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Italian gymnast Lorenzo Bonicelli ‘talking again’ and eating ‘naturally’ as he recovers from serious neck injury

Lorenzo Bonicelli “can finally exchange a few words with those around him,” said Paolo Gilardoni, president of the Ghislanzoni Gal club in Lecco where the Italian gymnast trained.

Speaking to Italian newspaper Corriere della Sera on Monday 11 August, Gilardoni described the first days of Bonicelli’s recovery back in Italy following the serious neck injury he suffered on 23 July at the 2025 FISU World University Games in Germany’s Rhine-Ruhr region. “Lorenzo’s father, Simone, is very happy with the way the doctors have welcomed and cared for him. I speak to him every day for updates,” Gilardoni added.

The 23-year-old was injured during his dismount from the rings in the artistic gymnastics qualifications. He was transferred to Milan’s Niguarda Hospital on 7 August after undergoing surgery at the University Hospital in Essen, Germany, to treat a cervical sprain trauma with subluxation of the fifth vertebra. He also had a tracheotomy to help him breathe.

“They’ve now removed one of the tubes,” Gilardoni said. “Of course, his voice is still altered — it’s not ‘his’ yet — because he still has a smaller tube in place to assist his breathing.” Bonicelli has also started eating independently: “He’s begun the weaning process, feeding himself naturally again.”

According to the Italian Gymnastics Federation (FGI), Bonicelli has suffered no cognitive impairment, though there is a neurological injury whose extent cannot yet be determined.

He remained conscious during the transfer from Germany to Italy, accompanied by his family and girlfriend, former gymnast and now nurse Lisa Rigamonti, who thanked supporters in an Instagram post.

The Ghislanzoni Gal club has also launched a fundraising campaign to help support Bonicelli’s rehabilitation.

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August 11, 2025
Knowledge, Attitudes, and Practices towards Waldenström’s Macroglobul

Introduction

Waldenström’s macroglobulinemia (WM), first described by J. Waldenström in 1944, accounts for approximately 2% of all hematologic malignancies.¹ This rare B-cell lymphoma, characterized by bone marrow infiltration of lymphoplasmacytic cells leading to the secretion of IgM proteins, falls within the category of indolent non-Hodgkin lymphomas (NHLs), with an incidence of merely 0.3 per 100,000 person-years.^2–5 Patients with WM often present with a spectrum of clinical manifestations, encompassing fatigue, discomfort, fever, weight loss, and, in certain instances, symptoms related to hyperviscosity.^6,7 The disease’s gradual onset, combined with its incurable nature, significantly impacts patients’ quality of life, necessitating sustained management. Beyond individual health implications, the scarcity of awareness surrounding WM on a societal level poses a potential challenge, potentially resulting in delayed diagnosis and treatment commencement. As such, the study of WM assumes paramount importance in the realm of public health.

The Knowledge, Attitude, and Practice (KAP) framework plays a crucial role in shaping health-related behaviors.⁸ It is often employed alongside the KAP questionnaire to comprehensively gauge the KAP of the target population within the healthcare domain, as well as to assess the demand and level of acceptance of relevant content.⁹ This model, integral to health literacy, is underpinned by the fundamental premise that knowledge exerts a positive influence on attitudes, and these attitudes, in turn, shape individual practices.¹⁰

Notably, WM is frequently diagnosed in the later stages of life, typically around the median age of 73 years, adding a considerable burden of medical and nursing stress on both patients and their families.¹¹ Although existing research indicates relatively low rates of adverse events and treatment discontinuation (with a 10% serious adverse events and a 6.4% discontinuation rate), our understanding of the challenges faced by patients and their families in coping with this rare disease remains limited.¹² Notably, patients and families contribute significantly to the overall well-being of those affected by WM by playing a pivotal role in adhering to treatment plans, attending regular follow-up appointments, and implementing essential lifestyle modifications. Therefore, the imperative to conduct a KAP study among WM patients and their families is underscored, as it promises to unveil crucial insights that can enhance communication, inform treatment strategies, and ultimately elevate the standard of care for this specific patient community.

Therefore, this study aimed to investigate the KAP towards WM among patients and their family members, and to explore differences in KAP scores between the two groups.

Methods

Study Design and Participants

This cross-sectional study was conducted in October 2023 at a tertiary hospital in Zhejiang Province, China. The participants included individuals diagnosed with WM and their family members. The inclusion criteria were: 1) aged > 18 years old; 2) Patients or their family members registered with the Chinese WM/LPL Patient Association. The study received ethical approval from the Clinical Research Ethics Committee of the First Affiliated Hospital of Zhejiang University (IIT20230387B) and informed consent was obtained from all participants.

Questionnaire Introduction

The questionnaire was developed based on a review of relevant literature and the Chinese guideline for diagnosis and treatment of lymphoplasmacytic lymphoma/Waldenström macroglobulinemia (2022). Initial items were drafted by the research team and subsequently reviewed by two hematology professors with over 10 years of clinical experience. Based on their feedback, the items were revised to improve clarity and clinical relevance. Additionally, one item regarding the slow onset of treatment and the importance of not changing treatment plans without clear evidence of disease progression was added to the knowledge section.

A pilot test was conducted among 60 participants (WM patients and family members). Participants were encouraged to report any unclear or ambiguous items. Minor revisions to wording and formatting were made to improve item clarity and readability. Internal consistency reliability was assessed using Cronbach’s α, yielding an acceptable value of 0.776.

The final questionnaire consisted of four sections: demographic characteristics, knowledge, attitudes, and practices (KAP). The knowledge section included eight items scored as 2 (“well-known”), 1 (“heard of”), or 0 (“unknown”), with a total score range of 0–16. The attitude section comprised 11 items measured on a five-point Likert scale; items A1, A2, and A4 were reverse-coded, while A3 and A5 were positively coded, yielding a total score range of 5–25. The practice section included six items measured on a five-point Likert scale ranging from 5 (“always”) to 1 (“never”), with a total possible score of 6–30.

The questionnaire was distributed online using the “Wenjuanxing” survey platform. A QR code and access link were shared through the official channel of the China WM/LPL Patient Association to ensure broad national reach. Patients and family members accessed and completed the survey voluntarily. Family members of WM patients were required to complete the knowledge and attitude dimensions based on their own experiences, while the practice dimension was completed based on the actions performed by the WM patients.

Overall knowledge, attitude, and practice scores were classified using a modified Bloom’s criteria cutoff point: scores between 80–100% were categorized as good, 60–79% as moderate, and less than 60% as poor knowledge, negative attitude, and inappropriate practice, respectively.¹³

Statistical Analysis

SPSS 26.0 (IBM, Armonk, NY, USA) and STATA 14 (Stata Corporation, College Station, TX, USA) were used for statistical analysis. Continuous variables were described using mean ± standard deviation (SD), and compared by analysis of variance (ANOVA) for those conforming to a normal distribution, and Kruskal–Wallis H-test for those conforming to a skewed distribution. Categorical variables were presented as n (%). The correlation among KAP scores was assessed using Spearman analysis, and the interactions among KAP were explored through structural equation modeling (SEM). Additionally, a subgroup analysis was conducted to compare individual KAP item scores between participants who were employed versus those who were not, to explore potential influences of socioeconomic status. Two-sided P<0.05 were considered statistically significant in this study.

Results

In this study, a total of 229 responses were collected, and 220 valid questionnaires were obtained after one response with completion time less than 180 seconds, one respondent below 18 years of age, and seven responses containing logical errors were excluded. Among them, 98 (44.55%) were families of the patients and 133 (60.45%) were males, with a mean age of 51.79±14.08 years. The mean duration of diagnosis of the patients was 51.34±32.90 months, 108 (49.09%) were undergoing BTK inhibitor-based treatment, 160 (72.73%) had not experienced relapse. This high proportion of BTKi usage among non-relapsed patients may be attributed to the increasing adoption of BTK inhibitors as first-line therapies in real-world practice, especially among elderly patients or those with comorbid conditions, due to their favorable safety profile and oral administration convenience. Additionally, 122 (55.45%) had no other underlying disease, 138 (62.73%) underwent their first visit due to physical symptoms, 147 (66.82%) attended in the hematology department, 129 (58.64%) experienced not suspected of having WM or misdiagnosed.

The mean knowledge, attitude, and practice scores were 10.38±4.07, 15.78±2.34, and 23.19±3.31, separately. Analyses of demographic characteristics showed that patients tended to have higher knowledge scores than family members (11.13±4.28 vs 9.78±3.79, P = 0.004), while no significant differences were found in attitude (15.78±2.27 vs 15.77±2.40, P = 0.889) or practice scores (23.59±2.94 vs 22.87±3.56, P = 0.134). Those with different education were more likely to have different levels of knowledge (P = 0.014). Differences in work status before developing WM were also more likely to show differences in knowledge, attitudes, and practices (P = 0.042, P = 0.018, P = 0.027, respectively). Moreover, participants with different current treatments (P = 0.023 and P = 0.023) and different reasons for initial visits (P = 0.033 and P = 0.034) were more likely to have different knowledge and practices (Table 1).

Table 1 Basic Characteristics and KAP Scores

The response for knowledge dimension shows that the two questions with the highest number of participants choosing the “Well-known” option were

WM is currently incurable, and most patients cannot achieve complete remission. The treatment goal is symptom relief and reducing the risk of organ damage. (K7) with 52.73%

And

Genetic testing (such as MYD88 and CXCR4 mutations) is necessary for WM, and treatment decisions should be guided by the patient’s genetic mutation status. (K6) with 49.55%

Oppositely, The two questions with the highest number of participants choosing the “Unknown” option were “Elevated IgM levels alone are not an indication to start treatment.” (K4) with 14.09% and “WM is a rare indolent lymphoma that primarily affects the elderly, with a median survival of 8 years.” (K1) with 13.64% (Supplemental Table 1).

The attitude dimension shows that 35.91% agree that the disease has caused them unbearable suffering (A1), but 52.27% are glad about the possibility of achieving objective remission or even complete remission through long-term treatment (A3). On the other hand, 42.73% were neutral about the adverse effects of drugs that make it difficult to adhere to standard treatment (A2). It is noteworthy that 41.36% were very concerned about the possibility of WM being passed on to future generations (A4). 63.18% were very interested in joining a patient group to share experiences and receive emotional support (A6) (Supplemental Table 2). Besides, 82.73% of participants were primarily perplexed about the progression of WM (A6). Following diagnosis, 71.36% demonstrated the ability to self-regulate and cope with their condition (A7). Furthermore, 57.73% reported that the doctor provided and explained multiple options during communication, allowing the patient to make an informed choice (A8). Concurrently, 75.91% expressed a desire to exercise autonomy in decision-making regarding their treatment (A9). Information was obtained through the Internet, WeChat, and other channels by 54.09% of participants (A10). In comparison with other considerations, 40.91% deemed the most crucial role to be the prolongation of life expectancy (A11) (Supplemental Table 3).

The practice dimension reveals that 43.18% consistently adhere to regular follow-ups (P1), while 71.82% consistently adhere to prescribed medication regimens. Furthermore, 47.27% frequently maintain a healthy and balanced diet and ensure sufficient sleep (P6). However, 50.91% have never received the latest influenza and pneumonia vaccinations (P5) (Supplemental Table 4).

