Orbital cellulitis with panophthalmitis and scleral necrosis - a case report

BACKGROUND

Orbital cellulitis is common in young children and is often secondary to coexisting sinus disease. Coexisting orbital cellulitis and panophthalmitis is a rare clinical event and usually occurs secondary to trauma or from an endogenous source.

CASE PRESENTATION

A febrile 2-year-old male presented with periorbital inflammation and exudative retinal detachment. Imaging showed acute sinusitis and extensive orbital cellulitis. Because of progressive scleral thinning, the patient underwent enucleation.

CONCLUSION

We present a case of concurrent orbital cellulitis, panophthalmitis, and scleral necrosis in an immunocompetent pediatric patient. Timely intervention is important to prevent life threatening complications with the rare occurrence of coexistent orbital cellulitis and panophthalmitis.

Sterile endogenous panophthalmitis with uncontrolled diabetes

A female patient with type 2 diabetes in her 50s presented to casualty with a 1-day history of red, painful right eye. Visual acuity (VA) bilaterally was 6/12, but a right anterior uveitis was noted, with hazy fundal view. She was discharged on topical steroid and mydriatic drops with a 2-day follow-up. VA remained unchanged, but she developed right proptosis, restricted eye movements, lid swelling, relative afferent pupillary defect and an intraocular pressure (IOP) of 39 mm Hg. She was admitted and treated with intravenous and intravitreal antibiotics, intravenous antifungals and IOP-lowering drugs. Blood tests showed raised inflammatory markers and an HbA1c of 127 mmol/mol. Over her admission, right eye vision deteriorated to no light perception. A B-scan ultrasound revealed panophthalmitis and a retinal abscess. All investigations looking for a source were negative. Inflammatory markers settled, but despite aggressive treatment, the panophthalmitis did not improve. She was discharged with a follow-up to consider enucleation.

Candida glabrata as an aetiological factor of the fulminant course of panophthalmitis

INTRODUCTION

The role of fungi in infections in immunocompromised patients is a growing problem in both diagnosis and treatment. Candida species are the most common cause of fungal, endogenous endophthalmitis and infections of the cornea.

CASE STUDY

A patient was admitted to hospital due to acute inflammation of the tissue of the left orbit, 1.5 years after the corneal penetrating transplantation of the left eye with intracapsular extraction of lens and simultaneous anterior vitrectomy. The microbiological system identified: Streptococcus pyogenes, Staphylococcus aureus, and Candida glabrata in the patient.

CONCLUSIONS

The factors conducive to fungal infections are: patient's old age, immune disorders and diabetes, as well as the presence of a necrotic tissue or a foreign body. All these parameters were met in this case. Only antibiotic therapy and long-term antifungal therapy, together with surgical debridement of the site of the ongoing infection produces clinical effects in such severe cases.

Panophthalmitis caused by Streptococcus dysgalactiae subsp. equisimilis: A case report and literature review

Lancefield group G β-hemolytic Streptococcus dysgalactiae subspecies equisimilis (SDSE) has become a leading causative pathogen of invasive streptococcal infection. In this report, we describe a case of disseminated SDSE infection complicated by endogenous endophthalmitis, resulting in panophthalmitis and blindness. A 65-year-old man who underwent mitral valve replacement surgery two months previously was hospitalized due to high fever and right visual loss. A systemic investigation revealed endophthalmitis complicated by mediastinal abscess, prosthetic infective endocarditis, cerebral emboli and hemorrhage, and multiple arthritis. The patient underwent various surgeries, including vitrectomy, mediastinal lavage, mitral valve replacements, joint lavages, as well as an intensive antibiotic treatment. His general condition gradually improved, but the ocular infection developed to panophthalmitis, which ultimately required ophthalmectomy. A literature review regarding Group G-associated endogenous endophthalmitis suggested that the disease occurs in elderly people, is frequently complicated with endocarditis, and yields poor visual prognosis regardless of appropriate antibiotic treatment and surgical therapies. In this aging society, invasive infections with SDSE should be much more recognized among medical practitioners in order to improve patient prognosis.

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.

