critically revised the manuscript. R.T.P. supervised methodology and contributed to clinical interpretation and manuscript revision. All authors helped with data acquisition and read and approved the final manuscript. Acknowledgement We sincerely thank the Ophthalmology Departments of the participating hospitals in Galicia and Asturias for their valuable contribution to this research, their willingness to take part in it and for the care of the patients included in this study. We would also like to thank the Microbiology Departments of the participating hospitals for their support in carrying out this study, specially Gema Barbeiro Castiñeiras (CHUS), Daniel Navarro de la Cruz (CHUS), Javier Alba Domínguez (HULA), María Isabel Paz Vidal (CHUO), Marina Oviaño García (CHUAC), Luz María Moldes Suárez (CHUAC), Pedro Miguel Juiz González (CHUF), Ana María Sáez Lopez (CHUP), Pablo González Moreno (HUCA) and Teresa Peláez de la Rasilla (HUCA). Data Availability De‑identified data are available from the corresponding author upon reasonable request. 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Retina 42:1721–1725. 10.1097/IAE.0000000000003600 Lee SM, Park JH, Jang CH, Byon I (2021) Intravitreal injection of povidone-iodine for vancomycin-resistant Enterococcus faecalis endophthalmitis in rabbit eyes. Exp Eye Res 208:108614. 10.1016/j.exer.2021.108614 Liu C, Xu K, Hu Y, Zhuang X, Fu B, Wang L et al (2023) Vitrectomy using 0.025% povidone-iodine irrigation for post-traumatic endophthalmitis with IOFB: two case reports. Front Surg 9:988776. 10.3389/fsurg.2022.988776 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 20 Apr, 2026 Reviews received at journal 26 Jan, 2026 Reviewers agreed at journal 20 Jan, 2026 Reviewers invited by journal 19 Jan, 2026 Editor assigned by journal 18 Dec, 2025 Submission checks completed at journal 18 Dec, 2025 First submitted to journal 17 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8389326","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":577300612,"identity":"36404e9b-ad70-424b-a19e-574e50cba66e","order_by":0,"name":"Elia de Esteban 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13:07:17","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":110222,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8389326/v1/8f91230df5412ad12d7b8be1.html"},{"id":100804111,"identity":"cf3bce74-60a2-423c-8474-d8ba52962024","added_by":"auto","created_at":"2026-01-21 14:37:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":955331,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8389326/v1/fb45de86-75e0-45ba-8c72-83dd9397fcea.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Traumatic Endophthalmitis After Ocular Injury: Microbiologic Spectrum and Predictors of Visual Outcome in a Multicenter Retrospective 22-Year Case Series","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOcular trauma is the leading cause of monocular blindness worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Traumatic endophthalmitis is a vision-threatening complication of open-globe injury, with reported incidences of approximately 4\u0026ndash;16% in prior series [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Prognosis remains guarded despite advances in ocular trauma care. Core management includes timely microbiologic sampling, broad-spectrum intravitreal antimicrobial therapy, and PPV in selected cases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. National guidance emphasizes prompt primary wound closure, adequate Gram-positive and Gram-negative intravitreal coverage, and early referral to vitreoretinal centers [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e We conducted a multicenter study across seven tertiary hospitals in northwest Spain to characterize presentation and microbiology, quantify visual and anatomic outcomes, and identify predictors of poor vision, situating our findings alongside current evidence and guidelines. In this context, the multicenter design, which covers a considerable number of hospitals within a defined geographical region (northern Spain) with a similar climate and lifestyle, is particularly valuable. It confers great methodological and clinical relevance, allowing for the standardization of diagnostic and therapeutic protocols, thereby reducing the variability associated with local hospital practices.\u003c/p\u003e "},{"header":"Methods","content":"\n\u003ch3\u003eStudy design and setting\u003c/h3\u003e\n\u003cp\u003eWe retrospectively reviewed consecutive cases of traumatic endophthalmitis managed between January 2003 and January 2025 across seven tertiary hospitals in northwest Spain. Reporting adheres to the STROBE guidelines.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eCollected variables included demographic data; injury mechanism and wound location; IOFBs presence and material; baseline ocular findings including initial BCVA; relevant medical history; timing variables (trauma to diagnosis; diagnosis to first intravitreal injection); microbiology and antimicrobial susceptibility; and treatment details (intravitreal, topical, and systemic antimicrobials; corticosteroids; PPV; and adjuvant therapies). Outcomes included final BCVA, evisceration, and structural sequelae.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eVisual acuity (VA)\u003c/h3\u003e\n\u003cp\u003eBCVA was recorded in logMAR units using predefined values for low-vision categories (counting fingers (CF)\u0026thinsp;=\u0026thinsp;2.00; hand motion (HM)\u0026thinsp;=\u0026thinsp;2.30; light perception (LP)\u0026thinsp;=\u0026thinsp;2.80; no light perception (NLP)\u0026thinsp;=\u0026thinsp;3.00) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was final BCVA (logMAR). Poor visual outcome was defined as final BCVA\u0026thinsp;\u0026ge;\u0026thinsp;1.0 logMAR.