To further explore the differences between patients and family members, additional analyses were performed to compare the detailed responses of the two populations. For the knowledge dimension questions, patients scored significantly higher than the family members on all questions except “Patients with symptomatic hyperviscosity should undergo plasmapheresis 2–3 times before systemic treatment.” (K5) and “The onset of WM treatment is relatively slow. Unless there is clear evidence of disease progression, treatment regimens should not be changed frequently.” (K8), showing a higher level of knowledge (Supplemental Table 5). For all attitude dimension questions, there was no significant difference in scores between patients and family members, showing similar attitudinal positivity (Supplemental Table 6). In the practice dimension, patients scored significantly higher than their families in regular follow-up appointments (P1), medication adherence (P2), and preventive hygiene measures (P4), reflecting potential discrepancies between self-reports and proxy assessments, which is consistent with existing literature on patient-proxy reporting differences (Supplemental Table 7).

Furthermore, subgroup comparisons based on employment status (employed vs unemployed) revealed significant differences in selected items across all three domains. Specifically, K5 (P=0.026), A2 (P=0.031), P3 (P=0.041), and P6 (P=0.015) showed statistically significant differences. These findings suggest that employment status, potentially reflecting socioeconomic or functional differences, may influence awareness and behavior related to WM (Supplementary Table 8).

The correlation analysis reveals that knowledge was positively correlated with attitudes (r = 0.1879, P = 0.0052) and practices (r = 0.1670, P = 0.0132), however, there was a negative correlation between attitudes and practices (r = −0.0784, P = 0.2468) (Table 2). And the SEM shows that there is no direct effect between knowledge and attitudes (P = 0.312), as well as knowledge and practices (P = 0.067). While, attitudes directly and negatively affect practices (β = −0.10, p = 0.036) (Table 3 and Supplementary Figure 1).

Table 2 Correlation Analysis

Table 3 SEM Path Analysis

Construct validity was supported by confirmatory factor analysis (CFA), which showed acceptable model fit, with the following indices: KMO = 0.831, CMIN/DF = 2.021, RMSEA = 0.068, IFI = 0.886, CFI = 0.884, and TLI = 0.867 (Supplementary Figure 1 and Supplementary Tables 9, 10).

Discussion

This study highlights that WM patients and their families exhibited moderate knowledge and attitudes, and suboptimal practices towards WM. The findings shed light on a critical gap in the practical aspects of disease management among this specific patient population. The research findings reveal suboptimal practices within the study population. Patients exhibited better knowledge scores than family members, suggesting potential differences in information accessibility and health literacy. This aligns with existing literatures that emphasizes the importance of tailoring educational interventions.^14,15 The observed association between education levels and knowledge scores further supports that educational background significantly influences health-related knowledge.¹⁶ Furthermore, work status impacts knowledge, attitudes, and practices, indicating that occupational factors may play a role in shaping health-related behaviors.¹⁷ In addition, differences in current treatments and initial reasons for seeking healthcare highlight the complexity of healthcare-seeking behavior, stressing the need for tailored interventions that account for individual circumstances. In addition, subgroup analysis based on employment status revealed that employed participants showed significantly different responses in several items, such as K5 (plasmapheresis before systemic treatment), A2 (adverse reactions and treatment adherence), P3 (avoiding crowded places), and P6 (healthy lifestyle). These findings suggest that occupational status may influence disease-related perceptions and behaviors, potentially reflecting differences in access to information, health literacy, or physical capacity for disease management. This underscores the need for socioeconomic-sensitive intervention strategies.

The correlation analysis and SEM results provided insights into the knowledge-attitudes-practices framework. Surprisingly, there was no direct effect between knowledge and attitudes, nor between knowledge and practices. This challenges the conventional belief that increased knowledge leads to more positive health behaviors. However, the practice data in our study were derived from both patient self-reports and caregiver proxy assessments, which may have introduced inconsistencies and affected the robustness of the observed relationships. Prior research has shown that proxy-reported behaviors can differ substantially from actual patient behaviors. Therefore, the lack of a direct association between knowledge and practice may partially reflect measurement bias rather than a true absence of effect.¹⁸ The negative direct effect of attitudes on practices suggests that certain negative or fearful attitudes may discourage patients from engaging in proactive health behaviors, such as regular follow-ups or vaccination.¹⁹

The response for specific items provide valuable insights into the knowledge, attitudes, and practices of WM patients and their families. Patients were generally well-informed about WM, there were notable gaps in understanding regarding the incurable nature of the disease. These results align with previous research highlighting the challenges in disseminating comprehensive information about rare diseases.^20,21 Knowledge gaps were also observed in treatment decisions based on genetic mutation status, reflecting broader trends in personalized medicine.^22,23

The desire to join patient groups for emotional support reflects the importance of peer networks. A strong inclination toward wanting to be more involved in treatment decision-making aligns with the broader trend of patient-centered care.²⁴ Participants’ reliance on their children or personal research for information underscores the importance of healthcare providers guiding patients toward reliable sources of information.²⁵

In the practice section, adherence to medical recommendations, regular follow-up appointments, and vaccination practices were encouraging. However, he low rates of influenza and pneumonia vaccination highlight the need for improvement. Targeted educational programs should be developed, focusing on specific knowledge gaps. Patient groups could be leveraged to disseminate accurate information, helping to reduce misconceptions.²⁶ Interventions promoting a healthy lifestyle, including regular vaccinations, should be prioritized to enhance overall disease management and quality of life.²⁷

The comparison between patients and family members shows that patients generally have a slightly better understanding of WM. Family members demonstrated lower knowledge in some key aspects. While attitudes towards the disease and treatment were mostly aligned, patients were more likely to express concerns about specific aspects, such as the hereditary nature of WM. This indicates patients may have a more nuanced understanding of the implications of the disease. Patients were more consistent in attending follow-up appointments, complying with medication regimens, and maintaining preventive health practices like hand hygiene. These differences suggest that patients are more proactive in managing their health, which may be crucial for effective disease management. Discrepancies between patient self-reports and family member reports may indicate gaps in communication. Moreover, the assessment of practices based on mixed sources-self-reports from patients and proxy reports from caregivers-represents a methodological limitation. Previous studies have shown that proxy reports may overestimate or underestimate actual patient behavior. This issue may have influenced the accuracy and comparability of the practice scores across the two groups. This highlights the need for better communication and shared decision-making between patients and their families. To address these gaps, particularly in family members’ knowledge and practices, targeted educational interventions could be beneficial. These may include informational workshops on WM and its management, as well as clear guidance on preventive health behaviors. Furthermore, patients and caregivers exhibit distinct informational needs, emotional burdens, and levels of engagement in disease management. Interventions aimed at patients may prioritize empowerment, self-management strategies, and reinforcement of practical health behaviors. In contrast, interventions for caregivers should address emotional support, clarification of their supportive role, and accurate understanding of treatment regimens. Tailoring interventions to the unique perspectives of each group may improve their effectiveness and ultimately enhance the patient-caregiver partnership in managing WM. Research highlights the value of involving family members in care.^28,29

Conclusions

This study has several limitations. First, the cross-sectional design limits the ability to infer causal relationships. Second, the practice data were collected using a mix of patient self-reports and caregiver proxy assessments, which may introduce measurement bias due to well-documented differences between actual and perceived patient behaviors. Third, all responses were self- or proxy-reported, which may be subject to recall bias and social desirability effects. Additionally, participants were recruited through the Chinese WM/LPL Patient Association, which may have led to a selection bias. These individuals are likely to be more motivated, better informed, or more proactive in disease management compared to the broader WM population. Therefore, the generalizability of the findings may be somewhat limited. Additionally, although subgroup analysis by employment status was conducted, other potentially influential factors-such as gender, age, or education level-were not separately analyzed due to sample size limitations. Future studies should include more comprehensive subgroup analyses to better understand how these variables shape KAP profiles and inform targeted interventions. Moreover, longitudinal designs and objective measures are also needed to capture temporal changes and enhance the robustness of conclusions.

In conclusion, WM patients and their family members had moderate levels of knowledge, attitudes, and practices toward WM, based on the scoring classification used in this study. By addressing patients’ attitudes and offering tailored support, healthcare professionals can significantly enhance the overall well-being and treatment outcomes of individuals affected by WM.

Data Sharing Statement

All data generated or analysed during this study are included in this published article and its supplementary information files.

Ethics Approval and Consent to Participate

This work has been carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association. The study was approved by the Clinical Research Ethics Committee of the First Affiliated Hospital of Zhejiang University (The first college of Zhejiang University, 2023 No. 0841) and written informed consent was obtained from all participants.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

There is no funding to report.

Disclosure

The authors declare that they have no competing interests.

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August 11, 2025
Save Up to 78% Off High Powered 2-Port Spigen USB-C Chargers

Phones and other tech no longer come with a charger in the box, and that means you’re going to have to provide your own. Thankfully, picking up a multiport USB-C charger continues to get cheaper and cheaper — and right now, Amazon is running a couple of discounts that make it even more affordable. Order soon, and you’ll get a two-port USB-C charger at up to 78% off.

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You can never have too many USB-C chargers. In fact, we suggest taking advantage of these prices and ordering some new ones even if you don’t need them right now. It’s a safe bet you’ll make good use of them at some point in the future.

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August 11, 2025
Bushra Ansari’s Statement About Amitabh Bachan Severely Criticized

Bushra Ansari is a veteran Pakistani television and film actor known for her hit plays including Aangan Terha, Tere Bin, Kabhi Main Kabhi Tum, Barat Series, Bilqees Kour, Zebaish, Deewar e Shab, Badlon Per Basaira, Pardes and others. She is also known for her active social media and digital media presence. Nowadays, she is busy in the shooting of her upcoming projects.

Recently, Bushra Ansari appeared on the Punjabi show Punjabi Kuriyaan, hosted by Asma Abbas and aired on Samaa TV. In the show, she expressed her respect for Noor Jahan and Lata Mangeshkar, but her unusual wish involving Amitabh Bachchan drew severe criticism.

Talking about it, Bushra Ansari said, “I asked a fan and friend, Sudaish, saying, ‘Yes, I was fortunate enough to have worn Noor Jahan’s saree, now please bring me Lata Ji’s one old saree, if possible.’ But then she passed away. So I told him, ‘If not Lata’s saree, then bring Amitabh Bachchan’s socks— even one from a pair would be enough.’ He said, ‘What are you talking about, Bushra Ansari Ji?’ but then he agreed to find it.” Here is the link to the video:

Bushra Ansari is facing severe public wrath, many didn’t like her statement especially when the ties between India and Pakistan are so complicated. One said, “Shame on you. Are they Muslim? They can’t see anything beyond showbiz,” one commented. Another wrote, “Sad to hear that our seniors are making such people their role models — what are they expecting from them? They aren’t even Muslims. May Allah guide everyone.” One stated, “I mean, seriously? I think artists should take at least two minutes before doing or saying something, as they represent and influence millions.” Another wrote, “Astaghfirullah! I have no words to say about this statement.” Read the comments:

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August 11, 2025
Recoded E. coli strain shows that life can function with significantly compressed genetic code | Research

A strain of Escherichia coli (E. coli) with a synthetic genetic code comprising just 57 codons, rather than the standard 64, is the most significantly recoded organism to date. The new strain, named Syn57, demonstrates that life can function with a significantly compressed genetic code.