Lupus vulgaris with endopthalmitis--a rare manifestation of extrapulmonary tuberculosis in India

We report a case of 17-year-old girl who presented with gradual destruction of the nose along with endopthalmitis and loss of vision of the left eye. On nasal examination, left alae nasi and nasal cartilage was destroyed. Left eye showed signs of endopthalmitis with pthisis bulbi with complete loss of vision. Skin biopsy, FNAC of the lymph nodes were suggestive of tubercular etiology. However, patient did not have any evidence of pulmonary TB. We report this case due to the rare clinical features. The importance of a high index of suspicion and prompt treatment in such atypical forms to prevent morbidity cannot be over-emphasised.

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.

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.

An orbital masquerade syndrome: a case report

This report presents the case of a 20-year-old female who presented with features of right panophthalmitis with secondary orbital cellulitis masquerading as an orbital tumour. This presented a diagnostic difficulty to several ophthalmologists. An orbital ultrasound scan revealed an underlying orbital mass, which on histology was discovered to be a well differentiated invasive large cell keratinizing squamous cell carcinoma. This report further emphasizes the value of ultrasound scan in detecting orbital tumours.

Suprachoroidal septic effusion leading to panophthalmitis following strabismus surgery

We describe a case of endophthalmitis following strabismus surgery. Drainage of the suprachoroidal effusion with injection of antibiotics was unsuccessful in salvaging vision. Endophthalmitis following strabismus surgery may present with findings simulating a choroidal effusion or hemorrhage. Treating physicians should be alert to signs and symptoms of this severe complication of strabismus surgery in preverbal children.

Nocardial endophthalmitis and subretinal abscess: CT and MR imaging features with pathologic correlation: a case report

Ocular nocardiosis is a rare but potentially aggressive process. Clinically, it can mimic other disease entities, including neoplasia and other types of infection. We present a case of nocardial panophthalmitis progressing to subretinal abscess and emphasize the radiologic and clinical features.

Orbital cellulitis, panophthalmitis, and ecthyma gangrenosum in an immunocompromised host with pseudomonas septicemia

PURPOSE

To describe a case of Pseudomonas aeruginosa septicemia complicated by orbital cellulitis, panophthalmitis, and ecthyma gangrenosum.

DESIGN

Observational case report.

METHODS

An immunosuppressed 62-year-old man developed an unusual skin rash and a painful, swollen right eye with decreased vision. He had myelodysplastic syndrome and P. aeruginosa septicemia. The skin rash manifested as ecthyma gangrenosum. Metastatic orbital cellulitis and panophthalmitis was diagnosed.

RESULTS

Despite intravitreal and topical gentamicin, the patient eventually required enucleation.

CONCLUSIONS

This case represents a rare combination of events: an immunocompromised man developed pneumonia, P. aeruginosa septicemia, and endogenous seeding of the Pseudomonas to the skin, orbit, and eye. Early recognition of endogenous ophthalmic disease is imperative. The prognosis of combined orbital cellulitis and panophthalmitis is poor.

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).

Orbital inflammation in a patient with extrascleral spread of choroidal malignant melanoma

An elderly woman presented with fever, dehydration, orbital inflammation, total external and internal ophthalmoplegia and blindness, resembling the clinical appearance at presentation of severe orbital inflammatory disease or mucormycosis. Orbital computed tomography scanning demonstrated a retrobulbar orbital mass. Subsequent B-scan ultrasound examination confirmed the orbital mass but also demonstrated a mass within the eye. At lateral orbitotomy, extrascleral spread of an entirely necrotic intraocular melanoma was demonstrated. As computed tomography scanning may not be able to delineate an entirely necrotic intraocular malignant melanoma, B-scan ultrasonography should be considered in patients with orbital inflammation, especially in the presence of a retrobulbar mass.

[Pneumonia and panophthalmitis as first signs of pneumococcal endocarditis]

A case of pneumonia associated with pneumococcal endocarditis of bicuspid aortic valve complicated by pneumococcal meningitis and panophthalmitis successfully treated by antibiotics and late valve replacement was described.

Postmortem diagnosis of Fusarium panophthalmitis by the polymerase chain reaction

PURPOSE

We undertook this study to determine if a polymerase chain reaction-based test that we developed for the filamentary fungus, Fusarium, could be used to detect the organism in postmortem ocular tissues.