\u003c/p\u003e\n\u003ch3\u003eClinical management\u003c/h3\u003e\n\u003cp\u003eAll patients were evaluated emergently by an ophthalmologist. Penetrating injuries underwent orbital computed tomography to assess for IOFB and prompt surgical repair of the open globe. When an IOFB was present, PPV with IOFB removal was performed. Ocular ultrasonography was performed in suspected endophthalmitis for diagnostic confirmation, and intravitreal antibiotics were administered in high‑risk presentations, consistent with national guidance [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median (interquartile range, IQR); categorical variables as frequencies and percentages. Two-sided p-values are reported to three decimals. Prespecified risk factors (initial BCVA thresholds, culture positivity, IOFB, retinal detachment, intravitreal therapy, and PPV) were evaluated using odds ratios (ORs) with 95% confidence intervals (CIs).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e The study adhered to the Declaration of Helsinki and received approval from the institutional review boards of all participating centers (coordinating center: Complejo Hospitalario Universitario de Santiago de Compostela; protocol RTP-MBR-E-2023-01, version 2.0, April 13, 2023). Informed consent was waived due to the use of de‑identified data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and baseline characteristics\u003c/h2\u003e \u003cp\u003eSeventy-four patients (74 eyes) with traumatic endophthalmitis were included. Mean age was 53.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18.3 years (range, 1.6\u0026ndash;91.5), and most were male (69/74, 93.2%) from rural background (67/74, 90.5%) \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Demographic and Injury Characteristics in 74 Eyes With Traumatic Endophthalmitis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) or Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18.3 (1.6\u0026ndash;91.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex \u0026ndash; male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (93.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex \u0026ndash; female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (6.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural background\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (90.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePenetrating trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (95.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; With IOFB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (45.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Without IOFB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlunt / non‑penetrating trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorneal wound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (60.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScleral wound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (12.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined corneal\u0026ndash;scleral wound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound location not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (27.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInjury characteristics\u003c/h2\u003e \u003cp\u003ePenetrating trauma occurred in 71/74 cases (95.9%), whereas 3/74 (4.1%) were blunt injuries. IOFB was identified in 34/74 eyes (45.9%). Wound location was corneal in 45/74 eyes (60.8%), scleral in 9/74 (12.2%), combined corneal\u0026ndash;scleral in 2/74 (2.7%), and not specified in 20/74 (27.0%). Metallic traumatizing material were present in 31/74 injuries (41.9%) and vegetal/organic materials in 18/74 (24.3%); the remaining cases involved inert or unknown materials \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. The mean time from trauma to diagnosis was 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 days (range, 0\u0026ndash;8).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAnatomical complications at presentation\u003c/h2\u003e \u003cp\u003eRetinal detachment (RD) was present in 23/74 eyes (31.1%). Lens involvement (traumatic cataract, dislocation, aphakia, or capsular opacity) occurred in 19/74 eyes (25.7%). Corneal alteration (edema, keratitis, or melting) was observed in 24/74 (32.4%). Hypopyon was present in 41/74 cases (55.4%) \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical Complications at Presentation in 74 Eyes With Traumatic Endophthalmitis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetinal detachment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (31.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLens involvement (traumatic cataract, aphakia, or dislocation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (25.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorneal alteration (edema, keratitis, or corneal melt)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (32.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypopyon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41 (55.