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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 31  |  Issue : 3  |  Page : 228-231

Bilateral endogenous endophthalmitis – An excellent visual outcome


1 Department of Ophthalmology, Gian Sagar Medical College and Hospital, Patiala, Punjab, India
2 Department of Ophthalmology, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India

Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Rajwinder Kaur
Department of Ophthalmology, Adesh Institute of Medical Sciences and Research, Bathinda - 151 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_47_19

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  Abstract 


We report a case of a young female patient presenting with bilateral endogenous endophthalmitis (EE) following meningitis due to Neisseria meningitidis with excellent visual outcome. A young 35-year-old female presented with chief complaint of decreased vision in both eyes (right eye more than left eye). On presentation, best-corrected visual acuity (BCVA) was <20/400 in the right eye and <20/120 in the left eye. The patient had a history of fever for which she was admitted in the hospital with the diagnosis of bacterial meningitis and received intravenous fluids with course of intravenous antibiotics. Four days after discharge from the hospital, she noticed diminution of vision; on ocular examination, the anterior segment was normal, and vitritis was present in both the eyes with multiple retinal exudates in between two arcades. Fundus fluorescein angiography and optical coherence tomography (OCT) were done. Diagnosis was made based on clinical profile secondary to bacterial meningitis. She was started on oral antibiotics for 1 week and oral steroids. The patient was kept on follow-up visits at 1 day, 1 week, 2 weeks, and monthly up to 6 months. BCVA, intraocular pressure, complete slit-lamp examination, indirect ophthalmoscopy, fundus photo, and OCT were done on each visit. She responded well to the treatment, with BCVA on the final visit being 20/80 (right eye) and 20/20 (left eye), and macular edema resolved in both eyes on the final visit. To conclude, EE is a rare complication following meningitis due to Neisseria meningitis which if diagnosed promptly and managed effectively can have a favorable prognosis.

Keywords: Endogenous, endophthalmitis, meningitis, Neisseria meningitidis


How to cite this article:
Khan B, Kaur R. Bilateral endogenous endophthalmitis – An excellent visual outcome. Kerala J Ophthalmol 2019;31:228-31

How to cite this URL:
Khan B, Kaur R. Bilateral endogenous endophthalmitis – An excellent visual outcome. Kerala J Ophthalmol [serial online] 2019 [cited 2020 Jan 23];31:228-31. Available from: http://www.kjophthal.com/text.asp?2019/31/3/228/274585




  Introduction Top


Intraocular infection which affects the inner coats of the eye and associated with a significant as well as progressive inflammation in the vitreous is termed as endophthalmitis.[1],[2],[3] Endogenous endophthalmitis (EE) is a severe sight-threatening complication presenting as an ocular emergency. EE can manifest at any age and frequently associated with many underlying systemic risk factors often poses a diagnostic challenge. Recent prolonged hospitalization, immunosuppression with underlying malignancy, neutropenia and HIV, diabetes mellitus, intravenous drug abuse, urinary tract infection, and indwelling catheter are certain systemic risk factors which can result in the spread of microorganism through blood from distant focus to the eye.[4],[5],[6],[7],[8],[9],[10] Approximately 2%–8% of all cases of endophthalmitis are EE.[2],[4]

EE usually has poor visual outcome even after aggressive treatment.

We report here a case of EE (bilateral) in a young female patient which shows an excellent visual outcome unexpected only on conservative treatment. A 35-year-old-female came to the Vitreo-retina Clinic in the Department of Ophthalmology of our tertiary care hospital with the chief complaint of decreased vision of both eyes for the past 4 days. Diminution of vision was sudden with associated heaviness and photophobia. There was no history in redness, itching, trauma, foreign body, and ocular surgery. A detailed history was taken; in her recent past history, she revealed that she had high-grade fever, headache associated with stiffness in the neck, and was admitted in the hospital for the same. Complete blood count showed increased white blood cell (WBC) count. Cerebral spinal fluid (CSF) showed increased WBC count predominantly neutrophils with decreased glucose content. Gram stain of the CSF exhibited Gram-negative cocci. She received intravenous fluids in the form of 500 ml NS every 12 h and intravenous third-generation cephalosporin (ceftriaxone) at a dose of 75 mg/kg initially followed by 50 mg/kg 12 h for 7 days, and 4 days after discharge from the hospital, she noticed diminution of vision and reported to our clinic on the same day. On the day of presentation, her best-corrected visual acuity (BCVA) in the right eye was <20/400 and in the left eye was 20/120; intraocular pressure in the right eye was 14 mmHg and in left eye 16 mmHg. Blood culture also showed gram negative cocci.