METHODS

We applied the polymerase chain reaction to amplify a target fragment of Fusarium DNA from formalin-fixed ocular tissues from a patient with endogenous Fusarium panophthalmitis.

RESULTS

By using the polymerase chain reaction-based test, we were able to amplify the target fragment of DNA from the infected eyes, but not from uninfected control eyes.

CONCLUSIONS

The technique appears to hold promise to be a sensitive, specific, and rapid method of diagnosing Fusarium infections.

[Ocular tuberculosis in systemic lupus erythematosus and immunosuppressive therapy]

BACKGROUND

A marked reduction in eye disease attributed to tuberculosis has occurred over the past several decades. In recent years, however, tuberculosis has reemerged as a serious public health problem. We report a case of a severe ocular tuberculosis in a patient with systemic lupus erythematosus and immunosuppressive therapy.

PATIENT

The 36-years-old woman underwent an immunosuppressive therapy because of a systemic lupus erythematosus detected two years earlier. After holidays on the Philippines Mycobacterium tuberculosis was found in a bronchial lavage. Two months later fundoscopy showed severe subretinal exsudation with overlying serous retinal detachment. Within several months these findings progressed to a panuveitis with spontaneous perforation. Histopathologically a granulomatous panophthalmitis could be found with giant cells. Two months later acid-fast bacilli were detected in orbital lesions.

CONCLUSION

In immunosuppressed patients there is still an increased risk for severe ocular tuberculosis. Therefore it is important to think of this almost forgotten disease in those cases.

Metastatic bacterial endophthalmitis: a contemporary reappraisal

Metastatic bacterial endophthalmitis remains a challenge to the clinician despite the success of antibiotics in reducing its frequency and severity. Controversy currently surrounds the management of this condition because of uncertainty about the value of and indications for vitreous surgery. We review 72 cases of metastatic endophthalmitis from the past decade, including five not previously published. The spectrum of causative bacteria changed significantly during this period, with displacement of meningococcus by Bacillus cereus as the most frequently reported agent and an increasing incidence of infection by organisms of low pathogenicity in immunologically compromised hosts. We propose a new classification scheme for metastatic endophthalmitis based on the location (anterior or posterior segment) and extent (focal or diffuse) of the primary intraocular infection. Focal and anterior cases appear to have a good prognosis, while posterior diffuse disease nearly always leads to blindness. Our analysis of outcomes suggests that systemic antibiotics are more valuable in metastatic than in postoperative or traumatic endophthalmitis and that intraocular antibiotic injection and vitrectomy make only a limited contribution to successful treatment in metastatic infection. We recommend a clinical approach to metastatic endophthalmitis that minimizes exposure of patients to the risks of invasive procedures.

[Group B streptococcal panophthalmia in neonatal infection]

Hemolyzing streptococci of group B were isolated from an ulcerative keratitis in a 14-day-old girl (gestational age: 39 weeks, birth weight: 3230 g) suffering from septicemia. The differential diagnosis includes all bacteria and virus species able to penetrate the intact cornea, e.g. Pseudomonas sp., N. gonorrhoeae and Herpes simplex virus II. Perinatal infection may be via the birth canal.

Lasiodiplodia theobromae panophthalmitis

Lasiodiplodia theobromae is a rare ocular pathogen. We report a case of panophthalmitis caused by this fungus. The patient was a healthy 62-year-old janitor with no history of ocular trauma in whom keratitis developed. Cultures of corneal scrapings identified the fungus. Despite treatment with appropriate antimycotics the keratitis progressed to infectious scleritis and then spontaneous perforation of the globe, which necessitated enucleation. The ultrasonographic, microbiologic and histologic findings are discussed and the results of in-vitro sensitivity testing presented.

Moraxella nonliquefaciens endophthalmitis after trabeculectomy

Endophthalmitis caused by Moraxella nonliquefaciens developed five years after trabeculectomy in a 67-year-old man and 15 months after trabeculectomy in a 62-year-old women. Symptoms in both cases included pain, inflammation, and decreased visual acuity. Aggressive treatment with antibiotics and corticosteroids led to resolution within a few days.

[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.