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMicrobiology and antimicrobial susceptibility\u003c/h2\u003e \u003cp\u003eCultures were positive in 43/74 cases (58.1%). Among culture-positive cases, 86.0% of isolates were bacterial (37/43) and 16.3% were fungal (7/43). Of note, 11.6% cases (5/43) were polymicrobial; 4/43 involved multiple bacteria and 1/43 included both bacteria and fungi (\u003cem\u003eAbsidia sp\u003c/em\u003e., \u003cem\u003eStaphylococcus warneri and Staphylococcus epidermidis)\u003c/em\u003e. The most frequent pathogens were \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e (14/74, 18.9%), \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (4/74, 5.4%), \u003cem\u003eBacillus cereus\u003c/em\u003e (4/74, 5.4%), and \u003cem\u003eStreptococcus\u003c/em\u003e (7/74, 9.5%). Among fungi, \u003cem\u003eFusarium oxysporum\u003c/em\u003e predominated (3/74, 4.1%) \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. Culture positivity was higher in vitreous samples (63.9%) than aqueous humor samples (37.9%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMicrobiologic Spectrum in 74 Eyes With Traumatic Endophthalmitis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathogen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) of total eyes (N\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny positive culture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43 (58.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGRAM- POSITIVE BACTERIA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e40 (54.1%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (18.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Other coagulase-negative \u003cem\u003eStaphylococci\u003c/em\u003e (\u003cem\u003eS. lugdunensis, S. hominis, S. warneri, S. cohnii, S. capitis\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eStaphylococcus aureus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eStreptococcus agalactiae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Oral viridans \u003cem\u003eStreptococci\u003c/em\u003e (\u003cem\u003eStreptococcus parasanguis, Streptococcus mitis, Viridans Group Streptococcus\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eBacillus cereus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eEnterococcus faecalis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eMicrococcus sp.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eClostridium sp.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eCutibacterium acnes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGRAM- NEGATIVE BACTERIA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3 (4.1%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eProteus mirabilis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eEscherichia coli\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eCitrobacter freundii\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFUNGI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e7 (9.5%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eFusarium oxysporum\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eScedosporium apiospermum\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eCandida parapsilosis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cem\u003eAbsidia sp. (Lictheimia)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePOLYMICROBIAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e5 (6.8%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBacterial isolates showed frequent resistance to macrolides and lincosamides. In \u003cem\u003eStaphylococcus\u003c/em\u003e spp., resistance to erythromycin and clindamycin was 28.3% and 10.9%, respectively; resistance to gentamicin was 10.9% and to oxacillin 6.5%. In \u003cem\u003eStreptococcus\u003c/em\u003e spp., resistance to penicillin, ampicillin, and amoxicillin\u0026ndash;clavulanate was 13.0%, 8.7%, and 4.3%, respectively. Although Gram-negative organisms were less common, multidrug-resistant isolates were identified, including \u003cem\u003eCitrobacter freundii\u003c/em\u003e and \u003cem\u003eProteus mirabilis\u003c/em\u003e. Quinolone resistance was low in our series (2.2% to ciprofloxacin; none to moxifloxacin). Aminoglycoside resistance was 10.9%. One Fusarium oxysporum isolate showed broad resistance across polyenes, azoles, and echinocandins; the remaining fungal isolates were susceptible. \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTreatment\u003c/h2\u003e \u003cp\u003eInitial management included PPV in 48/74 eyes (64.9%). Intravitreal antimicrobials were administered in 52/74 eyes (70.3%), with 20/74 (27.0%) receiving two or more injections. Vancomycin plus ceftazidime was the most common intravitreal regimen; intravitreal voriconazole or dexamethasone were used selectively. Systemic antibiotics were administered to 61/74 patients (82.4%), and systemic corticosteroids to 22/74 (29.7%). Hospital admission was required in 55/74 cases (74.3%), with a mean stay of 7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7 days (median, 7). The first intravitreal injection occurred at 0.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 days from diagnosis \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTreatment Modalities in 74 Eyes With Traumatic Endophthalmiti\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) of eyes (N\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePars plana vitrectomy (PPV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (64.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntravitreal antimicrobial injections (IVI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (70.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;2 IVI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (27.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime from diagnosis to first IVI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, days)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystemic antimicrobial treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (82.