Korean J Ophthalmol > Volume 31(3); 2017 > Article
Kim, Lee, Baek, Paik, Park, and Lee: Two Cases of Endogenous Endophthalmitis That Progressed to Globe Rupture
Dear Editor,
Infectious endophthalmitis is a condition in which the internal structures of the eye are invaded by replicating microorganisms. Early administration of antibiotics or early vitrectomy should be considered to preserve vision. However, the general health status including systemic infection should be considered in surgical intervention such as vitrectomy, especially in some cases of endogenous endophthalmitis. Whether vitrectomy is beneficial for endogenous endophthalmitis remains controversial, especially when visual outcome is predicted to be hopeless. Here we report two cases of endogenous endophthalmitis without vitrectomy that progressed to globe rupture, which was not expected.
A 56-year-old male patient with history of diabetes mellitus presented with blurred vision of the right eye for 10 days. Abdominal and chest computed tomography showed an emphysematous prostatic abscess with multiple pulmonary lesions. Thrombocytopenia (18 × 103/µL) derived from disseminated intravascular coagulation was detected. He was administered an intravenous injection of cefepime and meropenem. His visual acuity was hand motion. Moderate corneal edema and 3+ cells were found in the anterior chamber. Fundus was not visible. A B-scan ultrasound disclosed obvious thick vitritis. With the impression of endogenous endophthalmitis, intravitreal injection of ceftazidime and vancomycin was performed. Culture of the anterior chamber showed extended spectrum beta-lactamase (-) Klebsiella pneumoniae. However, 1 day after the intravitreal injection, his visual acuity was not improved, and there was no sign of recovery. Thus, vitrectomy was considered. However, it was abandoned because the risks derived from systematic factors were high, including poor general condition with systemic infection. Most importantly, his thrombocytopenia did not meet the criteria for minor surgery. Furthermore, his visual outcome was predicted to be hopeless due to prolonged disease duration. However, after 3 days, proptosis became profound. The ipsilateral eyelids were diffusely stretched and retracted (Fig. 1A), suggesting eyeball rupture, which was unexpected. Orbital computed tomography revealed eyeball rupture (Fig. 1B and 1C). Evisceration with wide debridement was performed.
An 83-year-old male patient with history of hepatocellular carcinoma presented with blurred vision of the right eye for 1 week. His visual acuity of the right eye was hand motion. The ipsilateral eyelid was mildly swollen. Severe corneal edema and 4+ cells were found in the anterior chamber. A B-scan ultrasound disclosed vitritis. There was no history of ocular surgery or trauma. Endogenous endophthalmitis was our impression. Therefore, we performed intravitreal injection of ceftazidime and vancomycin with intravenous injection of ceftazidime and vancomycin. Culture of the the anterior chamber showed extended spectrum beta-lactamase (-) Klebsiella pneumoniae. One day after the intravitreal injection, his ocular state was stationary. However, due to thrombocytopenia (36 × 103/µL) and his poor general condition, vitrectomy was not considered. The patient accepted the possibility of visual loss. However, proptosis and right eyelid swelling developed on the same day (Fig. 1D). Orbital magnetic resonance imaging revealed eyeball rupture (Fig. 1E and 1F), for which evisceration was performed.
Vitrectomy has been accepted as a treatment option supplementary to intravitreal antimicrobial therapy in patients with moderate or severe infectious endophthalmitis [1]. However, in clinical practice, whether vitrectomy is beneficial for patients with poor general condition remains controversial, especially when visual outcome is predicted to be hopeless. Vitrectomy was abandoned in our cases because the prognosis was predicted to be poor due to seriousness and prolonged disease period of endogenous endophthalmitis. Moreover, the two patients were in a poor general condition with thrombocytopenia. However, endophthalmitis progressed to orbital rupture. One systematic review with a total of 342 cases of endogenous bacterial endophthalmitis has reported that only five of 56 eyes (9%) undergoing vitrectomy required evisceration or enucleation, compared to 29 of 110 eyes (26%) that did not undergo vitrectomy (p = 0.08) [2]. These reports and our cases showed that prompt vitrectomy should be considered in endophthalmitis, even if visual prognosis does not seem to be good.
In conclusion, early vitrectomy should be considered in endogenous endophthalmitis to save the eyeball even if visual outcome is predicted to be hopeless. Even if vitrectomy is not feasible due to systematic factors, the patient should be informed beforehand that endophthalmitis without vitrectomy can lead to not only blindness, but also evisceration. Prompt surgical treatment can save the eyeball and prevent the spread of infection to adjacent tissues of these patients.

Notes

Conflict of Interest: No potential conflict of interest relevant to this article was reported.

REFERENCES

1. Jackson TL, Eykyn SJ, Graham EM, Stanford MR. Endogenous bacterial endophthalmitis: a 17-year prospective series and review of 267 reported cases. Surv Ophthalmol 2003;48:403-423.
2. Jackson TL, Paraskevopoulos T, Georgalas I. Systematic review of 342 cases of endogenous bacterial endophthalmitis. Surv Ophthalmol 2014;59:627-635.
Fig. 1

(A) Photograph showing right proptosis with marked lid swelling. Conjunctiva shows severe chemosis and necrotic change; (B,C) computerized tomography scan of the orbit. Right globe with irregular contour shows nasal superior, posterior scleral breakthrough (red arrow), suggesting a ruptured globe. (D) Photograph showing right proptosis. Conjunctiva shows severe chemosis and conjunctival hemorrhage; (E,F) magnetic resonance imaging scans with contrast enhancement showing proptosis and anteroposterior elongation of the right globe with an irregular contour. A defect at the superolateral aspect (red arrow) is visible.

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