intraocular injections were done in the operating room under topical anesthesia and prophylactic povidone - iodine eye drops were used pre- and postinjections . separate sterile drape , speculum , topical anesthetic drops , povidone - iodine preparation , syringe , and needle were used for each eye . the age , sex , the affected eye , lens status , the date of the most recent injection , the underlying diagnosis , clinical indication for intravitreal injection , the preinjection visual acuity , the presenting symptoms and signs , management , as well as the microbiology result and postinjection visual acuity were documented . a 28-year - old male presented with pain , redness , and diminution of vision in the left eye 24 hours after intravitreal methotrexate injection for idiopathic retinal vasculitis . on examination , his best - corrected visual acuity ( bcva ) in the left eye was 20/50 . the conjunctiva was congested with 4 + cells in the anterior chamber and a 2% hypopyon.10 the view to the posterior segment was hazy , with a media clarity of grade 2.11 he was diagnosed with acute - onset endophthalmitis and underwent vitreous biopsy and injection of intravitreal vancomycin 1 mg/0.1 ml , amikacin 400 g/0.1 ml , and dexamethasone 400 g/0.1 ml . the patient was started on oral ciprofloxacin along with oral and topical corticosteroids . the visual acuity started improving within 1 week , and the patient had a bcva of 20/50 after 8 months of follow - up . a 46-year - old male patient presented with diminution of vision , pain , and watering in both the eyes 6 hours after intravitreal methotrexate injection for pars planitis with cystoid macular edema . on examination , his bcva was hand motions in the right eye and counting fingers at 1 m in the left eye . both the eyes had conjunctival congestion with 34 + cells in the anterior chamber and a 5% hypopyon.10 on fundus evaluation , the disc could be hazily seen with a media clarity of grade 3.11 he was diagnosed with acute - onset endophthalmitis . the patient underwent vitreous biopsy and injection of intravitreal vancomycin 1 mg/0.1 ml , amikacin 400 g/0.1 ml , and dexamethasone 400 g/0.1 ml in both eyes and received oral ciprofloxacin and oral corticosteroids along with frequent topical corticosteroids ( figure 1a ) . the visual acuity started improving within 1 week ( figure 1b ) , and at last follow - up visit 8 months later , the patient had a bcva of 20/60 in right eye and 20/50 in the left eye . the patients presented with diminution of vision along with pain within 24 hours of injection . the vitreous samples of the patients along with the used vials of methotrexate and two unused vials from the same batch were sent for culture and sensitivity . microbiology cultures from both vitreous samples , and used and unused vials of methotrexate from the same batch grew r. pickettii . microbiological identification was done using the vitek 2 system ( biomrieux inc , marcy letoile , france ) . each of the isolates was susceptible to ciprofloxacin , amikacin , imipenem , moxifloxacin and was resistant to ceftazidime , chloramphenicol , and gentamicin . both these patients were not able to tolerate systemic methotrexate and hence were injected with intravitreal methotrexate . the profile of the patients , clinical features , and the result of treatment are summarized in table 1 . a 28-year - old male presented with pain , redness , and diminution of vision in the left eye 24 hours after intravitreal methotrexate injection for idiopathic retinal vasculitis . on examination , his best - corrected visual acuity ( bcva ) in the left eye was 20/50 . the conjunctiva was congested with 4 + cells in the anterior chamber and a 2% hypopyon.10 the view to the posterior segment was hazy , with a media clarity of grade 2.11 he was diagnosed with acute - onset endophthalmitis and underwent vitreous biopsy and injection of intravitreal vancomycin 1 mg/0.1 ml , amikacin 400 g/0.1 ml , and dexamethasone 400 g/0.1 ml . the patient was started on oral ciprofloxacin along with oral and topical corticosteroids . the visual acuity started improving within 1 week , and the patient had a bcva of 20/50 after 8 months of follow - up . a 46-year - old male patient presented with diminution of vision , pain , and watering in both the eyes 6 hours after intravitreal methotrexate injection for pars planitis with cystoid macular edema . on examination , his bcva was hand motions in the right eye and counting fingers at 1 m in the left eye . both the eyes had conjunctival congestion with 34 + cells in the anterior chamber and a 5% hypopyon.10 on fundus evaluation , the disc could be hazily seen with a media clarity of grade 3.11 he was diagnosed with acute - onset endophthalmitis . the patient underwent vitreous biopsy and injection of intravitreal vancomycin 1 mg/0.1 ml , amikacin 400 g/0.1 ml , and dexamethasone 400 g/0.1 ml in both eyes and received oral ciprofloxacin and oral corticosteroids along with frequent topical corticosteroids ( figure 1a ) . the visual acuity started improving within 1 week ( figure 1b ) , and at last follow - up visit 8 months later , the patient had a bcva of 20/60 in right eye and 20/50 in the left eye . the patients presented with diminution of vision along with pain within 24 hours of injection . the vitreous samples of the patients along with the used vials of methotrexate and two unused vials from the same batch were sent for culture and sensitivity . microbiology cultures from both vitreous samples , and used and unused vials of methotrexate from the same batch grew r. pickettii . microbiological identification was done using the vitek 2 system ( biomrieux inc , marcy letoile , france ) . each of the isolates was susceptible to ciprofloxacin , amikacin , imipenem , moxifloxacin and was resistant to ceftazidime , chloramphenicol , and gentamicin . both these patients were not able to tolerate systemic methotrexate and hence were injected with intravitreal methotrexate . the profile of the patients , clinical features , and the result of treatment are summarized in table 1 . endophthalmitis outbreaks following intravitreal injections , although rare , have been reported all over the world.12 most of these outbreaks were caused by drug contamination at the compounding pharmacies or even spurious drugs , and majority of the culture - positive cases involved staphylococcus and streptococcus species.13,14 r. pickettii previously known as burkholderia pickettii or pseudomonas pickettii is a nonfermenting gram - negative bacillus and an opportunistic pathogen in both the hospital setting and from environmental sources.15 it has been isolated from multiple clinical specimens including blood , urine , and cerebrospinal fluid.16 a wide variety of infections ranging from minor skin infections to septicemia may be caused by this organism . most of the cases of infection with r. pickettii have been attributed to contaminated solutions , including water for injection , saline solutions made with purified water , and sterile drug solutions.1720 contamination of the product usually happens at the manufacturing stage and may be due to the ability of r. pickettii to pass through both 0.45-mm and 0.2-mm filters that are used for the terminal sterilization of several medicinal products.21 the organism can also form a biofilm and can survive hospital disinfectants like chlorhexidine and ethacridine lactate.22,23 in the current study , the infection could be traced to the contaminated vials of methotrexate . the vials were of the same batch and had been manufactured at the same facility where the breach in sterility may have occurred . the cultured isolates from each of the vials and vitreous had similar antibiotic susceptibility patterns . the isolates were resistant to ceftazidime , a third - generation cephalosporin which is commonly used for empirical therapy in endophthalmitis . resistance to -lactam antibiotics is most commonly due to production of -lactatamase , which leads to the enzymatic deactivation of the drug . it has been reported previously that ralstonia may produce a variety of -lactamases , including ceftazidime and imipenem , hydrolyzing oxa-60.24 this can have implications in the treatment of ralstonia - associated endophthalmitis . polymerase chain reaction ( pcr ) may also be helpful in identifying organisms like ralstonia , which are not commonly implicated in postoperative endophthalmitis.25 good clinical outcome has been reported before in patients with pcr - proven r. pickettii endohthalmitis , with intravitreal ceftazidime.25 this indicates that all isolates may not be ceftazidime resistant .
purposeto report an outbreak of endophthalmitis in three eyes of two patients following intravitreal methotrexate , caused by ralstonia pickettii.designretrospective , noncomparative , consecutive case series.methodsmedical records and microbiology results of two patients who presented with acute endophthalmitis following intravitreal methotrexate injection in november 2013 were reviewed.resultsfollowing intravitreal injections , the patients experienced pain and decrease in vision in the affected eye within 24 hours of receiving intravitreal methotrexate injection . 
 the presenting visual acuity in case 1 was 20/50 in the left eye . 
 the presenting visual acuity in case 2 was hand motions in the right eye and counting fingers at 1 m in the left eye . 
 both the patients received methotrexate prepared in the same manufacturing facility . 
 both the patients underwent vitreous biopsy and intravitreal injection of vancomycin 1 mg/0.1 ml , amikacin 400 g/0.1 ml , and dexamethasone 400 g/0.1 ml . 
 microbiology cultures from vitreous , and used and unused vials of methotrexate from the same batch grew r. pickettii . 
 after 8 months of follow - up , both the patients had visual acuity 20/60 or better.conclusionr . 
 pickettii can be rarely associated with outbreak of endophthalmitis . 
 timely intervention can be associated with good visual outcome in such patients .