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystemic corticosteroids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (29.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (74.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eVisual and anatomic outcomes\u003c/h2\u003e \u003cp\u003eBaseline BCVA was 2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72 logMAR (median, 2.3), improving to 1.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26 logMAR at final follow-up. Overall, 43.2% achieved final BCVA\u0026thinsp;\u0026le;\u0026thinsp;1.0 logMAR and anatomical loss (phthisis bulbi or evisceration) occurred in 18 eyes (24.3%) \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. Evisceration occurred in 12/74 eyes (16.2%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVisual and Anatomical Outcomes in 74 Eyes With Traumatic Endophthalmitis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) or Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (median)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline BCVA (logMAR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal BCVA (logMAR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBCVA improvement from baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (41.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal BCVA\u0026thinsp;\u0026le;\u0026thinsp;1.0 logMAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (43.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal BCVA\u0026thinsp;\u0026gt;\u0026thinsp;1.0 logMAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (41.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere visual outcomes: LP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (9.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere visual outcomes: HM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere visual outcomes: NLP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (20.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal BCVA not registered\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (14.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvisceration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (16.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhthisis bulbi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlobe preservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (75.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFactors associated with poor visual prognosis\u003c/h2\u003e \u003cp\u003eOn univariate analysis, baseline BCVA was the only significant predictor of poor final BCVA (\u0026ge;\u0026thinsp;1.0 logMAR). Thresholds of 2.3 logMAR and 2.0 logMAR yielded ORs of 8.59 (95% CI 1.85\u0026ndash;39.79; p\u0026thinsp;=\u0026thinsp;0.004) and 7.15 (95% CI 1.53\u0026ndash;33.45; p\u0026thinsp;=\u0026thinsp;0.010), respectively.\u003c/p\u003e \u003cp\u003eIOFB presence, IOFB material, wound location, hypopyon, anterior chamber fibrin, flat anterior chamber, lens involvement, age\u0026thinsp;\u0026ge;\u0026thinsp;70 years, fungal vs bacterial etiology, and Gram-positive vs Gram-negative organisms were not significantly associated with outcome \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. Since only baseline BCVA demonstrated a significant association in univariate analysis, a multivariable model was not constructed. Though it was not statistically significant, we observed final BCVA (median) varied by pathogen: 2.00 logMAR for Gram positives, 2.50 logMAR for Gram negatives, and 1.25 logMAR for Fungi (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Polymicrobial infections had uniformly poor outcomes (final BCVA 3.0 logMAR) (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Final BCVA (median) also varied by the nature of the traumatizing material: 3.00 logMAR for blunt organic injuries, which caused keratitis with poor evolution, 0.80 logMAR for metallic penetrating injuries with IOFB, and 0.30 logMAR for penetrating organic injuries without IOFB (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinal BCVA by Microorganism group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMicrobiological Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFinal BCVA (logMAR), median (IQR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGram positives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.00 (0.40\u0026ndash;2.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGram negatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.50 (2.25\u0026ndash;2.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFungi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.25 (0.20\u0026ndash;2.83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolymicrobial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.00 (2.00\u0026ndash;3.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative culture / Not registered\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.40 (0.10\u0026ndash;2.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eGram positives included \u003cem\u003eStaphylococcus spp.\u003c/em\u003e (\u003cem\u003eS. epidermidis, S. aureus, S. hominis, S. capitis, S. cohnii, S. lugdunensis, S. warneri\u003c/em\u003e), \u003cem\u003eStreptococcus spp.\u003c/em\u003e (\u003cem\u003eS. viridans, S. mitis, S. parasanguis, S. agalactiae\u003c/em\u003e), \u003cem\u003eBacillus spp., Enterococcus faecalis, Micrococcus spp.\u003c/em\u003e and \u003cem\u003eCutibacterium acnes\u003c/em\u003e.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eGram negatives included \u003cem\u003eEscherichia coli, Proteus mirabilis\u003c/em\u003e and \u003cem\u003eCitrobacter freundii\u003c/em\u003e.