Detailed ocular examination was done. On slit-lamp examination, the anterior segment was normal in both eyes, whereas the posterior segment revealed vitritis +++, multiple retinal exudates involving the posterior pole more in the right eye as compared the left eye. Fundus of the left eye had lesion superotemporal to the disc and small lesion inferotemporal to the macula. Clinical suspicion was clear pointing toward EE. Her fundus fluorescein angiography (FFA) was done, and optical coherence tomography (OCT) was done on the first visit, and fundus photo (FP) was done on each follow-up visits. Fundus photography revealed perivascular white, fluffy lesion with superficial hemorrhages in the paramacular region in the right eye shown in [Figure 1], and in the left eye, there were similar lesions supero-temporal to the disc and inferotemporal to the macula as shown in [Figure 2]. FFA revealed hyperfluorescence corresponding to the lesion and hypofluorescence corresponding to hemorrhages in the right eye [Figure 3] and hyperfluorescence corresponding to the lesion in the left eye [Figure 4]. OCT pictures interpreted extensive elevation of the macula with underlying cystoid spaces more in the right eye [Figure 5]a and [Figure 5]b and cystoid macular edema with neurosensory detachment in the left eye.
Figure 1: Fundus photograph showing a yellow white mass in the temporal paramacular region with some superficial hemorrhages in the right eye

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Figure 2: Fundus photograph there is a yellowish-white lesion superotemporal to the disc and a small yellowish-white lesion inferotemporal to the macula in the left eye

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Figure 3: Fundus fluorescein angiography reveals hyperfluorescence corresponding to the yellowish-white lesion and hypofluorescence corresponding to hemorrhages in the right eye

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Figure 4: Fundus fluorescein angiography reveals hyperfluorescence corresponding to the lesion in the left eye

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Figure 5: (a and b) Optical coherence tomography pictures showed extensive elevation of the macula with underlying cystic spaces more in the right eye and neurosensory detachment in the left eye

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The diagnosis of EE depending on the clinical presentation was made, and she was started on oral antibiotics tablet cefixime 200 mg BD for 1 week. As the patient was very ill, empiric treatment was started based on clinical profile secondary to bacterial meningitis. Oral steroids tablet prednisolone at a dose of 1 mg/kg body weight in a tapering fashion was started. Topical drug therapy was given continuously to the patient with drugs including prednisolone acetate (1%) and atropine (1%) and oral steroids for 2 months tapering slowly and progressively. The patient was kept on follow-up visits at 1 day, 1 week, 2 weeks, and monthly up to 6 months. BCVA, intraocular pressure, complete slit-lamp examination, indirect ophthalmoscopy, FP, and OCT were done on each visit. She responded well to the treatment; 1 month later, vitreous had cleared significantly. Her BCVA on the final visit was 20/80 in the right eye and 20/20 in the left eye. Fundus picture showed few residual exudates [Figure 6]a and [Figure 6]b. OCT pictures on the final visit showed the absence of any cystic spaces and attained the normal foveal contour in both eyes [Figure 7]a and [Figure 7]b.
Figure 6: (a) On the last follow-up visit, fundus photography showed few residual exudates in the right eye. (b) On the last follow-up visit, fundus photography showed few residual exudates in the left eye

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Figure 7: (a) Optical coherence tomography pictures (right eye) on the final visit showed the absence of any cystic spaces and attaining the normal foveal contour in both eyes. (b) Optical coherence tomography pictures (left eye) on the final visit showed absence of any cystic spaces and attaining the normal foveal contour in both eyes

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  Discussion Top


The bacterial EE was first reported and published in 1856.[7] EE following bacterial infection differs in different geographic areas based on the organism responsible. In the Western world, Gram-positive organisms (streptococci and staphylococci) are predominantly responsible for the infection, whereas in developing countries (Asian), Gram-negative organisms are responsible.[6],[8] Apart from this, many studies in the Asian countries have also isolated fungus as causative organisms in approximately 11.1%–18% of total cases of EE, whereas the rest are due to bacteria.[8],[9]

In patients with bacteremia or fungemia, the organism spreads from the primary site of infection by metastatic spread resulting in EE. The posterior segment vasculature is the site from which the organism reached the eye frequently with right eye more often involved resulting from direct route via right carotid artery as in our case also; the right eye was showing more changes.