The researchers who carried out the work are based at the Medical Research Council’s Laboratory of Molecular Biology (LMB) in Cambridge, UK. They say that by freeing up codons – sequences of three nucleotide bases that correspond with specific amino acids – in the E. coli genome, Syn57 has more space to introduce unnatural amino acids. This could open up new applications, such as generating organisms that are resistant to viruses or produce new enzymes.

The same team previously made Syn61 – a strain of E.coli with 61 codons – in 2019. But the researchers were keen to find out if living organisms could tolerate additional codon compression, taking them further away from their natural genetic sequence.

‘We wanted to know how deeply you could compress the genetic code, because if you can compress it, you can then free up some of the previously redundant codons to repurpose them for a new application,’ explains Wes Robertson, a synthetic biologist at the LMB and co-leader of the project. ‘The idea is we can then use cells to make things that chemists used to make in a flask, but now we can do it in a more programmable [and] bio-sustainable way.’

To do this, the team started by developing a recoding scheme that would free up seven codons in the E. coli genome; four of the six codons which encode the amino acid serine, two of the four codons for the amino acid alanine and one stop codon. In total, this meant making more than 100,000 codon changes across the 4 million base pair genome of E. coli.

To make the task more manageable they split the genome up into 38 fragments of around 100,000 base pairs each and synthesised them individually using homologous recombination in yeast to ensure that the recoding scheme would work.

‘It worked for about 75% of them. For the 25% where it didn’t work, we then went in and mapped, via a variety of new linkage mapping techniques that we developed,’ says Robertson. ‘Once we could pinpoint the problems, we added different synthetic DNA designs, which maintained compression, but were slightly different to our original design. ’

They then stitched the fragments together, fixing potential problems as they went to enable the next step of the synthesis.

While Syn57 didn’t grow as well as the original strain, Robertson notes that it ‘grew well enough for us to characterise it in the lab’. He adds that further modifications could provide Syn57 with a ‘genetic firewall’ that would prevent it interacting with genetic material from the wild-type E. coli. ‘So this will yield a virus-resistant strain which could be quite useful in industrial purposes,’ he says.

Encoding new chemistry

Martin Spinck, who also worked on the project, says the reassignment of the codons is limited only by their creativity. ‘All of these seven codons can be reassigned to any combination of seven or a subset of seven unnatural amino acids … and these can introduce quite a lot of new motives into biology that naturally would never exist and would never occur.’

Farren Isaacs, an expert in molecular, cellular and developmental biology at Yale University in the US, describes the construction of a genome with 57 codons as a ‘significant’ accomplishment, although, he adds that the new functions that emerge will ultimately determine the impact of the work.

‘The key aspect of the design of this genome is to open up coding channels,’ he says. ‘There’s a number of potentially very useful properties that can emerge from organisms with a new genetic code: you can repurpose those codons to encode new chemistry, to create new kinds of synthetic proteins and polymers.’

‘They can confer resistance to viruses and other forms of horizontal gene transfer,’ he adds. ‘And you can also use them to engineer novel biocontainment solutions, where you can actually engineer these organisms to be dependent on synthetic amino acids preventing growth or escape in the wild.’

‘It’s the function that emerges that I think is most compelling for synthetic genomes with alternative codes.’

However, Isaacs says there are still several questions yet to be answered. ‘What they haven’t done yet is knocked out tRNAs or release factors that decode those codons they have eliminated and see how the cell responds – does it completely eliminate that function from the cell or are there other translation factors that overlap and respond? … How might it impact growth and viability?’

‘That is going to be essential in actually realising the function of these organisms.’

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August 11, 2025
Authorities investigate botulism outbreaks linked to contaminated food in Italy

By&nbspEuronews

Published on
11/08/2025 – 15:34 GMT+2

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Two separate outbreaks of botulism poisoning have been worrying Italy in recent weeks.

In Calabria, the most serious cluster has resulted in two deaths and 12 hospitalisations, while other botulism cases have been reported in Sardinia. All of these cases can be traced back to contaminated food, including industrial and household preserves.

Botulism is a rare but serious illness that can cause breathing problems, muscle paralysis, and death. People can get botulism by eating homemade foods that have not been properly canned, preserved, or fermented.

Sardinia’s outbreak, for example, has been linked to contaminated industrial sauce.

The outbreak in Calabria, which started between August 3 and 5 in Diamante in the Cosenza province, involved 18 people who ate sandwiches with sausage and turnip tops purchased from a street vendor. Two people died.

The Paola public prosecutor’s office is investigating nine potential suspects, including the vendor, three managers from the companies that made the contaminated food, and five doctors from two health facilities in the Cosenza area.

The alleged offences range from manslaughter to trading in harmful foodstuffs. The investigation is continuing; autopsies are planned and the food truck was seized for inspection.

Another 14 patients who were hospitalised are in stable condition. Six are in intensive care, with one patient already extubated and breathing independently, while three children are in paediatric care and five patients are in other wards.

The hospital has received several vials of botulinum toxin antidote, which is essential for the timely treatment of cases.

Diamante Mayor Achille Ordine called the illnesses “circumscribed and limited”.

Improper food canning raises risks of botulism

Italy confirmed 452 cases of botulism between 2001 and 2020, the Italian National Institute of Health said. The average fatality rate was 3.1 per cent.

Most of the cases (91 per cent) were foodborne, often related to the consumption of home canned foods.

In 2023, Italy recorded 36 botulism cases, the highest number in Europe followed by France (15), Romania and Spain (14 each), and Germany (16).

The Italian canning tradition, especially in southern regions, is one of the main causes of this high incidence. Home preservation of food, if not performed correctly, can promote the proliferation of Clostridium botulinum, the bacterium responsible for botulism.

“There is no alarm, but prevention is essential, especially in the preparation of home preserves,” said Carlo Alessandro Locatelli, director of the Pavia Poison Control Centre.

“Botulinum toxin is invisible and often does not alter the taste of food. The antidote is only effective in the early stages, when the toxin is still in the bloodstream”.

Signs of botulism and how to prevent it

Symptoms can occur from six hours up to seven days after eating contaminated food and include double vision, dilation of both pupils, drooping of the eyelids, difficulty speaking and swallowing, dry mouth, and constipation.

In severe cases, it can impair breathing, necessitating intubation.

Italian health authorities recommend carefully sterilising containers and tools for preserves, observing safe storage procedures, and avoiding giving honey and home-made preserves to children under one year old.

In case of suspected intoxication, it is important to immediately contact the emergency room or the Pavia Poison Control Centre.

Regarding the known outbreaks, health authorities are monitoring patients and have distributed doses of botulinum toxin antidote to the hospitals involved.

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August 11, 2025
Association of cataract history with dry eye disease signs and symptom

Aaron T Zhao,^1,² Jocelyn He,² Penny A Asbell,³ Vatinee Y Bunya,² Gui-Shuang Ying² On behalf of the DREAM Research Group

¹Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; ²Scheie Eye Institute, Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; ³Department of Ophthalmology, University of Memphis, Memphis, TN, USA

Correspondence: Gui-Shuang Ying, Center for Preventive Ophthalmology and Biostatistics, Scheie Eye Institute, Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, 51 North 39 th Street, Philadelphia, PA, 19104, USA, Tel +1 215-662-9514, Email [email protected]

Background: Dry eye disease (DED) and cataracts are highly prevalent ocular conditions, particularly among older adults. However, the relationship between cataracts, cataract surgery, and DED severity remains poorly understood. This study aimed to assess the associations between cataract history and DED signs and symptoms in participants with moderate-to-severe DED.
Methods: This is a secondary analysis of data from a double-blind randomized control trial of participants (n = 535) with moderate-to-severe DED in the DREAM Study. At baseline, cataract history and patient characteristics were collected; DED signs and symptoms were assessed at baseline, 6 and 12 months. Cataract history was classified as: no history of cataracts, ongoing cataracts (clinically diagnosed cataracts without surgical intervention), or history of cataract surgery > 6 months prior to enrollment. Associations between cataract history and DED signs and symptoms were evaluated by univariate and multivariate regression analysis.
Results: Among 1070 eyes from 535 participants, 646 eyes (60%) had no history of cataracts, 244 eyes (23%) had ongoing cataracts, and 180 eyes (17%) had a history of cataract surgery > 6 months prior. On univariate analysis of the combined data from baseline, 6 and 12 months, corneal staining scores were significantly worse in eyes with a history of cataract surgery than eyes with ongoing cataracts and eyes without history of cataracts (4.08 vs 3.63 vs 3.14; P=0.005). However, the difference became non-significant after adjustment by age alone (3.62 vs 3.38 vs 3.37, P=0.71) or by factors associated with DED severity (P=0.72). In multivariate analysis, meibomian gland dysfunction was significantly worse in eyes with no history of cataracts than in eyes with ongoing cataracts or with history of cataract surgery (3.1 vs 2.7 vs 2.6; P=0.02).
Conclusion: Cataract surgery was not independently associated with worse DED symptoms and signs. This indicates that exacerbations of DED severity following cataract surgery are either age-related or transient in patients with moderate-to-severe DED.

Plain Language Summary: Many older adults suffer from both dry eyes and cataracts, but doctors have not been sure if cataract surgery makes dry eye problems worse in the long term. Our research team studied 535 people with moderate-to-severe dry eye disease to find out.
We compared dry eye symptoms and clinical signs among people with no cataracts, ongoing cataracts, and those who had undergone cataract surgery at least six months before joining our study.
Our findings challenge the common belief that cataract surgery worsens dry eye. While patients who had cataract surgery initially appeared to have more severe dry eye signs, this difference disappeared when we accounted for their older age and other health factors.
Interestingly, people who had undergone cataract surgery showed healthier oil-producing glands in their eyelids compared to those without cataracts. This might be because they were more likely to use anti-inflammatory eye drops that could help these glands recover.
These results are reassuring for people with dry eyes who need cataract surgery. Any worsening of dry eye symptoms after surgery is likely temporary rather than permanent. This information helps eye doctors better counsel patients and manages their expectations regarding how cataract surgery might affect their pre-existing dry eye condition.

Introduction

Affecting 5–50% of the global population, dry eye disease (DED) is a multifactorial ocular surface disease characterized by the loss of tear film and accompanied by visual disturbances and discomfort.¹ The incidence of DED is known to increase with age: a recent meta-analysis estimated an incidence of 3.5% in the US population of 18 years and older compared with 7.8% in the US population of 68 years and older.² Similarly, cataracts are often considered a disease of aging: the prevalence of cataracts in the global population has been estimated to range from 3% in the 20–39-year-old population to over 50% in the over-60-year-old population.³ Despite the high prevalence of both DED and cataracts in the older population, there is limited knowledge on how cataracts and cataract surgery may affect the severity of DED signs and symptoms.

Cataract surgery may potentially affect DED through multiple mechanisms, including surgical trauma to the ocular surface, disruption of corneal innervation, and inflammatory responses that can alter tear film stability and composition.^4,5 Patients with pre-existing DED often express concerns about potential worsening of their symptoms following cataract surgery, making evidence-based counseling crucial for informed decision-making.⁶

While some reports suggest increased DED incidence following cataract surgery,^5,7 no studies have investigated how cataract surgery can exacerbate DED severity in patients with pre-existing DED. This study aims to provide a comprehensive assessment for the associations of cataracts and cataract history with severity of DED signs and symptoms through a secondary analysis of rich data from the Dry Eye Assessment and Management (DREAM) study.^8,9

Materials and Methods

DREAM Study

The DREAM study was a multicenter randomized placebo-controlled trial assessing the efficacy of omega-3 supplementation for the treatment of DED (NCT02128763). The details of the DREAM study design and its primary results have previously been reported.^8,9 The DREAM study was approved by the Institutional Review Board at each participating site, including approval from the University of Pennsylvania Institutional Review Board. The study followed the tenets of the Declaration of Helsinki, and informed consent was obtained from all participants. Only major features of DREAM study relevant to the study are described below.