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eFungi included \u003cem\u003eFusarium oxysporum\u003c/em\u003e, \u003cem\u003eCandida parapsilosis, Scedosporium apiospermum\u003c/em\u003e and \u003cem\u003eAbsidia sp\u003c/em\u003e.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003ePolymicrobial was defined as the isolation of \u0026ge;\u0026thinsp;2 microorganisms in the same episode.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFinal BCVA by Traumatizing Material\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIOFB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNature (grouped)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFinal BCVA (logMAR), median (IQR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlunt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVegetal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.00 (2.50\u0026ndash;3.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003ePenetrating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMetallic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.80 (0.15\u0026ndash;2.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVegetal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00 (\u0026mdash;)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOther / Unknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.30 (0.30\u0026ndash;3.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMetallic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.20 (0.10\u0026ndash;3.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVegetal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.30 (0.20\u0026ndash;3.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOther / Unknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.80 (0.00\u0026ndash;3.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTreatment-specific outcomes\u003c/h2\u003e \u003cp\u003ePoor final BCVA (\u0026ge;\u0026thinsp;1.0 logMAR) occurred in 58.8% of eyes receiving intravitreal therapy vs 40.0% of those without intravitreal therapy. PPV was not significantly associated with final BCVA (49.0% vs 34.5%; p\u0026thinsp;=\u0026thinsp;0.211). Similar outcomes were observed regardless of systemic antibiotic or corticosteroid use \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study population was predominantly rural, reflecting the socioeconomic context of Galicia and Asturias, where agricultural, livestock, and industrial activities are common and inherently increase the risk of ocular trauma from metallic and organic debris. The northwest of Spain has a temperate oceanic climate characterized by mild temperatures, high humidity, and frequent rainfall throughout much of the year. These environmental conditions\u0026mdash;together with rural occupational exposures\u0026mdash;may shape the local microbiological landscape of traumatic endophthalmitis, with a potentially higher burden of soil- and plant-associated organisms compared with drier or urban regions. Male predominance observed in our study, associated with a wide range of ages, is consistent with previous reports and appears to be related to the greater exposure of males to higher-risk work environments (industrial, agricultural, or involving the use of tools) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe nature of the trauma played a critical role in the etiology of the endophthalmitis cases analyzed. In our study, IOFB was identified in 45.9% of cases, with metallic objects being the most frequently implicated (41.9%), followed by organic materials in 24.3%. Zhuang et al. reported comparable rates of IOFB identification in cases of traumatic endophthalmitis (33.9%) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Other authors, consistent with our observations, have also documented a predominance of metallic IOFBs among those identified [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Nonetheless, it is important to emphasize that although the presence of an IOFB substantially increases both severity and infection risk, it is not a prerequisite for the development of post-traumatic endophthalmitis.\u003c/p\u003e \u003cp\u003eFunctional recovery following traumatic endophthalmitis remained markedly limited. Although most eyes maintained anatomical integrity, only 43.2% achieved a final BCVA\u0026thinsp;\u0026le;\u0026thinsp;1.0 logMAR, underscoring the substantial visual morbidity associated with these injuries. These findings are consistent with aggregated evidence from large cohorts assessing prognostic determinants and surgical timing in open-globe trauma [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The ocular manifestations documented in our study align with previous reports and are indicative of a marked and often abrupt inflammatory response [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Corneal perforation, identified in 60.8% of cases, was most strongly associated with poor baseline VA and the subsequent need for complex, highly invasive reconstructive procedures.\u003c/p\u003e \u003cp\u003eIn our series, baseline VA was the only variable significantly associated with poor visual outcome, while culture positivity, IOFB, and RD showed trends aligned with published literature but did not reach statistical significance. The unadjusted association between intravitreal therapy and poorer visual outcomes likely reflects confounding by indication: eyes with greater baseline severity (e.g., dense vitritis, IOFB, or media opacity) were preferentially treated more intensively; therefore, this correlation should not be inferred as causal [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14 CR15\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Prospective capture of injection number and timing, alongside standardized severity metrics and multivariable methods to adjust for baseline imbalances, would help clarify this relationship in future studies.