The diagnosis of EE is based on the presence of one of the above-mentioned systemic risk factors with/without characteristic ocular findings on detailed ophthalmoscopic examination with a high index of suspicion. The diagnosis can be made on the basis of systemic infection as seen in blood culture where the blood is withdrawn on 3 consecutive days with sterile precautions and involvement of the vitreous cavity.[11]

Subretinal and choroidal abscess is suggestive of severe involvement of the vitreous in EE. A high rate of retinal detachment is seen in patients where endophthalmitis is due to methicillin-resistant Staphylococcus aureus and if the time period between the onset of symptoms and presentation is more than 2 weeks. OCT helps in localizing the pathology within the retinal layers and subretinal space in patients of EE. The intraretinal lesions with/without extrusion into the vitreous and sub-retinal exudates (elevation of retinal pigment epithelium, choroidal thickening as well as posterior vitreous cells) can be shown by OCT.[12]

Intravitreal antimicrobial agents may be required in most patients of severe bacterial EE. The treatment is initiated with empirical intravitreal antibiotics that provide a cover for both Gram-positive and Gram-negative organisms when the etiology is not known. Diagnostic pars plana vitrectomy may also be needed for the treatment of bacterial EE. For a better prognosis, early diagnosis and treatment of EE is must, but the patients might have a poor prognosis due to delayed diagnosis.[8]

The use of intravitreal as well as systemic steroids has given excellent results in various studies.[2] Steroids act by multiple mechanisms which include attenuating production of inflammatory cytokines, decreased leukocyte recruitment, and stabilizing membrane barriers (blood–retinal barrier).


  Conclusion Top


This case reports highlights the use of systemic antibiotics, and judicious use of systemic steroids in a case of EE can result in an excellent visual outcome. For a better prognosis, early diagnosis and treatment of EE is must. Detail history taking is important in dealing such cases. Our case is different from previously reported cases, being in the unexpected improvement of visual acuity only with conservative treatment in the era of vitreo-retinal surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khan FA, Slain D, Khakoo RA. Candida endophthalmitis: Focus on current and future antifungal treatment options. Pharmacotherapy 2007;27:1711-21.  Back to cited text no. 1
    
2.
Novosad BD, Callegan MC. Severe bacterial endophthalmitis: Towards improving clinical outcomes. Expert Rev Ophthalmol 2010;5:689-98.  Back to cited text no. 2
    
3.
Vilela RC, Vilela L, Vilela P, Vilela R, Motta R, Pôssa AP, et al. Etiological agents of fungal endophthalmitis: Diagnosis and management. Int Ophthalmol 2014;34:707-21.  Back to cited text no. 3
    
4.
Connell PP, O'Neill EC, Fabinyi D, Islam FM, Buttery R, McCombe M, et al. Endogenous endophthalmitis: 10-year experience at a tertiary referral centre. Eye (Lond) 2011;25:66-72.  Back to cited text no. 4
    
5.
Sridhar J, Flynn HW Jr., Kuriyan AE, Miller D, Albini T. Endogenous fungal endophthalmitis: Risk factors, clinical features, and treatment outcomes in mold and yeast infections. J Ophthalmic Inflamm Infect 2013;3:60.  Back to cited text no. 5
    
6.
Durand ML. Endophthalmitis. Clin Microbiol Infect 2013;19:227-34.  Back to cited text no. 6
    
7.
Keyashian K, Malani PN. Endophthalmitis associated with intravenous drug use. South Med J 2007;100:1219-20.  Back to cited text no. 7
    
8.
Cheng HH, Ding Y, Wu M, Tang CC, Zhang RJ, Lin XF, et al. Endogenous Aspergillus endophthalmitis after kidney transplantation. Int J Ophthalmol 2011;4:567-71.  Back to cited text no. 8
    
9.
Wu ZH, Chan RP, Luk FO, Liu DT, Chan CK, Lam DS, et al. Review of clinical features, microbiological spectrum, and treatment outcomes of endogenous endophthalmitis over an 8-year period. J Ophthalmol 2012;2012:265078.  Back to cited text no. 9
    
10.
de Lima LM, Cecchetti SA, Cecchetti DF, Arroyo D, Romão EA, Dantas M, et al. Endophthalmitis: A rare but devastating metastatic bacterial complication of hemodialysis catheter-related sepsis. Ren Fail 2012;34:119-22.  Back to cited text no. 10
    
11.
Lashof AM, Rothova A, Sobel JD, Ruhnke M, Pappas PG, Viscoli C, et al. Ocular manifestations of candidemia. Clin Infect Dis 2011;53:262-8.  Back to cited text no. 11
    
12.
Reedy JS, Wood KE. Endogenous Pseudomonas aeruginosa endophthalmitis: A case report and literature review. Intensive Care Med 2000;26:1386-9.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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