Bilateral enucleation due to multi-bacterial fulminant endogenous panophthalmitis

The case is presented of a 62 year-old woman with a rapid, progressive bilateral decrease in visual acuity and panuveitis with orbital cellulitis. She was also in poor general condition, with emesis and fever. Septicaemia due to Klebsiella pneumoniae and bilateral endogenous panophthalmitis were diagnosed. The ocular infection quickly progressed to sclerokeratitis and bilateral perforation despite broad spectrum systemic antibiotic management, and eventually the patient required bilateral enucleation. Microbiological cultures of the surgical pieces identified Klebsiella pneumoniae and Candida magnoliae. To our knowledge, this is the third published case that required bilateral enucleation or evisceration due to endogenous panophthalmitis, and the first case of endogenous ocular infection caused by Candida magnoliae.

Prevention of Evisceration or Enucleation in Endogenous Bacterial Panophthalmitis with No Light Perception and Scleral Abscess

Panophthalmitis is the most extensive ocular involvement in endophthalmitis with inflammation in periocular tissues. Severe inflammation of the anterior and posterior segments is frequently accompanied by corneal opacity, scleral abscess, and perforation or rupture. Enucleation or evisceration was the only remaining viable treatment option when all options to salvage the eye had been exhausted. The purpose of this retrospective study is to examine the outcomes of patients with endogenous bacterial panophthalmitis, no light perception and scleral abscess who were treated with multiple intravitreal and periocular injections of antibiotics and dexamethasone. Evaluation included spreading of infection to contiguous or remote sites, following evisceration or enucleation, and sympathetic ophthalmia. Eighteen patients were diagnosed with EBP, with liver abscesses in eight patients, retroperitoneal infection in four, pneumonia in two, infective endocarditis in one, cellulitis in one, drug abuse in one, and mycotic pseudoaneurysm in one. Culture results were positive for Klebsiella pneumoniae in 12 patients, Streptococcus spp. in three, Pseudomonas aeruginosa in one, Escherichia coli in one, and Staphylococcus aureus in one. The average number of periocular injections was 2.2, and the average number of intravitreal injections was 5.8. No eye required evisceration or enucleation and developed the spreading of infection to contiguous or remote sites during the follow-up. No sympathetic ophthalmia was observed in the fellow eye of all patients. Prevention of evisceration or enucleation in patients with EBP, NLP and scleral abscess can be achieved by multiple intravitreal and periocular injections of antibiotics and dexamethasone.

Bilateral endogenous bacterial panophthalmitis

We present a case of meningitis with bilateral endogenous bacterial panophthalmitis in a previously healthy individual. The management of this ocular condition is unclear, and the prognosis is poor. The patient was admitted to the Clinic of Eye Diseases after a 9-day treatment with systemic antibiotics with a complete systemic recovery but impaired vision of both eyes. Functional vision was restored in the better eye with intravitreal vancomycin and pars plana vitrectomy. Nevertheless, after the removal of silicone oil, phthisis bulbi began to develop. Better outcomes could be expected if bacteremic patients were examined routinely by an ophthalmologist and, in case of endogenous bacterial endophthalmitis, treated with intravitreal antibiotics.

Panophthalmitis after spontaneous perforation in glaucomatous eye

Panophthalmitis is an acute, purulent inflammation of the eyeball that involves all its structures and extends into the orbit. A case of a fifty-seven year old male treated earlier due to glaucoma and trophic ulcus of the cornea, was presented in this paper. He was admitted to hospital with intensive orbital pain and redness of the right eye, elevated body temperature, bulbus protrusion with limited movement, chemosis, edematous cornea, hypopyon, iris of invisible drawing and relief. The ocular fundus was not visible. At the admittance, amaurosis of the right eye was present as well as spontaneous cornea perforation. The patient was treated with antibiotic, corticosteroid, analgesic and antiglaucomatous therapy. Intravitreal administration of antibiotics was impossible due to spontaneous cornea perforation. The patient was discharged from the hospital in a good general condition. The condition of the right eye was stable, there was no danger of eye loss, while infection of the same eye was cured.

[Endogenous Clostridium septicum panophthalmitis associated with gastrointestinal malignancy]

Endogenous panophthalmitis due to Clostridium septicum (C. septicum) is a rare, but life-threatening condition. There is a known association between infection and malignancy. Our patient presented with panophthalmitis - with visual loss, proptosis, raised intraocular pressure and air bubble in the anterior chamber. C. septicum was found in cultures of pus. He was treated with antibiotics and surgery, and recovered. Further investigations showed carcinoma of the colon. This case stresses the need for urgent treatment and subsequent investigation for occult malignancy.