Participant Selection

Individuals ≥18 years old with moderate-to-severe symptomatic DED, defined by having an Ocular Surface Disease Index (OSDI) of 25–80, were eligible for enrollment for the DREAM study. To enroll in the study, participants must have had symptoms of DED for at least 6 months prior to the initial screening visit and have used or had the desire to use artificial tears at least twice a day for the past two weeks before the initial screening visit. Participants also had to satisfy at least 2 of the following 4 criteria for dry eye signs in the same eye at two consecutive visits (screening and baseline visits within 2 weeks apart): 1) corneal fluorescein staining ≥4 (out of a possible 15 per eye); 2) conjunctival staining present ≥1 (out of a possible score of 6 per eye); 3) tear film break-up time (TBUT) ≤7 seconds; 4) Schirmer’s test ≥1 to ≤7 mm/5 minutes. Importantly, a recent history of ocular surgery, including laser-assisted in situ keratomileusis and cataract surgery within 6 months of the screening visit were ineligible for the study. The full comprehensive inclusion and exclusion criteria can be found in the DREAM Study protocol.⁹

Study Measures

Following the screening visit, relevant medical history and participant characteristics were collected at the baseline visit. Medical history included self-reported history of smoking, rosacea, Sjögren’s syndrome, peripheral vascular disease, thyroid dysfunction, hypertension, rheumatoid arthritis, irritable bowel, osteoarthritis, hypercholesterolemia, and depression. Other components of physical and mental health, including depression were assessed. Lastly, the use of ongoing treatments for dry eye disease, including, but not limited to artificial tears, cyclosporine drops, warm lid soaks, punctal plugs, and steroid eye drops, were recorded. Participants self-reported either no history of cataracts, ongoing cataracts (clinically diagnosed cataracts without surgical intervention), or the presence of a pseudophakic or aphakic eye (representing a history of cataract surgery >6 months prior to enrollment).

Outcome measures of dry eye symptoms and signs were assessed at baseline, 6 months, and 12 months. Dry eye symptoms were measured using the OSDI score and the Brief Ocular Discomfort Inventory (BODI) score. The OSDI score ranged from 0–100, with a score of 0 indicating the lack of any ocular symptoms and 100 indicating the most severe symptoms of dry eye.¹⁰ The BODI score uses a similar rating system, with a rating scale of 0–100; it is often used as an alternative measure to OSDI for scoring dry eye symptoms, especially for patients with severe DED.¹¹ Dry eye signs in each eye were evaluated using 6 different dry eye sign measures including: TBUT, Schirmer’s test, corneal staining score, conjunctival staining score, meibomian gland dysfunction, and tear osmolarity. TBUT was measured as the time it took for a break to appear in the tear film following a blink. Schirmer’s test involved using paper strips placed in the lower eyelid to measure the distance of wetting on the paper in 5 minutes. Corneal staining was performed using fluorescein staining, and the staining score was determined using the National Eye Institute grading scale, grading each of 5 cornea sections with a score of 0–3 and combining the score for a maximum of 15 points.¹² Similarly, conjunctival staining score was evaluated on a scale of 0–3 in both the temporal and nasal sections of the conjunctiva with a maximum total score of 6 points. MGD was assessed using a TearScience Meibomian Gland Evaluator™ on silt-lamp examination, which evaluated the consistency of secretions and plugging on a 0–3 scale with a maximum total score of 6 points. Tear osmolarity was evaluated using a TearLab™ Osmolarity System (San Diego, CA), which measured the osmolarity level of the tear film from a range of 275 to 400 mOsm/L. Higher scores indicate more severe DED signs for corneal staining, conjunctival staining, MGD, and tear osmolarity, whereas lower scores indicate more severe DED signs for TBUT and Schirmer’s test. A composite severity score of DED signs from 0–1 was generated with the aforementioned measures by using a modified method from previous studies.^13–15

Statistical Analysis

We evaluated associations between cataract history at baseline and DED symptoms and signs by grouping participants into three groups: 1) no history of cataracts; 2) ongoing cataracts; and 3) previous history of cataract surgery. We compared the DED signs and symptoms among these three cataract history groups using univariate and multivariate regression analyses. Multivariate analyses were adjusted for factors previously found to be associated with DED severity in the DREAM study, including age, gender, race, ethnicity, smoking status, Sjögren’s syndrome, facial rosacea, rheumatoid arthritis, peripheral artery disease, and depression (defined by a mental health component scale ≤42).^16–20 These comparisons were based on combined data from baseline, 6 and 12 months, with correlation from repeated measures and inter-eye correlation (for comparison of signs) accounted for by using generalized estimating equations. Since the DREAM study did not find a significant treatment effect from ω-3 supplementation on DED symptoms and signs, these analyses were conducted on the two original study groups combined (ω-3 supplementation and placebo).⁸ Missing data were handled using available case analysis, with participants included if they had data for the specific outcome being analyzed.

All statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC). Two-sided P<0.05 was considered statistically significant without adjustment for multiple comparisons.

Results

Participant Characteristics and Medical History

Among the 535 participants (1070 eyes) enrolled in the DREAM study, 646 eyes (60%) had no history of cataracts, 244 eyes (23%) had ongoing cataracts, and 180 eyes (17%) had a history of cataract surgery >6 months prior (ie, pseudophakic/aphakic). Following the baseline evaluation, 479 participants (89.5%) completed the 6-month follow-up evaluation, and 486 (90.8%) participants completed the 12-month follow-up evaluation.

A comprehensive comparison of the baseline participant characteristics among the three cataract history groups can be found in Table 1. The three groups were similar in gender (P = 0.07). However, participants with a history of cataract surgery were significantly older (P < 0.0001), less likely to identify as Hispanic or Latino (P < 0.0001), less likely to have never smoked (P = 0.03), and more likely to have ongoing hypertension (P < 0.0001), osteoarthritis (P < 0.0001) and hypercholesterolemia (P < 0.0001) than participants with ongoing cataracts or no history of cataracts. A significantly higher percentage of participants with a history of cataract surgery and with ongoing cataracts self-identified their race as white (P < 0.0001), have ongoing facial rosacea (P = 0.05), and have ongoing diabetes (P = 0.04) compared to participants with no history of cataracts. The prevalence of other notable comorbidities such as Sjögren’s syndrome, peripheral vascular disease, thyroid dysfunction, rheumatoid arthritis, irritable bowel syndrome, and depression were similar across the three groups (all P > 0.05).

Table 1 Comparison of Baseline Characteristics by Baseline Cataract Status (n = 535 Patients, 1070 Eyes)

At baseline, participants with a history of cataract surgery were more likely to use artificial tears or gels (93% vs 78% vs 76%, respectively; P = 0.001), lubricating ointment (22% vs 10% vs 10%, respectively; P = 0.03), and cyclosporine drops (31% vs 27% vs 14%, respectively; P<0.001) compared to participants with ongoing cataracts or no history of cataracts (Table 2). There was no significant difference in the use of other dry eye therapeutics among the three groups.

Table 2 Comparison of Treatments for Dry Eye Disease by Baseline Cataract Status

Cataract History and DED Signs and Symptoms

In the univariate analysis (Table 3), corneal staining scores were significantly worse in eyes with a history of cataract surgery compared to eyes with ongoing cataracts and eyes with no history of cataracts (mean ± SE: 4.1 ± 0.3 vs 3.6 ± 0.2 vs 3.1 ± 0.1 respectively; P=0.005). However, this difference became non-significant after adjusting by factors previously found to be associated with DED severity (adjusted mean ± SE: 3.6 ± 0.3 vs 3.3 ± 0.2 vs 3.4 ± 0.1 respectively; P = 0.72) (Table 4) and was not significant after being adjusted by age alone (adjusted mean ± SE: 3.6 ± 0.3 vs 3.4 ± 0.2 vs 3.4 ± 0.2, respectively; P = 0.70) (Supplementary Table 1). In univariate analysis, tear osmolarity was significantly worse in eyes with a history of cataract surgery than in eyes with ongoing cataracts and eyes with no history of cataracts (mean ± SE: 305.7 ± 1.4 vs 304.0 ± 1.1 vs 301.8 ± 0.7 respectively; P=0.03) but was not significant in multivariate analysis (adjusted mean ± SE: 304.7 ± 1.5 vs 303.6 ± 1.1 vs 302.5 ± 0.8, respectively; P = 0.42) (Table 4). MGD was not different among the three groups in univariate analysis (P=0.67), but in multivariate analysis (Table 4), the MGD score was significantly higher in eyes with no history of cataracts than in eyes with cataracts and eyes with a history of cataract surgery (adjusted mean ± SE: 3.1 ± 0.1 vs 2.7 ± 0.1 vs 2.6 ± 0.2, respectively; P = 0.02). There was no significant difference in TBUT, Schirmer’s test, conjunctival staining score, and composite dry eye severity (all P > 0.11) among the 3 groups in both univariable and multivariable analyses. Cataract history was not associated with any dry eye symptoms, assessed by OSDI (P=0.98), BODI (P = 0.18), and BODI pain scores (P = 0.46) (Table 3).

Table 3 Univariate Analysis for the Comparison of DED Symptoms and Signs at Baseline, 6 month, 12 month Combined by Baseline History of Cataract

Table 4 Multivariate Analysis for the Comparison of DED Symptoms and Signs at Baseline, 6 month, 12 month Combined by Baseline History of Cataract

Discussion

Our study evaluated associations between cataract history and DED severity among well-characterized participants with moderate-to-severe DED. While corneal staining and tear osmolarity were significantly worse in participants with a history of cataract surgery, these associations were not significant upon adjusting for age and other factors previously found to be associated with DED. Interestingly, our study found an atypical association between cataract history and MGD, where eyes with a history of cataract surgery tended to have less severe MGD than eyes with no history of cataracts.

Contrary to studies suggesting increased DED incidence after cataract surgery, our findings indicate that DED exacerbations are likely transient.^21,22 Our study found that a history of cataract surgery was not independently associated with worse DED signs and symptoms in participants with moderate-to-severe DED. The use of eye drops, particularly ones containing benzalkonium chloride preservatives, are commonly administered during the postoperative period following cataract surgery. Studies have shown that preservative eye drops can significantly increase DED signs compared to non-preservative eye drops in patients not previously affected by DED.^23,24 It is plausible that our patients may have experienced increased DED signs and symptoms immediately after cataract surgery due to a combination of the surgical trauma and usage of postoperative preservative eye drops, which were alleviated after the discontinuation of preservative eye drops in the following months, allowing for the recovery of the ocular surface.

