About OJO | Search | Ahead of print | Current Issue | Archives | Author Instructions | Reviewer Guidelines | Online submissionLogin 
Oman Journal of Ophthalmology Oman Journal of Ophthalmology
  Editorial Board | Subscribe | Advertise | Contact
https://www.omanophthalmicsociety.org/ Users Online: 993  Wide layoutNarrow layoutFull screen layout Home Print this page  Email this page Small font size Default font size Increase font size


 
 Table of Contents    
CASE SERIES
Year : 2022  |  Volume : 15  |  Issue : 2  |  Page : 204-207  

Acute postoperative infectious endophthalmitis caused by Gram-negative organisms


1 Department of Ophthalmology, Sultan Qaboos University Hospital, Seeb, Sultanate of Oman
2 Department of Ophthalmology, Ibri Hospital, MOH, Muscat, Sultanate of Oman

Date of Submission15-Nov-2021
Date of Decision23-Apr-2022
Date of Acceptance20-May-2022
Date of Web Publication29-Jun-2022

Correspondence Address:
Dr. Mohamed Al-Abri
Department of Ophthalmology, Sultan Qaboos University Hospital, P.O. Box: 38 Al-Khod, PC 123, Muscat
Sultanate of Oman
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.ojo_334_21

Rights and Permissions
   Abstract 


Endophthalmitis is a rare but potentially sight-threatening ophthalmic condition characterized by marked inflammation of intraocular tissues and fluids. Bacteria is the most common cause of postoperative acute infectious endophthalmitis of which Gram-positive (GP) bacteria is the predominant isolate which constituted 47% of all positive vitreous cultures in endophthalmitis vitrectomy study. On the other hand, Gram-negative bacteria constituted 11.5% with poor visual outcomes compared to GP cases due to the fulminant and destructive nature of such pathogens despite prompt and appropriate treatment initiation. In this report, we would like to share the three cases of acute postoperative infectious endophthalmitis caused by Gram-negative organisms and highlight the challenges that might be faced when dealing with such presentations.

Keywords: Acute, endophthalmitis, Gram-negative, postoperative


How to cite this article:
Al-Abri M, Al-Hinai A, Al-Abri A, Lobo RM. Acute postoperative infectious endophthalmitis caused by Gram-negative organisms. Oman J Ophthalmol 2022;15:204-7

How to cite this URL:
Al-Abri M, Al-Hinai A, Al-Abri A, Lobo RM. Acute postoperative infectious endophthalmitis caused by Gram-negative organisms. Oman J Ophthalmol [serial online] 2022 [cited 2022 Aug 15];15:204-7. Available from: https://www.ojoonline.org/text.asp?2022/15/2/204/348993




   Introduction Top


Endophthalmitis is a rare but potentially sight-threatening ophthalmic condition characterized by marked inflammation of intraocular tissues and fluids.[1] Bacteria is the most common cause of postoperative acute infectious endophthalmitis of which Gram-positive (GP) bacteria is the predominant isolate which constituted 47% of all positive vitreous cultures in endophthalmitis vitrectomy study. On the other hand, Gram-negative bacteria constituted 11.5% with poor visual outcomes compared to GP cases due to the fulminant and destructive nature of such pathogens despite prompt and appropriate treatment initiation. In this report, we would like to share the three cases of acute postoperative infectious endophthalmitis caused by Gram-negative organisms and highlight the challenges that might be faced when dealing with such presentations.


   Case Reports Top


Case 1

A 69-year-old-female, known hypertensive on medications. She underwent uneventful right eye (OD) phacoemulsification with foldable posterior chamber intraocular lens (PCIOL) for mature cataract with baseline visual acuity (VA) of 1/60. Postcataract surgery day 1, OD cornea was hazy with diffuse epithelial edema and 1 mm hypopyon in the anterior chamber (AC) and no fundus view. Brightness scan ultrasonography (B-scan) showed posterior vitreous detachment, vitreous opacities with flat retina. She underwent AC and vitreous tap and intravitreal injection of vancomycin and ceftazidime. AC tap showed Gram-negative bacilli while vitreous tap showed bacterial growth of Serratia marcescens sensitive to ceftazidime, gentamicin, ciprofloxacin, trimethoprim, and sulfamethoxazole. On the 3rd postoperative day (48 h after intravitreal injection), OD cornea was hazy, AC filled with exudates, hypopyon 2.5 mm. Hence, the patient was referred immediately for further management.