Endogenous Pseudomonas endophthalmitis in an immunocompetent patient

PURPOSE

To report an unusual case of community-acquired Pseudomonas aeruginosa pneumonia in an immunocompetent host complicated by orbital cellulitis, panophthalmitis, and subcutaneous nodules.

METHODS

An otherwise healthy 47-year-old woman presented with a 24-hour history of fever, cutaneous nodules, right sided pleuritic chest pain, and eyelid edema with severe vision loss in her right eye. A chest X-ray demonstrated a homogeneous infiltrate in the right upper lobe. Ophthalmic examination revealed signs of metastatic orbital cellulitis and panophthalmitis. Culture specimens from blood, sputum, skin, and vitreous showed a significant growth of P. aeruginosa species.

RESULTS

Intravenous antibiotic therapy led to resolution of the pneumonia, cutaneous nodules, and orbital cellulitis. Despite intravitreal and topical antibiotics, the patient finally required enucleation.

CONCLUSION

This case represents a rare combination of manifestations in an immunocompetent patient with P. aeruginosa infection. It highlights the accelerated course that may result from P. aeruginosa infection, the difficulties of treatment, and the poor prognosis in the case of eye involvement.

Severe Candida albicans panophthalmitis treated with all available and potentially effective antifungal drugs: fluconazole, liposomal amphotericin B, caspofungin, and voriconazole

A severe case of Candida albicans panophthalmitis, probably prompted by an underlying diabetes mellitus, is reported. The course was prolonged (more than 16 weeks), although favourable after treatment with several antifungal agents, all with a predictable activity in this ocular complication and with proven susceptibility in the present case: fluconazole, liposomal amphotericin B, caspofungin, and voriconazole.

Ocular tuberculosis in acquired immunodeficiency syndrome

PURPOSE

To present the clinical, histopathological, and molecular biologic findings in fifteen cases of ocular tuberculosis (TB) in patients with acquired immune deficiency syndrome (AIDS).

DESIGN

Retrospective, observational, noncomparative case series of HIV-infected patients with ophthalmic complaints and/or with advanced disease (CD4+ cell count < 200), seen between the years 1993 to 2005 at tertiary care ophthalmic and AIDS care hospitals.

METHODS

Each patient underwent a complete ophthalmic examination and relevant laboratory and radiologic investigations and was treated accordingly. The study was carried out in this cohort to describe the ocular manifestations of TB. The main outcome measures were to describe the clinical course histopathologic and molecular biologic features of ocular lesions attributable to tuberculosis in AIDS patients in our center.

RESULTS

Ocular TB was seen in 15 (1.95%) out of 766 consecutive cases of HIV/AIDS. Nineteen eyes of 15 patients were affected. Four cases (26.66%) had bilateral presentation. Presentations of ocular TB included choroidal granulomas in 10 eyes (52.63%), subretinal abscess in seven eyes (36.84%), worsening to panophthalmitis in three eyes, conjunctival tuberculosis, and panophthalmitis each in one eye (5.26%). All cases had evidence of pulmonary tuberculosis. Coexistent central nervous system (CNS) tuberculosis was seen in two cases and one case had abdominal tuberculosis. CD4+ cell counts were done in 14 patients; the count ranged from 14 to 560 cells/microl--mean 160.85 cells/microl.

CONCLUSIONS

Ocular TB in AIDS is relatively rare and can occur even at CD4+ cell counts greater than 200 cells/microl. It can have varied presentations with severe sight-threatening complications.

[The effect of carnosine on inflammatory processes during contusion of the eyeball]

The effect of dipeptide carnosine on proteolytic processes accompanying inflammation was investigated in lacrimal fluid of patients with eyeball contusion. Eye drops containing 5% carnosine in combination with traditional treatment reduced elastase-like activity in lacrimal fluid and increased effectiveness of therapy.

An outbreak of Pasteurella pneumotropica in genetically modified mice: treatment and elimination

