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 Table of Contents    
CASE REPORT
Year : 2020  |  Volume : 13  |  Issue : 1  |  Page : 37-39  

Unusual case of endophthalmitis: Case report and literature review


1 Department of Ophthalmology, Sultan Qaboos University Hospital, Seeb, Muscat, Sultanate of Oman
2 Oman Medical Specialty Board, Muscat, Sultanate of Oman

Date of Submission02-Apr-2018
Date of Decision29-Jun-2019
Date of Acceptance23-Oct-2019
Date of Web Publication17-Feb-2020

Correspondence Address:
Dr. Mohamed Al-Abri
Department of Ophthalmology, Retina Unit, Sultan Qaboos University Hospital, P.O. Box 38 Al-Khod, P C 123, Muscat
Sultanate of Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.OJO_48_2018

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   Abstract 


Endophthalmitis is an inflammation of both the anterior and posterior chamber. It is diagnosed clinically and involvement of retina and choroid has been documented. (1) Endophthalmitis is classified into infectious and no-infectious categories. Furthermore, the infectious categoery is classified into endogenous and exogenous (Postoperative, Posttraumatic, Bleb associated) which can be caused by either bacterial or fungal infection. Blurry of vision and pain are main symptoms and coagulase negative organisms (gram positive) are main causative of exogenous endophthalmitis. (2) We report a rare case of delayed-onset postoperative endophthalmitis secondary to a rare causative pathogen.

Keywords: Endophthalmitis, fungus, postoperative, treatment


How to cite this article:
Al-Abri M, Al-Hinai A, Al-Farsi A, Al-Fadhil N. Unusual case of endophthalmitis: Case report and literature review. Oman J Ophthalmol 2020;13:37-9

How to cite this URL:
Al-Abri M, Al-Hinai A, Al-Farsi A, Al-Fadhil N. Unusual case of endophthalmitis: Case report and literature review. Oman J Ophthalmol [serial online] 2020 [cited 2020 Apr 6];13:37-9. Available from: http://www.ojoonline.org/text.asp?2020/13/1/37/278557




   Introduction Top


Endophthalmitis is an inflammation of both the anterior and posterior chamber. It is diagnosed clinically, and involvement of retina and choroid has been documented.[1] Endophthalmitis is classified into infectious and noninfectious categories. Furthermore, the infectious category is classified into endogenous and exogenous (postoperative, posttraumatic, and blebassociated) types. The latter may be caused by either bacterial or fungal infection. Blurred vision and pain are main symptoms, and coagulase-negative organisms (Gram-positive) are main cause of exogenous endophthalmitis.[2]

We report a rare case of delayed-onset postoperative endophthalmitis secondary to a rare causative pathogen (scedosporium apiospermum).


   Case Report Top


A 45-year-old healthy female had an uneventful phacoemulsification of the left eye (OS) with posterior chamber intraocular lens (IOL) implantation performed elsewhere. Three months later, she presented to us with a history of redness and reduction in vision in the operated eye. These symptoms were noted 6 weeks after the operation and managed as uveitis.

On presentation, unaided visual acuity was counting fingers (CFs) at one feet distance OS, and slit-lamp examination showed conjunctival chemosis, corneal edema, anterior chamber (AC) cells +4, 1 mm hypopyon, and fibrin over IOL. Fundus examination OS revealed faint red reflex with no further details. B-scan OS showed hyperechoic vitreous debris and flat retina [Figure 1]. The right eye examination was unremarkable with uncorrected distance visual acuity of 0.5.
Figure 1: On presentation, left eye: B-scan showed hyperechoic vitreous debris, retina attached

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She was admitted with a diagnosis of delayed-onset postoperative endophthalmitis. A vitreous tap-inject (vancomycin 1 mg/0.1 ml + ceftazidime 2.25 mg/0.1 ml) was performed. Systemic (ciprofloxacin 750 mg) and fortified topical antibiotics were commenced; however, after 48 h, her vision deteriorated to light projection (LP). Pars plana vitrectomy (PPV) 23G + membranectomy + IOL extraction + intravitreal antibiotics injection (vancomycin 1 mg/0.1 ml + ceftazidime 2.25 mg/0.1 ml) were performed immediately. Undiluted vitreous sample was sent in a sterile syringe for direct examination (gram stain) and further culture for both bacteria and fungi.