Our findings suggest that exacerbations of DED signs and symptoms associated with cataract surgery are time-limited and reversible. Previous research indicates that corneal sensitivity and tear functions return to preoperative levels within 1–3 months post-surgery.^25,26 This theorized timeframe of recovery is consistent with other recent studies as well: a 2024 study of patients with mild-to-moderate DED found that after six months of cataract surgery, signs of dry eye significantly improved compared to signs of dry eye immediately post-surgery in both patients who used eye drops with or without preservatives postoperatively.²⁷ While this seems to suggest that the ocular surface of patients with DED will eventually recover from cataract surgery, it is important to note that it is yet to be elucidated whether these transient exacerbations of DED signs and symptoms post-surgery affect eyes with pre-existing DED for longer than healthy eyes. The presence of significantly worse corneal staining scores in participants with a history of cataract surgery that disappeared upon adjusting solely for age suggests that DED severity, if associated with cataract surgery, is more related to the age of the patient population than the surgery itself. The lack of significant difference in DED signs and symptoms in patients with ongoing cataracts and patients with no history of cataracts also suggests that the development of the cataract itself does not increase DED severity.

Interestingly, in our study, MGD was significantly less severe in participants with a history of cataract surgery than patients with no history of cataracts. This is counter to what the prevailing consensus is in the literature—studies in the literature suggest that there is an exacerbation of MGD, with lower meibum expressibility and lower meibum quality, in patients following cataract surgery.²⁸ One possible explanation of our findings is that in the months following cataract surgery, and before enrollment, participants with a history of cataract surgery had time for any damaged meibomian glands to heal. Past studies have shown that MGD aggravation due to cataract surgery normally resolves by 3 months post-surgery.²⁹ Some studies report that meibomian gland expressibility and meibum quality return as soon as 1 month post-operatively.³⁰ Additionally, in our study, participants with a history of cataract surgery were significantly more likely to use cyclosporine A eye drops as treatment for DED. Cyclosporine A is a calcineurin inhibitor known to suppress T-cell mediated immune responses, and these anti-inflammatory effects may alleviate MGD.³¹ For example, a randomized control trial of 33 patients with MGD found that patients who were randomized to topical cyclosporine A had significantly lower number of meibomian gland inclusions, improved tarsal telangiectasis, and improved lid margin vascularity—all indications of MGD severity—compared to the placebo group at 3 months.³² This seems to indicate that cyclosporine A not only treats the accompanying DED signs and symptoms but can also treat the underlying MGD as well. However, while the greater usage of cyclosporine A in participants with a history of cataract surgery can be a possible explanation of our finding, we cannot conclusively determine why participants with a history of cataract surgery had significantly better MGD compared to the other two groups. Future studies are needed to better understand the role cataract surgery plays in MGD in patients with DED.

There were some limitations to our study. First, cataract history was self-reported, which may introduce recall bias. Second, participants who enrolled in the DREAM study could not have undergone cataract surgery within 6 months of the initial baseline visit. Therefore, we could only evaluate the long-lasting association of cataract surgery with DED severity. The short-term effects of cataract surgery on DED severity could be investigated through a future study which includes patients with a recent history of cataract surgery (ie <6 months). Third, we did not collect data on specific surgical techniques or intraoperative medications that might influence DED outcomes. Fourth, the DREAM study only enrolled patients with moderate-to-severe DED; thus, we were unable to assess how cataract surgery is associated with DED severity in patients with mild DED. Fifth, we did not adjust for multiple comparisons across many dry eye outcome measures, which may increase the risk of Type I error. However, our primary analyses focused on clinically meaningful differences rather than statistical significance alone. Additionally, our study did not evaluate the molecular and cellular effects of cataract surgery on the tear film. Future studies that investigate how cataract surgery impacts the cornea on a cellular level in patients with DED would be helpful in our understanding of how cataract surgery impacts DED. A study of 48 eyes that underwent phacoemulsification found that while TBUT improved significantly and returned to pre-operative levels 1-month following the surgery, goblet cell density was significantly decreased at 1 day, 1 month, and 3 months post-surgery.³³ Thus, while the exacerbation of signs and symptoms of DED may be transiently induced in cataract surgery, the decrease in goblet cell density post-surgery could have a longer-lasting effect on the eyes of DED patients. Finally, in our study, participants with a history of cataract surgery were significantly more likely to use artificial tears, gels, cyclosporine drops, and lubricating ointment than participants without history of cataracts. These therapeutics are known to attenuate DED signs and symptoms (eg, artificial tears lower OSDI scores) and thus may have masked the effect of phacoemulsification on DED severity in our participants.^34–36 Moreover, past studies have shown that the usage of topical medications such as cyclosporine A or artificial tears has improved DED symptoms (as measured by OSDI) in patients post-phacoemulsification.³⁷ Future studies that evaluate the microscopic ocular surface changes in post-cataract surgery patients with DED can better evaluate the effect of cataract surgery on DED signs and symptoms without confounders (ie, therapeutics alleviating dry eye signs and symptoms).

Conclusions

In patients with moderate-to-severe DED, cataracts and a history of cataract surgery were not independently associated with more severe DED symptoms and signs. However, this study was limited to long-term effects because participants with recent cataract surgery (<6 months) were excluded. This lack of association suggests that increased DED severity following phacoemulsification is either related to patient age and/or are transient in DED patients. The use of anti-inflammatory eye drops may be able to mitigate MGD after cataract surgery in patients with moderate-to-severe DED. However, this merits further investigation. Additional studies are needed to better understand how cataract surgery affects DED severity and MGD in patients with DED.

Acknowledgments

This work was supported by National Eye Institute Grants U10EY022879, U10EY022881, R21EY031338, and an unrestricted grant from Research to Prevent Blindness (RPB). The funding organization had no role in the design or conduct of this research. Previously presented at the World Ophthalmology Congress 2024, Vancouver, CA.

Collaborators

Please see supplementary material for The members of the DREAM Study Research Group.

Disclosure

Dr Penny Asbell reports personal fees from Iolyx, outside the submitted work. Dr Vatinee Bunya is part of the advisory board for Kowa (paid) and Sjogren’s Foundation (unpaid), outside the submitted work. The authors report no other conflicts of interest in this work.

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11. Pistilli M, Ying G-S, Maguire MG, et al. Symptom questionnaires for dry eye disease: a comparative rasch analysis of the OSDI, BODI and IDEEL. Invest Ophthalmol Visual Sci. 2011;52(14):3865.

12. Lemp MA. Report of the national eye institute/industry workshop on clinical trials in dry eyes. Clao J. 1995;21(4):221–232.

13. Ong ES, Felix ER, Levitt RC, Feuer WJ, Sarantopoulos CD, Galor A. Epidemiology of discordance between symptoms and signs of dry eye. Br J Ophthalmol. 2018;102(5):674–679. doi:10.1136/bjophthalmol-2017-310633

14. Sullivan BD, Whitmer D, Nichols KK, et al. An objective approach to dry eye disease severity. Invest Ophthalmol Vis Sci. 2010;51(12):6125–6130. doi:10.1167/iovs.10-5390

15. Vehof J, Sillevis Smitt-Kamminga N, Nibourg SA, Hammond CJ. Predictors of discordance between symptoms and signs in dry eye disease. Ophthalmology. 2017;124(3):280–286. doi:10.1016/j.ophtha.2016.11.008

16. Gill SC, Butterworth P, Rodgers B, Mackinnon A. Validity of the mental health component scale of the 12-item short-form health survey (MCS-12) as measure of common mental disorders in the general population. Psychiatry Res. 2007;152(1):63–71. doi:10.1016/j.psychres.2006.11.005

17. Yu K, Bunya V, Maguire M, Asbell P, Ying GS. Systemic conditions associated with severity of dry eye signs and symptoms in the dry eye assessment and management study. Ophthalmology. 2021;128(10):1384–1392. doi:10.1016/j.ophtha.2021.03.030

18. Zhou Y, Murrough J, Yu Y, et al. Association between depression and severity of dry eye symptoms, signs, and inflammatory markers in the DREAM study. JAMA Ophthalmol. 2022;140(4):392–399. doi:10.1001/jamaophthalmol.2022.0140

19. Zhao M, Yu Y, Roy NS, Ying GS, Asbell P, Bunya VY. Sex-related differences and hormonal effects in the dry eye assessment and management (DREAM) study. Br J Ophthalmol. 2023;108(1):23–29. doi:10.1136/bjo-2022-322238

20. Zhao M, Yu Y, Ying GS, Asbell PA, Bunya VY. Age associations with dry eye clinical signs and symptoms in the dry eye assessment and management (DREAM) study. Ophthalmol Sci. 2023;3(2):100270. doi:10.1016/j.xops.2023.100270

21. Gomes JAP, Azar DT, Baudouin C, et al. TFOS DEWS II iatrogenic report. Ocular Surf. 2017;15(3):511–538. doi:10.1016/j.jtos.2017.05.004

22. Sidaraite A, Mikalauskiene L, Grzybowski A, Zemaitiene R. Evaluation of ocular surface after cataract surgery-A prospective study. J Clin Med. 2022;11(15):4562. doi:10.3390/jcm11154562

23. Muzyka-Woźniak M, Stróżecki Ł, Przeździecka-Dołyk J. Assessment of the eye surface and subjective symptoms after using 0.1% dexamethasone drops with and without preservatives in patients after cataract surgery. Sci Rep. 2023;13(1):18625. doi:10.1038/s41598-023-44939-1

24. Walsh K, Jones L. The use of preservatives in dry eye drops. Clin Ophthalmol. 2019;13:1409–1425. doi:10.2147/opth.S211611

25. Khanal S, Tomlinson A, Esakowitz L, et al. Changes in corneal sensitivity and tear physiology after phacoemulsification. Ophthalmic Physiol Opt. 2008;28(2):127–134. doi:10.1111/j.1475-1313.2008.00539.x

26. Shimabukuro M, Maeda N, Koh S, Abe K, Kobayashi R, Nishida K. Effects of cataract surgery on symptoms and findings of dry eye in subjects with and without preexisting dry eye. Jpn J Ophthalmol. 2020;64(4):429–436. doi:10.1007/s10384-020-00744-1

27. Jensen P, Nilsen C, Gundersen M, et al. A preservative-free approach – effects on dry eye signs and symptoms after cataract surgery. Clin Ophthalmol. 2024;18:591–604. doi:10.2147/opth.S446804

28. Han KE, Yoon SC, Ahn JM, et al. Evaluation of dry eye and meibomian gland dysfunction after cataract surgery. Am J Ophthalmol. 2014;157(6):1144–1150.e1. doi:10.1016/j.ajo.2014.02.036

29. Song P, Sun Z, Ren S, et al. Preoperative management of MGD alleviates the aggravation of MGD and dry eye induced by cataract surgery: a prospective, randomized clinical trial. Biomed Res Int. 2019;2019:2737968. doi:10.1155/2019/2737968

30. Eom Y, Na KS, Hwang HS, et al. Clinical efficacy of eyelid hygiene in blepharitis and meibomian gland dysfunction after cataract surgery: a randomized controlled pilot trial. Sci Rep. 2020;10(1):11796. doi:10.1038/s41598-020-67888-5

31. Qiao J, Yan X. Emerging treatment options for meibomian gland dysfunction. Clin Ophthalmol. 2013;7:1797–1803. doi:10.2147/opth.S33182

32. Perry HD, Doshi-Carnevale S, Donnenfeld ED, Solomon R, Biser SA, Bloom AH. Efficacy of commercially available topical cyclosporine A 0.05% in the treatment of meibomian gland dysfunction. Cornea. 2006;25(2):171–175. doi:10.1097/01.ico.0000176611.88579.0a

33. Oh T, Jung Y, Chang D, Kim J, Kim H. Changes in the tear film and ocular surface after cataract surgery. Jpn J Ophthalmol. 2012;56(2):113–118. doi:10.1007/s10384-012-0117-8

34. Ames P, Galor A. Cyclosporine ophthalmic emulsions for the treatment of dry eye: a review of the clinical evidence. Clin Investig. 2015;5(3):267–285. doi:10.4155/cli.14.135

35. Jeon J, Park S. Comparison of the efficacy of eyelid warming masks and artificial tears for dry eye symptoms in contact lens wearers. Contact Lens Anterior Eye. 2021;44(1):30–34. doi:10.1016/j.clae.2020.02.013

36. Semp DA, Beeson D, Sheppard AL, Dutta D, Wolffsohn JS. Artificial Tears: a Systematic Review. Clin Optom. 2023;15:9–27. doi:10.2147/opto.S350185

37. Cetinkaya S, Mestan E, Acir NO, Cetinkaya YF, Dadaci Z, Yener HI. The course of dry eye after phacoemulsification surgery. BMC Ophthalmol. 2015;15(1):68. doi:10.1186/s12886-015-0058-3

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August 11, 2025
AMC earnings Q2 2025 narrow losses

People walk past an AMC theatre in Manhattan in New York City, U.S., February 25, 2025.