A closed breeding colony comprising genetically engineered, wild-type, and stock mice presented with varying degrees of bilateral mucopurulent conjunctivitis and panophthalmitis. The one mouse with unilateral corneal ulceration, a knockout animal, was submitted for necropsy, and bacterial culture samples were obtained from the affected eye and uterus. In addition, ocular swabs from another 12 clinically affected animals, consisting of knockout, transgenic, wild-type, and stock mice, were submitted for bacterial culture analysis. All samples revealed pure cultures of Pasteurella pneumotropica. At the time of the outbreak, there were approximately 600 mice in the affected colony, with the majority of clinical cases (58 of 79) involving knockout mice and the remainder (21 of 79) in the other strains. Treatment consisted of enrofloxacin in the drinking water at 85 mg/kg daily for 14 days. Within 7 days of initiation of treatment, all existing clinical cases had resolved and no new clinical cases developed. Four weeks after completion of treatment, two groups of mice were submitted for multiple organ bacteriological analyses. One group of mice represented those animals which had complete resolution of clinical signs, and the second group of mice represented those individuals which had remained asymptomatic throughout the outbreak. All post treatment bacterial culture samples were negative for Pasteurella pneumotropica. By using the oral enrofloxacin suspension in the drinking water rather than the parenteral counterpart, concerns regarding the pharmacokinetics, specifically drug bioavailability via the oral route, problems with aqueous immiscibility and drug degradation within an aqueous medium were not potentially confounding variables. The clinical management, ease of administration, and efficacy of using an oral antibiotic formulation for the treatment and eradication of Pasteurella pneumotropica from a large mouse colony are presented in this paper.

Ocular manifestations of tuberculosis

OBJECTIVE

To present the clinical and histopathologic findings in five cases of tuberculosis (TB) with various ocular manifestations.

DESIGN

Observational case series.

METHODS

Retrospective review of clinical findings, course, and treatment of five patients. Diagnostic techniques, including biomicroscopic, histopathologic, and molecular biologic test results, are presented.

MAIN OUTCOME MEASURES

Visual acuity, slit-lamp biomicroscopy, indirect ophthalmoscopy, and fluorescein angiography results.

RESULTS

The ocular manifestations of TB in our patients included panophthalmitis, endophthalmitis, posterior uveitis with choroidal tubercles, keratitis, and a lid mass. Mycobacterium tuberculosis was identified in four cases in ocular specimens using acid-fast bacilli microscopy and in three cases by culture. Rapid diagnosis using polymerase chain reaction was obtained in one case. Extraocular foci of TB were identified in three cases with an intraocular infection at presentation. No patients had the human immunodeficiency virus (HIV) and none were immunocompromised. Two eyes could not be saved using antituberculous treatment because of delayed diagnosis and treatment.

CONCLUSIONS

In this age of the HIV pandemic, TB is becoming more common. Because it is curable, heightened awareness and better understanding of the disease's ocular manifestations should be of concern to all ophthalmologists.

Bilateral panophthalmitis as the initial presentation of meningococcal meningitis in an infant

Endophthalmitis is a well-recognized, frequently devastating ophthalmic disease. The colonization of the eye and the subsequent development of endophthalmitis may be exogenous (including postsurgical and post-traumatic infections) or it may be of endogenous origin, representing a metastasis from a focus of infection elsewhere in the body associated with bacteremia (such as meningitis or cellulitis).

Endophthalmitis and orbital cellulitis after radial keratotomy

PURPOSE

To report the findings concerning three patients with endophthalmitis and one with panophthalmitis and orbital cellulitis radial keratotomy surgery.

METHODS

One man referred with panophthalmitis and orbital cellulitis and three women referred with endophthalmitis were treated.

RESULTS

After radial keratotomy surgery, during which no microperforation or macroperforation had been reported, a severe Pseudomonas panophthalmitis and orbital cellulitis developed in the man. All vision was lost in that eye. Staphylococcus epidermidis endophthalmitis developed in one woman, Streptococcus pneumoniae endophthalmitis in the second woman and Pseudomonas endophthalmitis in the third woman, after undergoing radial keratotomy procedures during which microperforations occurred. In the latter patient, bilateral simultaneous surgery was performed, but only one eye became infected. The latter two infections resulted in light perception and hand motion vision respectively. In three cases, an initial keratitis was located in the inferior cornea.

CONCLUSIONS

Severe bacterial endophthalmitis can occur after radial keratotomy surgery, even in the absence of microperforation during the procedure. Any evidence of postoperative keratitis must be regarded seriously and treated aggressively. Despite use of this approach, the effect on final visual acuity can be devastating.

Clostridium bifermentans panophthalmitis after penetrating eye injury

BACKGROUND

Intraocular and orbital anaerobic infections usually result from penetrating eye injuries with soil-contaminated foreign bodies. The outcome of these infections almost always has been loss of the globe, despite appropriate antibiotic and surgical treatment. The most prevalent etiologic microbe of anaerobic panophthalmitis is Clostridium perfringens.

CASE REPORT

To the authors' knowledge, this is the first report of panophthalmitis caused by Clostridium bifermentans after penetrating eye injury. The patient had severe signs and symptoms of intraocular and orbital infection, with early total loss of visual function. Parenteral and intravitreal therapy with penicillin and clindamycin, administered according to antibiotic sensitivity studies of cultures from the anterior chamber and vitreous, did not restore vision.