Vitreous sample showed Gram-positive cocci and bacilli. However, culture showed heavy growth of scedosporium apiospermum. Therefore, oral voriconazole (400 mg bid, followed by a maintenance dose of 200 mg bid) was started along with oral steroids 20 mg (tapering dose). After 11 days, she showed dramatic improvement with uncorrected visual acuity improvement to 0.4 at 2 m, clear cornea, quiet AC, and normal fundus examination in the involved eye. At this point, oral voriconazole had to be stopped due to elevated liver enzyme levels. Patient was maintained on systemic and topical antibiotics as well as oral steroids. One week later, she presented with recurrent reduction in vision to CF, eye pain, and redness OS vitreous tap; intravitreal injection of voriconazole (50 ug/0.1 ml), vancomycin, and ceftazidime (2.25 mg/0.1 ml) was performed. Oral voriconazole (200 mg bid for 4 weeks) along with moxifloxacin (400 mg OD for 2 weeks) were started (liver enzymes were normal). Vitreous sample this time showed no growth. Her OS condition improved, uncorrected visual acuity improved to 0.8 at 2-meter, clear cornea, quiet AC, and normal fundus examination. One month later, she presented with OS recurrent redness, pain, and reduced vision to hand movements (HM). Slit lamp examination of OS showed clear cornea, inferior keratic precipitates, aphakia, and AC cells +4. Fundus showed normal disc and hard exudates in the macula [Figure 2]. Oral voriconazole was restarted. Two days later, a whitish membrane was observed behind the iris inferionasally. Repeat PPV + membranectomy with intravitreal voriconazole was advised. The patient refused treatment and left against medical advice. She underwent OS PPV and silicon oil injection elsewhere.
Figure 2: One-month postoperative, left eye: Fundus photomedia clear with multiple hard exudates in the macula

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After 4 months, she was referred back with OS severe pain and poor LP. During this episode, OS was found to have vision of light perception (LP) with inaccurate light projection (PR), diffuse conjunctival congestion, central deep corneal thinning (no infiltrates), and AC filled with thick abscess/membranes covering the pupil and touching the endothelium [Figure 3]. After detailed discussion, the patient underwent pars plana oil removal, AC wash/membranectomy, air-fluid exchange, and intravitreal injection of voriconazole 50 ug/0.1 ml, vancomycin, and ceftazidime. She was restarted on oral voriconazole in addition to topical vigamox and voriconazole. She showed improvement with reduced pain and HM vision. The patient was advised for intravitreal voriconazole every 2 weeks till further improvement, but she did not consent to this procedure. She remained pain free. However, the OS became soft and phthisical with opaque cornea and poor projection of light. Keeping in mind the poor visual prognosis, the recurrent episodes, the unusual causative pathogen, and the current cosmetic status of the eye, enucleation followed by prosthesis was done. Histopathology of the globe showed features consistent with fungal endophthalmitis (PAS and GMS stains showed fungal hyphae) with no signs of malignancy.
Figure 3: Four months form initial presentation with recurrence, left eye: Anterior segment photo: Ciliary congestion, corneal epithelial defect, thick abscess/membrane covering the pupil and touching the endothelium

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   Discussion Top


Of all causes of exogenous endophthalmitis, fungal endophthalmitis is a rare entity. Among fungi, candida is the most common causative pathogen implicated for endogenous fungal endophthalmitis while molds are the most common for the exogenous type. Among them, aspergillus specious is the most common organism after cataract surgery.[3] The incidence of fungal endophthalmitis in a cohort study in USA was only 0.002%–0.005%, in contrast to India and China, where the incidence was reported to be 21.8% and 12.7%, respectively.[3]