Jeenah Moon | Reuters

Shares of AMC Entertainment rose 8% in early trading Monday after the movie theater chain reported stronger-than-expected second-quarter results.

The company posted revenue of nearly $1.4 million, up about 35% year over year and topping the $1.35 billion Wall Street estimate, according to LSEG.

AMC reported a net loss of $4.7 million, or just 1 cent per share, notably narrower than the loss of $32.8 million, or 10 cents per share, the company reported in the second quarter of 2024.

On an adjusted, per-share basis, AMC reported breaking even. Wall Street analysts had expected AMC to report an adjusted loss per share of 8 cents, per LSEG.

AMC also said it saw a 26% increase in moviegoers’ attendance compared to last year.

CEO Adam Aron said the company’s results are indicative of a “recovering industry-wide box office” after previously struggling to pare losses amid dual writers’ and actors’ strikes and an overall post-pandemic decline in movie attendance.

The company is also navigating a significant debt load.

“We’ve now addressed all of our 2026 debt maturities pushing them out to 2029,” Aron said. “In so doing, we have put in place a solid foundation to capitalize on what we believe will be our industry’s continued growth momentum, especially evident in the fourth quarter of 2025 and continuing deep into 2026.”

Aron also said the company saw consolidated admissions revenue per patron topping $12 for “the first time ever,” with total consolidated revenue per patron reaching an “unprecedented” $22.26.

The company reported significant growth in its premium offerings, including its AMC Go Plan, with premium auditoriums operating at nearly three times the occupancy of regular auditoriums.

“The combination of a resurgent box office, our unparalleled theatre footprint with premium experiences galore, our compelling marketing programs and our increasing financial strength have a flywheel impact when they all are happening simultaneously,” Aron said.

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August 11, 2025
‘Empathie’ Renewed For Season 2 At Crave & Canal+

EXCLUSIVE: Canada’s Crave and France’s Canal+ are going in for another round of empathy.

The French and Canadian players have recommissioned Empathie from creator and star Florence Longpré shortly before Season 1 launches on Canal+.

Exploring the depths of mental illness, Empathie tells the story of Suzanne (Longpré), a criminologist-turned-psychiatrist who goes to work at the Institut psychiatrique Mont-Royal. There, she befriends Mortimer, an intriguing security officer, and meets a variety of patients with compelling stories.

Empathie is Crave and Canal+’s first joint project. Season 1 has been a hit for Crave, with the Bell Media-owned streamer saying it is the second most popular original series since the launch of the platform and the top-watched Crave original this year across all languages in Canada. Empathie won the Audience Award at France’s Séries Mania earlier this year. Season 1 launches on Canal+ on September 1.

“Putting ourselves in someone else’s shoes, understanding them, and sharing their feelings is the greatest journey we can take from the couches in our living rooms,” said Longpré.

Suzane Landry, Bell Media’s Vice-President, Content Development, Programming and News, added: “Building on the phenomenal success of Empathie on Crave, we are proud to present this remarkable work to a new audience. Our partnership with Canal+ illustrates Bell Media’s focus on making great original series that resonate at home and abroad.”

Produced by Trio Orange in collaboration with Bell, Empathie is written by Longpré and directed by Guillaume Lonergan. The series is produced with the participation of the SODEC (Société de développement des entreprises culturelles) Film and Television Tax Credit, the Canada Media Fund, the Canadian Film or Video Production Tax Credit, SODEC Québec, the TELUS Fund, the Quebecor Fund and the Independent Production Fund for COGECO. International distribution in French-speaking territories is handled by Trio Orange, while other territories are handled by Beta Group.

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August 11, 2025

Two-Decade Retrospective Analysis of Postoperative Endophthalmitis at

Introduction

Postoperative endophthalmitis is a particularly serious complication of ophthalmic surgery. Severe and irreversible visual loss can occur in a large proportion of cases, particularly if diagnosis and proper treatment are delayed. Although culture methods may fail to identify the causative pathogen, clinical signs of disease can be sufficient to recognize this condition and initiate treatment.

The most common types of intraocular surgeries performed worldwide are cataract extraction, glaucoma filtration surgery, pars plana vitrectomy (PPV), and intravitreal injection (IVI). The reported incidence of acute-onset postoperative endophthalmitis ranges from 0.036% to 0.36% of eyes undergoing intraocular surgery.^1–3 Additionally, the incidence of post-injection endophthalmitis is reportedly 0.049%–0.056%.⁴

Since 2000, intraocular surgery underwent substantial changes, such as increased numbers of cataract surgeries and PPVs. Surgical advancements included small clear corneal incision cataract surgery, manual small incision cataract surgery, sutureless small-gauge PPV (instead of 20-gauge PPV), and an exponential increase in the use of intravitreal injections for ophthalmic treatment. These developments may influence the incidence of postoperative endophthalmitis.^5,6

Categorization helps to predict the causative organism and underlying etiology. According to the Endophthalmitis Vitrectomy Study, acute-onset postoperative endophthalmitis is defined as an infection arising within 6 weeks after surgery. Conversely, delayed-onset postoperative endophthalmitis is defined as an infection occurring more than 6 weeks after surgery.⁷

This study was performed to evaluate the clinical features, causative organisms, treatment modalities, and visual outcomes associated with acute-onset and delayed-onset postoperative endophthalmitis during the past 20 years at a university referral center.

Ramathibodi Hospital, a tertiary referral facility in central Thailand, receives endophthalmitis cases from local and distant areas. This single-center retrospective study focused on postoperative endophthalmitis cases from the surrounding region.

Materials and Methods

This study adhered to the tenets of the Declaration of Helsinki and was approved by the Mahidol University Ethics Committee for Human Research (MURA2023/888). Informed consent was waived due to the retrospective nature of the study. No identifiable patient data or images are included in this publication. A retrospective review was conducted involving the medical records of all patients who received treatment for postoperative endophthalmitis at Ramathibodi Hospital between 2001 and 2022. The study included patients with the following International Classification of Diseases and Related Health Problems-10 codes: H44.0 for purulent endophthalmitis, H44.1 for other endophthalmitis, H45.1 for endophthalmitis in diseases classified elsewhere, H59.8 for other postprocedural disorders of the eye and adnexa, such as keratoplasty-associated endophthalmitis and bleb-associated endophthalmitis, and T89.1 for unspecified procedure complications. Diagnoses of endophthalmitis were based on clinical signs and symptoms, including eye pain, vision loss, eyelid edema, conjunctival hyperemia and chemosis, anterior chamber inflammation (eg, flare, cells, hypopyon, pupillary fibrin membrane), blebitis, vitritis, and vitreous opacity on B-scan ultrasonography. In our study, follow-up was defined as the period from the initial diagnosis of endophthalmitis to at least nine months after treatment. The main outcome measurement was the evaluation at nine months post-treatment; therefore, patients who were lost to follow-up before this timepoint were excluded from the analysis.

For all suspected cases of endophthalmitis, demographic data were recorded; these data included age, sex, underlying diseases, laterality, onset and duration, best-corrected visual acuity (VA) at initial presentation (defined as the VA measured at the patient’s first visit to our hospital at the time of endophthalmitis diagnosis) and after recovery, pathogen etiology, type of intraocular surgery and associated complications, culture results, and treatments.

Prior to initiating treatment, vitreous and/or aqueous samples were collected for microbiological analysis in all cases. In patients undergoing intravitreal tapping, undiluted vitreous samples were aspirated using a 23-gauge needle attached to a syringe under aseptic conditions at the operating microscope. For patients treated with PPV, undiluted vitreous specimens were obtained at the start of the procedure before infusion was initiated, using the vitrectomy cutter connected to a sterile syringe or tubing. Standard 20- or 23-gauge systems were used, and all procedures were performed by experienced vitreoretinal surgeons. Collected specimens were immediately submitted for microbiological workup, which included inoculation on blood agar, chocolate agar, Sabouraud dextrose agar, and thioglycollate broth to detect aerobic and anaerobic bacteria and fungi. In some cases, molecular testing using 16S and 18S rRNA gene polymerase chain reaction (PCR) assays were performed to enhance pathogen detection. However, molecular diagnostics were not consistently available during the first five years of the study period due to laboratory limitations. Bacterial detection was performed using primers 27F and 519R, commonly applied for broad-range bacterial identification.⁸ For fungi, the internal transcribed spacer (ITS1–ITS2) region was amplified using ITS1 and ITS2 primers, which are widely recommended for broad fungal coverage.⁹ Immediate PPV was defined as surgery performed within 24 hours of endophthalmitis diagnosis, whereas delayed PPV was performed more than 24 hours after diagnosis in cases where there was no clinical improvement or worsening following primary vitreous tapping and antimicrobial injection. In cases of bacterial infection, ceftazidime and vancomycin were prescribed as empiric therapy, whereas amphotericin or voriconazole were administered in cases of fungal infection. Specific treatments for each patient were determined based on culture results.

To facilitate statistical analysis, Snellen VA measurements were converted to logarithm of the minimum angle of resolution (logMAR) values. Poor VA measurements were assigned logMAR values of 2.0, 2.3, 2.5, 2.7, and 3.0 for counting fingers, hand motion, light projection, light perception, and no light perception, respectively. The primary outcome measure was VA assessed at nine months, which was used as the reference point for determining the final visual outcome after endophthalmitis management.¹⁰

Statistical Analysis

Categorical data (eg, sex, laterality, underlying diseases, prior surgeries, and treatment modalities) are shown as numbers and percentages. Continuous variables are presented as means and standard deviations; for variables with skewed distributions, medians and interquartile ranges (IQRs) are presented. Normally distributed continuous variables were analyzed using t-tests. For skewed distributions, the Mann–Whitney U-test was used. Categorical variables were analyzed using the Pearson chi-squared test or Fisher’s exact test. Multivariate logistic regression analysis was utilized to identify factors associated with poor visual prognosis. Multilevel linear random intercepts and random slope regression models were used to analyze the mean difference in VA (logMAR) from preoperative to postoperative across the three treatment groups. The models also compared the mean preoperative VA (logMAR) among the treatment groups and accounted for variations between individual participants at the preoperative stage (intercepts). Additionally, the models calculated the mean difference in the effect over time (slopes) on VA (logMAR) between preoperative and postoperative stages across the three groups. Statistical analysis was performed using STATA version 14.0 (Stata Corp LP, College Station, TX, USA). P-values <0.05 were considered statistically significant.