Rare complications in a case of generalized meningococcal disease: immunologic reaction versus bacterial metastasis

A 14-year-old girl was suffering from meningococcal sepsis with initial endophthalmitis. During a secondary and prolonged fever attack including aseptic meningitis, temporary complications such as pericarditis, arthralgic pains, headache and localized phlebitis were observed. There were three relapses of pericarditis within nine months. Their course was benign. The discussion deals with the pathogenesis of these complications as metastatic and immunologic reactions. The possibility of these complications should be considered during diagnostic investigation and therapeutic treatment.

Bacillus cereus panophthalmitis: source of the organism

Serious infections with the "nonpathogenic" Bacillus species are increasingly being recognized, especially in drug abusers. Cases of panophthalmitis secondary to infection with Bacillus cereus, with and without associated bacteremia, have been reported. Three drug abusers with panophthalmitis seen in our hospitals during a three-year period are described, and the similar cases reported in the literature are reviewed. The syndrome is characterized by an acute onset with a rapid fulminating course that eventually leads to enucleation or evisceration of the eye. The pathogenic mechanism is unknown, but is probably related to the production of toxin (lecithinase) by B. cereus. Clindamycin appears to be the antibiotic of choice in the treatment of this infection. In order to identify a possible source of the organism, 59 samples of heroin and injection paraphernalia were cultured. Twenty cultures yielded organisms; Bacillus species were the predominant isolates. Thirty-eight percent of the isolates were identified as B. cereus. Thus, infections caused by Bacillus species in drug abusers can probably be associated with intravenous heroin abuse because heroin mixtures and injection paraphernalia are frequently contaminated with this organism.

Bilateral endogenous Aspergillus endophthalmitis

A case of successfully treated Aspergillus endophthalmitis is presented. Treatment consisted of wide vitrectomy. At the end of surgery, 5 micrograms of amphoteracin B were injected into the center of the vitreous cavity, and an additional .75 mg was given subconjunctivally both at surgery and on the second postoperative day, at which time 2 mg of dexamethasone were also given subjunctivally. Systemic antifungal agents were not used. After 2 1/2 months, the second eye developed a similar metastatic infection from heart value vegetation. This case illustrates that use of wide vitrectomy and intravitreous antifungal agents alone can cure Aspergillus endophthalmitis and preserve useful vision.

Bilateral metastatic endophthalmitis

A case of bilateral metastatic endophthalmitis secondary to Staphylococcus aureus urinary tract infection is presented. Systemic antibiotic therapy was used to treat the bilateral and endophthalmitis. Anterior chamber and vitreous aspirations as well as later enucleation of the fellow eye confirmed the diagnosis of S. aureus endophthalmitis. The case is most unusual in that the patient developed a rhegmatogenous retinal detachment in one of the involved eyes. The detachment was successfully repaired, and the patient has maintained useful visual acuity.

Bilateral endogenous Escherichia coli endophthalmitis

Escherichia coli endophthalmitis developed in a 62-year-old man following an inadequately treated lower urinary tract infection. Treatment with intravenous and local antibiotics and steroids was successful in eradicating the infection, but blindness was not reversed. The pathogenesis and management of secondary bacterial endophthalmitis are reviewed.

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.

The diagnosis of uveal malignant melanomas in eyes with opaque media

Of 358 eyes enucleated between 1962 and 1975, and found to contain posterior uveal melanomas, 31 had opaque media (8.6%). Eighteen of these patients with opaque media were seen between 1962 and 1971, before the use of combined ultrasonography and the radioactive phosphorus uptake (32P) test. Melanoma was unsuspected at enucleation in one third of these patients and there was often a long delay in diagnosis. Of the 13 patients seen between 1971 and 1975, after the initiation of combined ultrasonography and 32P) test, there was no delay in diagnosis becuase a melanoma pattern was recognized immediately with ultrasonography and confirmed with a positive 32P test. During the latter part of this study, 19 patients with opaque media had a "melanoma pattern" with ultrasonography. The 32P test was positive in 12 cases and a melanoma was confirmed histologically in every instance. The 32P test was negative in seven cases and all were documented on follow-up to have benign lesions, such as subretinal hemorrhages.