CONCLUSIONS

Due to the early devastating outcome, penetrating eye injuries with soil-contaminated foreign bodies should be regarded as being at high risk for clostridial infection and should be treated promptly with vitrectomy and antibiotic therapy for aerobic and anaerobic infection.

Intravitreal amikacin in the treatment of bacterial endophthalmitis

Intravitreal administration of broad-spectrum antibiotics is a widely accepted component of initial therapy for bacterial endophthalmitis. Four cases of culture-proved bacterial endophthalmitis are reported to demonstrate the safety of intravitreal administration of amikacin sulfate in conjunction with cephalosporins in patients. The benefits of using amikacin rather than gentamicin sulfate in intravitreal drug therapy are discussed, and a wider role for amikacin as the aminoglycoside of choice for initial intravitreal injection in presumed bacterial endophthalmitis is suggested.

Mycotic endophthalmitis caused by Penicillium sp. after parenteral drug abuse

A 30-year-old man developed endophthalmitis three weeks after an intravenous injection of hydromorphone hydrochloride. Penicillium species was recovered from a vitreous aspirate. Treatment with amphotericin B and flucytosine resulted in documented sterilization of the vitreous. At a six-month follow-up examination, the visual acuity of the involved eye was still limited to light perception.

[Candida endophthalmitis: diagnosis, course and therapy in 8 patients]

Over a two-year period 8 patients were hospitalized with a presumptive diagnosis of Candida endophthalmitis. 6 patients were heroin addicts, while in the 2 other patients no risk factor could be identified. The presumptive diagnosis was based on the typical findings of retinohyalitic exudate and exclusion of other factors causing endophthalmitis. Intravenous therapy with amphotericin-B and flucytosin resulted in definitive scar healing. In 1 patient vitrectomy was necessitated by recurrence of endophthalmitis resistant to antifungal therapy.

The problem of bacillus species infection with special emphasis on the virulence of Bacillus cereus

Although Bacillus cereus is an uncommon ocular pathogen, infection with it usually results in loss of the eye. Although previous reports have emphasized endogenous infection, our recent experience indicates the importance of B cereus infection following trauma. Management is hampered by ineffectiveness of current empirical antibiotic regimens. This microorganism is resistant to both the penicillins and the cephalosporins. Although B cereus is susceptible to gentamicin, our studies indicate that gentamicin by itself is inadequate to eradicate the infection. B cereus, however, is susceptible to clindamycin and combined therapy with gentamicin and clindamycin appears to offer the best approach. Early diagnosis is the key to successful treatment. We believe the clinical circumstances likely to lead to B cereus infection, as well as the manifestations of the disease itself, are sufficiently distinctive to alert the ophthalmologist to the possibility of this infection. Prompt recognition of the infection should allow institution of appropriate therapy before permanent structural changes occur.

Bacillus cereus endogenous panophthalmitis

A case of severe suppurative endogenous panophthalmitis caused by Bacillus cereus resulted from intravenously administered medications. This is the first, to our knowledge, well-documented case of endogenous endophthalmitis associated with this organism. It is recommended that if on Gram's stain of the anterior chamber fluid, Gram-positive rods are seen, chloramphenicol should be administered in addition to penicillin because of the possibility of B cereus infection.

Tuberculous panophthalmitis

The case of a one-year-old Nigerian with tuberculous panophthalmitis is reported. He presented initially with a localised episceleral mass which was thought to be retinoblastoma due to rapid spread over the fundus induced by subconjunctival depromedrol. Histological examination of the enucleated eye showed that the lesion was due to tuberculosis. The subsequent favorable response of the ocular and radiological chest lesions to antituberculous therapy was quite remarkable. In contrast, there was an adverse response to radiotherapy which had followed enucleation on the strong suspicion of retinoblastoma. Not unnaturally, ocular tuberculosis was not thought of because of the rarity of ocular involvement with this disease. To our knowledge, this is the first case of its type reported from the African Continent.

[Drainage of the vitreous body space in cases of intra-ocular infection (author's transl)]

In the last 2 years we saw eight cases with massive i.o.infection (panopht-almitis) following perforating injuries. We took measures as follows: After trepanation of the sclera we washed out the space of the vitreous body with diluted solution of Gentamycin and simultaneously we used massive systemic therapy of Gentamycin and of Penicillin. In this way we stopped the infection in four eyes and we were successful in maintaining in various degree the function of these eyes.

Panophthalmitis due to Pasteurella septica

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