Results

This study initially included 181 patients with suspected endophthalmitis, according to their electronic medical records. After the exclusion of 18 patients (Figure 1) due to incomplete records, altered diagnoses, or loss to follow-up, 163 eyes of 163 patients were analyzed (Table 1). The participants comprised 89 men and 74 women with a mean age of 64.8±13.0 years. Endophthalmitis involved the right eye in 82 cases (50.3%). The two most prevalent underlying diseases were hypertension and diabetes mellitus, observed in 53% and 31% of cases, respectively, as presented in Table 1.

Table 1 Demographic Data of 163 Patients with Postoperative Endophthalmitis

Figure 1 Post-operative endophthalmitis inclusion and subgroup treatment analysis flow diagram.

Abbreviations: EMRs, electronic medical records; ICD10, 10th revision of the International Classification of Diseases; IVI, intravitreal injection; PPV, pars plana vitrectomy.

Notes: Bold text in the diagram indicates the total number of eyes included in the study cohort.

All included patients had postoperative endophthalmitis; 53% of eyes (87 of 163) were acute-onset. The median intervals from surgery to presentation were 8 days (IQR, 3–14) and 730 days (IQR, 125–1753) in the acute and chronic postoperative endophthalmitis groups, respectively. Cataract surgery was the primary procedure associated with the highest incidence of postoperative endophthalmitis (94 cases, 57.7%). Eighteen eyes (11%) received vitreous tapping and intravitreal antibiotics at the referring hospital prior to presentation at our center. Of these, 14 were in the cataract surgery group, 2 in the PPV group, and 1 each in the glaucoma and IVI groups. Among these, 10 cataract cases and all PPV and glaucoma cases were culture negative.

Microbiological investigations of vitreous fluid were performed for all patients prior to treatment. The treatment modalities utilized in this study, including intravitreal or intracameral injections, immediate PPV, delayed PPV, and enucleation, are summarized in Table 2. All PPV procedures were combined with antimicrobial intravitreal injection (IVI). Immediate PPV was the most common approach, employed in 98 eyes (60.1%), followed by vitreous tapping with IVI alone in 50 eyes (30.7%). Delayed PPV was performed in 12 eyes (7.4%) following initial IVI due to clinical deterioration. The mean time to delayed PPV after initial presentation was 3.9 days (range 2–10 days). Intracameral injection was performed in two eyes (1.2%), when the anterior and posterior chambers were considered as a single chamber, either due to prior scleral fixation of an intraocular lens procedure or the aphakic status of the patient.

Table 2 Trends in Treatment Modalities and Antimicrobial Agents for Endophthalmitis Across Different Time Periods

Additionally, trends in treatment modalities for endophthalmitis from 2001 to present are summarized in Table 2. A shift in management strategies was observed over the years. Immediate PPV became the predominant approach in recent years, particularly after 2016. In contrast, vitreous tapping IVI alone and delayed PPV were more frequently employed in earlier years, especially before 2010.

Variations in drug treatment for postoperative endophthalmitis are presented in Table 2. Antimicrobial agents were administered to all patients based on suspected pathogens. The most commonly used intravitreal antibiotic regimens for bacterial infections were combinations of ceftazidime and vancomycin. Among the 163 total cases, 141 (86.5%) received systemic antibiotics, predominantly second- or third-generation fluoroquinolones, administered primarily via the oral route. Furthermore, 33 of 141 cases received intravenous antibiotics, predominantly involving a combination of ceftazidime and vancomycin.

Table 3 presents the preoperative and postoperative VA across the three treatment groups: vitreous tapping with IVI, immediate PPV, and delayed PPV. Two eyes that received intracameral injections were included in the IVI group. The mean initial VA before treatment was 2.0 logMAR in the immediate PPV group and 1.7 logMAR in both the IVI and delayed PPV group. Significant VA improvements were observed in the immediate PPV and delayed PPV groups, with mean improvements of 0.8 logMAR (p < 0.001) and 0.9 logMAR (p = 0.001), respectively. Multilevel linear regression models with random intercepts and slopes were used to analyze the mean differences in VA changes between treatment groups. The IVI group showed significantly less VA improvement compared to the immediate PPV group (mean difference: 0.6 logMAR, p < 0.001) and the delayed PPV group (mean difference: 0.7 logMAR, p = 0.029). No statistically significant difference in VA improvement was found between the immediate and delayed PPV groups.

Table 3 Mean VA (Log MAR) Value and Mean Difference of Participants From Initial and Final Visual Acuity of Three Different Treatment Groups

Among acute-onset cases, 60 of 87 eyes (69%) underwent immediate PPV with IVI, whereas in delayed-onset cases, 38 of 76 eyes (50%) underwent the same treatment. One patient with a prior history of corneal transplantation required immediate enucleation due to severe infection. During the follow-up period, five additional eyes required enucleation due to inadequate response to treatment. For patients who retained their eye, the median final VA was 20/200, corresponding to 0.9 (0.3, 2.3) logMAR. VA improved by more than five letters in 61.2% of cases, remained stable in 11.5%, and declined by more than five letters in 27.4%.

Prior Intraocular Surgeries

We analyzed the relationships between prior intraocular surgeries and postoperative endophthalmitis (Table 4). Our results showed that cataract surgery was the most common procedure among the 94 eyes (57.7%) with postoperative endophthalmitis. Within this group, complicated surgeries involving posterior capsular rupture occurred in 12 eyes (12.8%). Other procedures included glaucoma surgeries (trabeculectomy and glaucoma drainage devices) in 23 eyes (14.1%), vitrectomy in 16 eyes (9.8%), corneal transplantation (penetrating keratoplasty and keratoprosthesis implantation) in 10 eyes (6.1%), and IVI in eight eyes (4.9%). Twelve eyes (7.4%) had undergone combined cataract surgery with other procedures, such as vitrectomy and trabeculectomy.

Table 4 Different Prior Intraocular Surgeries with Their Associated Factors and Visual Outcomes

The median age at presentation for patients undergoing glaucoma surgery was 61 years, the lowest among all surgical groups. Conversely, the highest median age at presentation was 70 years, observed in the corneal transplantation group. The interval between surgery and endophthalmitis diagnosis varied among procedures. Most patients with cataract surgery–, combined cataract surgery–, or intravitreal injection–related postoperative endophthalmitis presented with acute disease. Conversely, most patients who underwent prior glaucoma surgeries or corneal transplantation presented with chronic disease.

Furthermore, we examined variations in globe salvage rates across surgical groups. The lowest rate was observed in the prior glaucoma surgery group (87%), whereas the highest rates were observed in the IVI and combined cataract surgery groups (100%). After the exclusion of cases requiring enucleation, the most favorable visual outcomes were achieved in the cataract and vitrectomy groups: median (IQR) VA of 0.5 (0.2–2.0) logMAR and 0.5 (0.5–2.3) logMAR, respectively. In subgroup analysis focusing on cataract surgery, the final median (IQR) VA after endophthalmitis treatment was less favorable in cases involving complicated cataract surgery (1.15 [IQR 0.60–2.15] logMAR) than in non-complicated cases (0.40 [IQR 0.20–2.0] logMAR). However, this difference in VA was not statistically significant (p=0.06). The least favorable visual outcome was observed in the prior corneal transplantation group, with a median (IQR) VA of 3.0 (2.0–3.0) logMAR.

Causative Microorganisms

Positive cultures were obtained in 52 of 163 eyes (31.9%). Bacteria were isolated in 42 eyes (80.7%), fungi were isolated in five eyes (9.6%), multiple bacterial organisms were isolated in one eye (2.0%), and mixed causative organisms in four eyes (7.7%). Notably, seven bacterial infections were identified through 16S rRNA analysis and negative culture methods, whereas two fungal infections were identified through 18S rRNA analysis and negative culture methods. The specific causative organisms, classified according to onset timing, and their visual outcomes are presented in Table 5. When considering the previous surgical procedures, the positive-culture rate was highest in the glaucoma surgery group (52.2%) and lowest in the vitrectomy group (25.0%). In acute postoperative endophthalmitis, positive cultures were obtained in 26 of 87 eyes (29.9%). The most frequently identified microorganism was coagulase-negative Staphylococcus (CoNS; 15/26, 57.7%), followed by Enterococcus faecalis (4/26, 15.9%).

Table 5 Culture-Positive Pathogen Results According to Onset, Ocular-Related Surgeries and Visual Acuity

Among cases of delayed-onset postoperative endophthalmitis, positive cultures were obtained in 22 of 76 eyes (29.0%). CoNS was again the most frequently identified microorganism (4/22, 18.2%). Most culture-positive delayed-onset postoperative endophthalmitis cases were associated with glaucoma surgery (11/21, 52.4%), and Streptococcus species were the predominant organisms in three cases. Pseudomonas aeruginosa infection was the most virulent organism, causing final VA of no light perception in all three affected patients. Staphylococcus aureus and CoNS were comparatively less virulent, with the best median final VA.

Among five eyes with culture-proven fungal endophthalmitis, three were infected with Aspergillus spp., one with Penicillium, and one with Rigidoporus. Based on initial treatment modality, one eye received IVI (amphotericin and voriconazole) without vitrectomy and achieved successful infection control (Penicillium). Two eyes underwent immediate PPV (Aspergillus) and both were successfully salvaged. The remaining two eyes received only IVI as delayed PPV was not feasible due to uncontrolled infection and poor corneal clarity; both subsequently required enucleation (Aspergillus and Rigidoporus). The remaining three cases with preserved eyes, the median VA was 2.4 logMAR. All fungal infection cases exhibited delayed onset, with mean and median intervals from surgery (two keratoprostheses, one trabeculectomy, one phacoemulsification, and one scleral fixation of an intraocular lens) to diagnosis of 96.6 and 56.4 weeks, respectively.

Subsequently, participants were categorized into two groups based on visual outcomes, as determined by the median final VA (Table 6). These groups had VA better than 20/200 and VA equal to or less than 20/200; six enucleation cases were excluded from the analysis. Univariate analysis revealed that diabetes mellitus, initial VA of 20/200 or worse, hypopyon at initial presentation, and delayed-onset postoperative endophthalmitis were factors significantly associated with poor visual outcomes. No significant differences in visual outcomes were observed based on other factors, such as sex, immunocompetence, end-stage renal disease status, culture results, and vitrectomy status. Stepwise logistic regression analysis confirmed significant associations of poor visual outcomes with diabetes mellitus (odds ratio [OR]=2.65; 95% confidence interval [CI], 1.17–5.96), VA at initial presentation of 20/200 or worse (OR=35.87; 95% CI, 7.15–179.89), and delayed-onset postoperative endophthalmitis (OR=3.9; 95% CI, 1.79–8.50).