\u003c/p\u003e \u003cp\u003eMicrobiologically, Gram-positive bacteria predominated, accounting for 93.0% of positive cultures (40/43), with \u003cem\u003eStaphylococcus\u003c/em\u003e species being the most frequently isolated organisms (55.8% of positive cultures, 24/43). Among these, coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003e represented 46.5% of positive samples (20/43). \u003cem\u003eBacillus cereus\u003c/em\u003e constituted 9.3% of positive samples (4/43) and has traditionally been associated with rapidly progressive post-traumatic presentations and infections related to intraocular foreign bodies (IOFBs), particularly in reports from rural or industrial settings where such microorganisms are common contaminants of open-globe injuries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis profile supports empirical intravitreal coverage targeting Gram-positive and Gram-negative organisms, in line with national guidance from the Spanish Vitreo-Retinal Society (SERV), which advocates empirical intravitreal treatment combining vancomycin with a third-generation cephalosporin (or equivalent Gram-negative coverage), and aligns with recently published reviews on traumatic endophthalmitis [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFungal infections were less common in our series (16.3% of positive cultures, 7/43) but remained clinically relevant\u0026mdash;particularly in injuries involving vegetative material\u0026mdash;consistent with published traumatic series [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Nevertheless, they occurred at a slightly higher rate than that reported in other series (5%\u0026ndash;15%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This increased incidence may be related to local climatic conditions\u0026mdash;specifically a humid and temperate environment\u0026mdash;as well as greater agricultural and livestock activity in the region, factors that heighten the risk of trauma involving vegetative material, a well-recognized vector for fungal inoculation.\u003c/p\u003e \u003cp\u003eMost of the microorganisms isolated in our series demonstrated good susceptibility to the antimicrobial regimens commonly used for empirical intravitreal therapy. However, over the course of more than 20 years, some cases exhibited resistance patterns, particularly to macrolides and lincosamides among \u003cem\u003eStaphylococcus\u003c/em\u003e, and although Gram-negative organisms were less common, multidrug-resistant isolates were identified during this period, especially \u003cem\u003eCitrobacter freundii\u003c/em\u003e and \u003cem\u003eProteus mirabilis\u003c/em\u003e. These findings underscore the need to adjust the therapeutic regimen once antimicrobial susceptibility results became available. Given that initial treatment in most cases of endophthalmitis is administered empirically, the availability of local antimicrobial susceptibility data is essential to guide the selection of first-line therapy and optimize clinical outcomes.\u003c/p\u003e \u003cp\u003eRegarding prophylaxis after open-globe injury, recent meta-analytic data shows no benefit to extending systemic antibiotics beyond 24 hours and no superiority of intravenous or intraocular routes over oral administration; ciprofloxacin monotherapy underperforms versus vancomycin plus a third-generation cephalosporin [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These results support concise, risk-adapted prophylaxis\u0026mdash;particularly in patients with IOFB, rural injuries, or lens rupture\u0026mdash;and reinforce our cohort\u0026rsquo;s empirical Gram-positive/Gram-negative approach, in harmony with SERV recommendations [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBecause management is initiated empirically, rapid diagnostics can complement culture-based testing. Polymerase chain reaction (PCR) can refine early treatment decisions and support diagnosis when initial cultures are negative [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Among host-response biomarkers, vitreous soluble Triggering Receptor Expressed on Myeloid cells-1 (sTREM-1) may help discriminate infectious from non-infectious presentations; elevations have been reported in both culture-positive and culture-negative traumatic cases, supporting escalation when clinical suspicion remains high despite negative cultures [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe traditional Endophthalmitis Vitrectomy Study (EVS) paradigm is frequently challenged in the context of traumatic endophthalmitis. The role and timing of PPV should be individualized. In our series, PPV was performed early in 64.9% of cases and was not independently associated with worse visual outcomes. When IOFB, dense vitritis, or media opacity are present, early PPV facilitates source control, direct sampling, and removal of necrotic/toxic material\u0026mdash;though definitions of \u0026ldquo;early\u0026rdquo; vary across studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Notably, PPV serves both therapeutic and diagnostic purposes by enabling removal of inflamed and infected vitreous, enhancing intravitreal antibiotic penetration, and providing samples for culture. In eyes with total media opacity where a temporary keratoprosthesis is not feasible, ultrasound-guided PPV (USG‑PPV) can enable safer debulking under intraoperative imaging [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Recently, the complementary use of intravitreal injections or low-concentration diluted povidone\u0026ndash;iodine irrigation (0.025%\u0026ndash;1.25%) has been recommended, as it has demonstrated bactericidal, fungicidal, and virucidal activity in infections associated with intraocular foreign bodies, without inducing inflammation or retinal toxicity; however, the overall quality of evidence remains limited [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBroader epidemiologic experience similarly emphasizes the ongoing burden of trauma-related endophthalmitis and the importance of coordinated regional care networks, consistent with our multicenter experience in Asturias and Galicia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStrengths of this study include its multicenter design, standardized VA conversion, and comprehensive capture of microbiology, treatment, and outcomes across two decades. Limitations inherent to retrospective analyses include potential selection/referral bias, incomplete timing data, and residual confounding by indication (notably for intravitreal therapy and PPV). Inter-hospital variability in practice, small fungal and Gram-negative subgroups, and possible misclassification of IOFB material may limit generalizability. Future prospective studies should incorporate prespecified, penalized multivariable analyses, standardized time-to-intervention metrics, and systematic handling of missing data.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this multicenter series of traumatic endophthalmitis, infection control and globe preservation were high, yet functional recovery remained limited. The long study period of over 20 years allowed for the demonstration of stability in the spectrum of causative microorganisms, although resistance to certain antibiotics (macrolides and lincosamides) and multidrug-resistant Gram-negative organisms was observed. Epidemiological experience from a specific region of northern Spain, characterized by specific climatic conditions and occupational activities, can inform the development of empirically tailored therapeutic strategies aligned with the local microbial profile and resistance patterns. Early risk stratification, primarily based on initial visual acuity, combined with careful assessment of injury severity, IOFB status, and RD, may assist in patient classification and treatment planning, thereby facilitating prompt source control and management of trauma-associated endophthalmitis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBCVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebest-corrected visual acuity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evisual acuity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIOFB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintraocular foreign body\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epars plana vitrectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eretinal detachment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCounting fingers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehand motion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elight perception\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNLP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eno light perception\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003elogMAR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elogarithm of the minimum angle of resolution\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003einterquartile range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eodds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003econfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSERV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpanish Vitreo-Retinal Society\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEVS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEndophthalmitis Vitrectomy Study\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003esTREM-1\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTriggering Receptor Expressed on Myeloid cells-1\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePolymerase chain reaction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSG‑PPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eultrasound‑guided pars plana vitrectomy.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e The study adhered to the tenets of the Declaration of Helsinki and was approved by the Institutional Review Boards of all participating centers (coordinating center: Complejo Hospitalario Universitario de Santiago de Compostela; protocol RTP-MBR-E-2023-01, v2.0, April 13, 2023). The requirement for individual informed consent was waived for de‑identified data.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable (aggregated, de‑identified data).\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eE.d.E.M. conceived the study, curated data, and drafted the manuscript. M.F.B.R. performed data analysis/interpretation and critically revised the manuscript. R.T.P. supervised methodology and contributed to clinical interpretation and manuscript revision. All authors helped with data acquisition and read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe sincerely thank the Ophthalmology Departments of the participating hospitals in Galicia and Asturias for their valuable contribution to this research, their willingness to take part in it and for the care of the patients included in this study. We would also like to thank the Microbiology Departments of the participating hospitals for their support in carrying out this study, specially Gema Barbeiro Casti\u0026ntilde;eiras (CHUS), Daniel Navarro de la Cruz (CHUS), Javier Alba Dom\u0026iacute;nguez (HULA), Mar\u0026iacute;a Isabel Paz Vidal (CHUO), Marina Ovia\u0026ntilde;o Garc\u0026iacute;a (CHUAC), Luz Mar\u0026iacute;a Moldes Su\u0026aacute;rez (CHUAC), Pedro Miguel Juiz Gonz\u0026aacute;lez (CHUF), Ana Mar\u0026iacute;a S\u0026aacute;ez Lopez (CHUP), Pablo Gonz\u0026aacute;lez Moreno (HUCA) and Teresa Pel\u0026aacute;ez de la Rasilla (HUCA).