Scedosporium apiospermum is a filamentous fungus, opportunistic in nature, and more common in immunocompromised patients. However, it can cause infections after trauma or surgery. In University of Texas Health Science System at San Antonio, this organism was isolated in and around 7% of infected eyes.[4]

Diagnosis is established based on high clinical suspicion and confirmed by direct examination with fungal stains (e.g., calcofluor white and Giemsa stain) or by inoculation in culture media (e.g., 2% sabouraud dextrose agar). Polymerase chain reaction may yield faster results. Vitreous sample obtained by vitrectomy has a higher diagnostic yield for culture around two times compared to simple vitreous aspirate culture.[5]

There are no standard guidelines for treatment of fungal endophthalmitis. Several approaches are available such as intracameral/intravitreal injection of antifungal agents, systemic antifungal therapy and vitrectomy or combined approaches. A combined approach is the most commonly performed treatment. Initial pars plan vitrectomy with concurrent systemic antifungal, intravitreal voriconazole at least twice weekly, and cessation of steroids yield good results.[6] Visual acuity improvement is more frequent with PPV and intravitreal antifungal injection compared to intravitreal antifungal injection alone.[7] Systemic antifungal therapy should be continued for at least 4 weeks if candida is identified and for 12 weeks for molds.[3]

Role of topical or intravitreal steroids in fungal endophthalmitis is not well established. Steroids reduce the intraocular inflammation. In one retrospective study, the role of intravitreal dexamethasone in exogenous fungal endophthalmitis was examined in twenty patients; there were no statistically significant difference in terms of final visual acuity or the incidence of phthisis bulbi.[5]

Prognosis of fungal endophthalmitis is usually poor, and molds carry worse prognosis compared to candida infections. Poor baseline visual acuity and corneal involvement are considered as independent prognostic factors for final outcome.[3],[6]

It has been reported that among fusarium endophthalmitis, 67.5% of affected eyes retained visual acuity of 6/60 or worse and 13.5% end up with enucleation.[6] Moreover, reported cases of scedosporium endophthalmitis, carry worse prognosis, among 25 affected eyes; 28% underwent enucleation or evisceration and 36% had visual acuity of CF or worse.[6] In our case, it was delayed-onset postoperative endophthalmitis, and causative agent was a rare type of fungal molds; all carry poor prognosis for our patient.


   Conclusion Top


Endophthalmitis is an ophthalmic emergency. It is rare condition and carries devastating outcome if not recognized and treated promptly. Prevention, early recognition, prompts management, and close monitoring can minimize such outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
American Academy of Ophthalmology. BCSC Intra-Ocular Inflammation and Uveitis. San Francisco CA: American Academy of Ophthalmology; 2014. p. 94120-7424.  Back to cited text no. 1
    
2.
Safneck JR. Endophthalmitis: A review of recent trends. Saudi J Ophthalmol 2012;26:181-9.  Back to cited text no. 2
    
3.
Smith TC, Benefield RJ, Kim JH. Risk of fungal endophthalmitis associated with cataract surgery: A Mini-review. Mycopathologia 2015;180:291-7.  Back to cited text no. 3
    
4.
Cortez KJ, Roilides E, Quiroz-Telles F, Meletiadis J, Antachopoulos C, Knudsen T, et al. Infections caused by Scedosporium spp. Clin Microbiol Rev 2008;21:157-97.  Back to cited text no. 4
    
5.
Majji AB, Jalali S, Das T, Gopinathan U. Role of intravitreal dexamethasone in exogenous fungal endophthalmitis. Eye (Lond) 1999;13(Pt 5):660-5.  Back to cited text no. 5
    
6.
Bui DK, Carvounis PE. Favorable outcomes of filamentous fungal endophthalmitis following aggressive management. J Ocul Pharmacol Ther 2016;32:623-30.  Back to cited text no. 6
    
7.
Kim DY, Moon HI, Joe SG, Kim JG, Yoon YH, Lee JY, et al. Recent clinical manifestation and prognosis of fungal endophthalmitis: A 7-year experience at a tertiary referral center in Korea. J Korean Med Sci 2015;30:960-4.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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