Table 6 Factors Associated with Final Visual Outcome After Treatment of Postoperative Endophthalmitis by Univariate and Multivariate Analysis (Enucleation Eyes Were Excluded)

In this study, six patients underwent enucleation due to uncontrolled infection after treatment, representing a globe salvage rate of 96.3%. The infections occurred after three postoperative trabeculectomies, one phacoemulsification, one vitrectomy with scleral fixation, and one keratoprosthesis implantation.

Discussion

In cases of postoperative endophthalmitis, intraocular fluid smears and cultures remain the gold standard for identifying causative organisms. The culture-positive rate in our study was lower than typically reported in the literature, where postoperative endophthalmitis culture yields generally range from 40% to 70%.^11–13 Several factors may explain this finding. Eighteen eyes (11%) had received intravitreal antibiotics prior to referral, potentially suppressing organism growth by the time of sample collection. Additionally, limited vitreous volume in some cases and the use of conventional culture methods without molecular diagnostics could have reduced detection sensitivity. Culture-positive rates also varied by prior surgery type, with higher rates in the glaucoma group and lower rates in the cataract and PPV groups. This may be partly due to pre-referral treatment: 14 of the 18 pretreated eyes were in the cataract group (10 culture-negative), and all pretreated PPV and glaucoma cases were also culture-negative. Differences in sample size across surgical subgroups may also have contributed to the variability in culture positivity.

The Endophthalmitis Vitrectomy Study (1995) showed that early vitrectomy significantly improved outcomes in patients with light perception vision, with a threefold greater chance of achieving 20/40 vision.¹⁴ Since then, advances in surgical techniques have increased the success of PPV, which has become more widely adopted in managing endophthalmitis.⁵ The Complete and Early Vitrectomy for Endophthalmitis (CEVE) approach is now recommended as a primary treatment, especially when the fundus view is obscured or macular involvement cannot be excluded.¹⁵ We compared VA at initial presentation among three groups: IVI alone, immediate PPV with IVI, and delayed PPV with IVI. Initial VA was generally better in the IVI and delayed PPV groups, likely reflecting clinical decisions to reserve immediate PPV for eyes with more severe vitritis.

Post-treatment outcomes showed significant visual improvement in both the immediate and delayed PPV groups, while the IVI group showed no significant change. Visual improvement was also significantly greater in the PPV groups compared to the IVI group. These findings suggest that PPV—whether performed initially or after IVI—offers superior visual outcomes, particularly in patients with poor baseline vision or severe vitritis. This aligns with previous studies reporting that immediate PPV results in better visual outcomes compared to IVI alone in cases of postoperative endophthalmitis presenting with poor vision or severe vitritis.^15,16

The limited improvement in the IVI group may be due to the absence of mechanical clearance of infectious and inflammatory material. Additionally, less severe initial presentations in this group may have led to smaller observed gains in visual acuity. The difference in outcomes between immediate and delayed PPV was not statistically significant, likely due to the small sample size in the delayed PPV group. These findings underscore the need for individualized treatment based on disease severity, with close monitoring to allow timely surgical intervention when needed.

Intravitreal antibiotics are essential for initial management of postoperative endophthalmitis and are often combined with topical and systemic agents. Vancomycin and ceftazidime are commonly used due to their broad-spectrum coverage. Vancomycin targets gram-positive bacteria, including methicillin-resistant strains, while ceftazidime is preferred for gram-negative coverage and is safer than amikacin.¹⁷ The use of topical and systemic antibiotics alongside intravitreal therapy in postoperative endophthalmitis depends on disease severity and patient factors. The EVS recommends systemic antibiotics in cases with severe presentation, such as dense hypopyon or poor initial vision. The 2013 ESCRS guidelines also advise that if systemic antibiotics are used for severe acute-onset cases, they should align with the spectrum of intravitreal agents.¹⁸ In our study, systemic antibiotics were used in 87% of cases, primarily via oral administration. Intravenous antibiotics were given in 20%, typically for more severe presentations. While intravenous antibiotics may be perceived as beneficial in advanced cases, their efficacy remains uncertain, especially in milder disease, as existing studies have not shown a clear advantage.

Cataract surgery was the most common procedure among the 94 eyes with endophthalmitis. Previous studies have identified posterior capsule rupture as a significant risk factor for post-cataract endophthalmitis.^13,19–26 In our study, we were unable to calculate the true incidence of posterior capsule rupture; therefore, we could not analyze its relationship with endophthalmitis. Of the 94 cataract cases, 82 (87.2%) were uncomplicated and 12 (12.8%) were complicated. Final median VA was poorer in the complicated group (1.15 logMAR) compared to the uncomplicated group (0.40 logMAR), though this difference was not statistically significant.

In our cohort, the median time from surgery to presentation in the chronic group was 730 days, which is longer than the typical duration of two to three months but remains plausible given that delayed-onset chronic endophthalmitis can present months to years after surgery. These indolent cases may remain subclinical for prolonged periods before eventually manifesting with signs of inflammation, as described in previous reports.^27–29 The timing of endophthalmitis onset varied by procedure. Acute-onset cases were more common after cataract surgery, combined cataract procedures, and IVI, while delayed-onset cases occurred more frequently after glaucoma surgery or corneal transplantation. Our findings align with prior reports indicating that bleb-associated endophthalmitis occurs in 0.2% to 9.6% of glaucoma filtering surgeries, typically presenting more than one month postoperatively.^30–32 Delayed-onset cases often have poor outcomes despite infection control and 22% requiring enucleation or evisceration.^30,32

Our study included 10 cases of delayed-onset post-keratoplasty endophthalmitis, with one requiring enucleation. The remaining cases had a median final VA of 3.0 logMAR, reflecting poor outcomes. Similarly, Tran et al reported unfavorable visual outcomes in patients with delayed-onset endophthalmitis following penetrating keratoplasty.³³

In this study, the spectrum of endophthalmitis isolates predominantly comprised gram-positive microorganisms, such as CoNS (Staphylococcus epidermidis), E. faecalis and Staphylococcus aureus. In culture-positive acute-onset cases, CoNS was the most common isolate (57.7%). This aligns with their known role as common skin and ocular surface flora, which may be introduced during intraocular procedures. Although consistent with prior studies,^34–36 our data underscore the continued predominance of CoNS in postoperative endophthalmitis and highlight the need for meticulous perioperative aseptic precautions to minimize contamination risk.

Delayed-onset postoperative endophthalmitis is typically caused by Propionibacterium spp., CoNS, and fungi.^37–39 In the present study, CoNS remained the predominant microorganisms among cases of delayed-onset postoperative endophthalmitis (18.18% of culture-positive cases); our findings reinforce previous reports that CoNS constitute common pathogens in chronic cases of postoperative endophthalmitis. We also identified three cases each of S. aureus, E. faecalis, and fungal isolates. Notably, over half of delayed-onset culture-positive cases followed glaucoma surgery, with Streptococcus spp. being the most frequent, aligning with previous findings in bleb-associated infections.³⁰ The prevalence of other bacterial species can vary in delayed-onset endophthalmitis, highlighting the importance of understanding the microbial profile to ensure effective treatment.

All five cases of fungal postoperative endophthalmitis in our study presented with delayed onset. Two required enucleations, while the remaining eyes were salvaged but had poor final visual acuity. This aligns with prior reports that fungal endophthalmitis often results in poor visual outcomes.⁴⁰ Aspergillus is known for its aggressive course and high risk of vision loss, whereas data on Penicillium and Rigidoporus remain limited. Current strategies involve PPV, intravitreal amphotericin (5–10 mg/0.1 mL) or voriconazole, and systemic antifungal therapy.^41,42 Given the indolent nature of delayed-onset fungal infections, prolonged systemic treatment (6 weeks to 6 months) may be warranted to improve outcomes.⁴²

Importantly, clinical outcomes vary among bacterial species. P. aeruginosa infections were associated with the worst visual outcomes, as indicated by the absence of light perception in all three affected patients. Similarly, Lin et al⁴³ reported dismal visual outcomes in cases of P. aeruginosa endophthalmitis, such that nearly all patients experienced final VA of counting fingers or worse; additionally, the rate of evisceration was high. In contrast, S. aureus and CoNS exhibited less virulence, resulting in better median final VA. These findings emphasize the importance of identifying specific microbial profiles to predict clinical outcomes and tailor treatment strategies.

Retinal detachment (RD) was identified in a small proportion of eyes with postoperative endophthalmitis (4.9%), though underreporting may have contributed to this low rate. All culture-positive RD cases involved bacterial pathogens and had poor visual outcomes (median final VA: 2.3 logMAR). Zhang et al⁴⁴ also reported worse prognosis and higher complication rates in eyes with RD. At our center, silicone oil is routinely used in eyes with concurrent RD for its antimicrobial and tamponade properties, which may help reduce RD recurrence. Other studies have shown that the risk of RD is reduced in eyes with adjuvant silicone oil implantation.^45,46

In this study, several factors were identified as significantly influencing visual outcomes in postoperative endophthalmitis. These factors included diabetes mellitus (OR=2.7), VA at initial presentation of 20/200 or worse (OR=35.9) and delayed-onset postoperative endophthalmitis (OR=3.9). Diabetic patients may be more susceptible to infection due to impaired neutrophil function and hyperglycemia-related immune dysfunction.^47,48 An additional reported risk factor is renal disease.¹⁶ Despite the significant morbidity associated with infectious endophthalmitis, this study highlights the potential benefits for microbiological analysis and prompt, tailored antimicrobial and/or surgical interventions in improving visual outcomes, even in cases with poor initial VA.

Conclusions

Postoperative endophthalmitis most commonly followed cataract surgery. Coagulase-negative Staphylococcus species were the leading causative microorganisms in both acute- and delayed-onset cases. Immediate PPV with intravitreal injection was the most frequent treatment, yielding significant improvements in VA, with a median final VA of 20/200 and a globe salvage rate of 96.3%. Visual improvement was achieved in most cases, though factors such as diabetes mellitus, poor VA at initial presentation and delayed-onset endophthalmitis were significantly associated with worse outcomes. These findings underscore the importance of timely and appropriate management to optimize visual and anatomical outcomes.

Abbreviations

CI, confidence interval; CoNS, coagulase-negative Staphylococcus; ESCRS, European Society of Cataract and Refractive Surgeons; EVS, Endophthalmitis Vitrectomy Study; IQR, interquartile range; IVI, intravitreal injection; logMAR: logarithm of the minimum angle of resolution; OR, odd ratio; PPV, pars plana vitrectomy; RD, retinal detachment; RNA, ribonucleic acid; rRNA, ribosomal RNA; VA, visual acuity.

Funding

There is no funding to report.

Disclosure

The authors report no conflicts of interest in this work.

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August 11, 2025

Blog

Introduction

Methods

Study Design and Participants

Questionnaire Introduction

Statistical Analysis

Results

Discussion

Conclusions

Data Sharing Statement

Ethics Approval and Consent to Participate

Author Contributions

Funding

Disclosure

References

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Introduction

Materials and Methods

DREAM Study

Participant Selection

Study Measures

Statistical Analysis

Results

Participant Characteristics and Medical History

Cataract History and DED Signs and Symptoms

Discussion

Conclusions

Acknowledgments

Collaborators

Disclosure

References

Introduction

Materials and Methods

Statistical Analysis

Results

Prior Intraocular Surgeries

Causative Microorganisms

Discussion

Conclusions

Abbreviations

Funding

Disclosure

References