\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDe‑identified data are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eQuiroz-Reyes MA, Quiroz-Gonzalez EA, Quiroz-Gonzalez MA, Lima-G\u0026oacute;mez V (2024) Early versus delayed vitrectomy for open globe injuries: a systematic review and meta-analysis. 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Front Surg 9:988776. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fsurg.2022.988776\u003c/span\u003e\u003cspan address=\"10.3389/fsurg.2022.988776\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-ophthalmic-inflammation-and-infection","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joii","sideBox":"Learn more about [Journal of Ophthalmic Inflammation and Infection](http://joii-journal.springeropen.com)","snPcode":"12348","submissionUrl":"https://submission.nature.com/new-submission/12348/3","title":"Journal of Ophthalmic Inflammation and Infection","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"traumatic endophthalmitis, open‑globe injury, intraocular foreign body, microbiology","lastPublishedDoi":"10.21203/rs.3.rs-8389326/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8389326/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTraumatic endophthalmitis remains a vision-threatening emergency after open globe injuries. We aimed to describe epidemiology, microbiology, management patterns, and outcomes across tertiary centers, and to identify factors associated with poor final best-corrected visual acuity (BCVA).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eMulticenter retrospective case series of consecutive eyes with traumatic endophthalmitis treated from January 2003 to January 2025 in seven tertiary hospitals. Demographics, injury details (including intraocular foreign body, IOFB), clinical findings, microbiology, and treatments (intravitreal antibiotics and pars plana vitrectomy, PPV) were analyzed. The primary outcome was final BCVA (logMAR).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSeventy-four eyes were included (93.2% male; 95.9% penetrating injuries; 60.8% corneal; 45.9% with IOFB). Culture positivity was 58.1%, predominantly \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e. Intravitreal antibiotics were given in 70.3% and PPV in 64.9%. Mean time from trauma to diagnosis was 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 days; mean time from diagnosis to first intravitreal injection was 0.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 days. Mean BCVA improved from 2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72 to 1.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26 logMAR at last follow up. Final BCVA\u0026thinsp;\u0026le;\u0026thinsp;1.0 logMAR was achieved in 43.2%, while 16.2% required evisceration. On univariate analysis, worse baseline BCVA was associated with poor final BCVA (\u0026ge;\u0026thinsp;1.0 logMAR), whereas IOFB, retinal detachment (RD), culture positivity, intravitreal therapy, and PPV were not significant predictors\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDespite standardized early care, functional recovery was limited. Baseline BCVA was the strongest prognostic indicator, supporting early risk stratification and rapid source control with guideline-concordant empiric therapy adapted to the work environments and climatic conditions.\u003c/p\u003e","manuscriptTitle":"Traumatic Endophthalmitis After Ocular Injury: Microbiologic Spectrum and Predictors of Visual Outcome in a Multicenter Retrospective 22-Year Case Series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-21 13:07:12","doi":"10.21203/rs.3.rs-8389326/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"96684165129428591993944622068095996233","date":"2026-04-20T13:51:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-26T11:45:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188563359741210057360227800636145696396","date":"2026-01-20T07:44:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-19T10:57:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-18T08:58:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-18T08:51:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Ophthalmic Inflammation and Infection","date":"2025-12-17T21:46:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-ophthalmic-inflammation-and-infection","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joii","sideBox":"Learn more about [Journal of Ophthalmic Inflammation and Infection](http://joii-journal.springeropen.com)","snPcode":"12348","submissionUrl":"https://submission.nature.com/new-submission/12348/3","title":"Journal of Ophthalmic Inflammation and Infection","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"93a37de1-b345-4e82-85a5-0244fd379919","owner":[],"postedDate":"January 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-21T13:07:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-21 13:07:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8389326","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8389326","identity":"rs-8389326","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}