On admission (day 5 postcataract surgery), the patient had worsening pain in OD with VA of light perception (LP) with poor projection while left eye (OS) VA was 6/18. Anterior segment of OD examination showed diffuse lid edema, diffuse and severe conjunctival chemosis, diffuse corneal cloudiness, organized hypopyon 40% of AC, iris details not visualized, no red reflex [Figure 1]a and B-scan showed diffuse vitreous hyperechoic opacities and attached retina [Figure 1]b. The patient was diagnosed with OD acute postoperative endophthalmitis. The patient underwent immediate OD AC tap, vitreous biopsy, limited pars plana vitrectomy (PPV), PCIOL removal and intravitreal antibiotics (vancomycin 1 mg/0.1 ml and ceftazidime 2.25 mg/0.1 ml), and intravitreal dexamethasone (0.4 mg/0.1 ml) under general anesthesia (GA). Post PPV day 1, the patient was doing well, pain was minimal, VA was LP, anterior segment examination showed mild edema of the eyelids, conjunctival congestion, cornea total epithelial defect, total corneal haze, AC hypopyon mixed with hyphema and intraocular pressure (IOP) digitally was soft [Figure 2]. The patient was kept on topical fortified vancomycin and fortified ceftazidime, systemic ciprofloxacin 500 mg twice per day and oral prednisolone 30 mg daily on tapering dosage. Microbiology laboratory reports showed S. marcescens isolated from the PCIOL sample which was sensitive to ciprofloxacin, cefepime, gentamycin, meropenem, and trimethoprim/sulfamethoxazole. Over the course of admission, the patient remained pain free and on discharge (post PPV day 10), digitally IOP was soft, corneal epithelial defect gradually reduced in size, AC hypopyon organized inferiorly around 3.5 mm, rest of details were not visualized. She was discharged on oral ciprofloxacin for a total period of 14 days, along with topical ceftazidime and moxifloxacin eye drops every 6 hourly as well as fusidic acid eye drops at night and she was scheduled for regular follow ups.
Figure 1: Anterior segment photo of the right eye shows diffuse lid edema, diffuse and severe conjunctival chemosis, diffuse corneal cloudiness, organized hypopyon, iris details not visualized, no red reflex (a) and B-scan shows diffuse vitreous hyperechoic opacities and attached retina (b)

Click here to view
Figure 2: One day post-PPV anterior segment photo of the right eye shows mild lid edema, conjunctival congestion, total corneal haze and epithelial defect, hypopyon mixed with hyphema. PPV: Pars plana vitrectom

Click here to view


On her final follow-up, almost a month later, she had minimal discomfort in OD, VA was no LP (NLP), IOP was 2 mmHg, anterior segment examination showed residual conjunctival hyperemia, no corneal epithelial defect, AC organized exudates, faint view of the peripheral iris, no further details were visible.

Case 2

A 52-year-old-male known to have diabetes mellitus on oral hypoglycemic agents and hypertension on treatment, underwent uneventful OD phacoemulsification and PCIOL under peribulbar anesthesia elsewhere. On day 1 postcataract surgery, the patient started to have mild pain OD, anterior segment examination showed conjunctival congestion, diffuse corneal epithelial edema, exudative membrane on the corneal endothelium, white keratic precipitates, hypopyon, cells and flare, PCIOL was in place and no fundus glow. The patient was started on chloramphenicol and dexamethasone drops every 10 min. As the condition worsened and AC hypopyon increased to 1.5 mm overnight, the patient underwent aqueous and vitreous tap and intravitreal injection of ceftazidime and vancomycin. The initial microbiology results showed Gram-negative bacilli. Hence, the patient was referred for further management.

On admission, day 2 postcataract surgery OD, pain was worse, VA was only LP present only temporally. Anterior segment examination OD showed severe lid edema, mucopurulent discharge, diffuse conjunctival chemosis, diffuse corneal cloudiness with subtotal epithelial defect, organized hypopyon 1.5 mm, PCIOL in place and no red reflex [Figure 3]a and B-scan showed diffuse vitreous hyperechoic opacities and attached retina. The patient underwent OD AC wash, membranectomy, vitreous biopsy, limited PPV, PCIOL removal, intravitreal antibiotics (vancomycin 1 mg/0.1 ml and ceftazidime 2.25 mg/0.1 ml), intravitreal dexamethasone (0.4 mg/0.1 ml) and silicone oil injection under GA. Intraoperatively, it was noted that the vitreous was full of inflammatory membranes and optic disc was noted to be pale with retinal necrotic areas and hemorrhages in the posterior pole, vessels noted to be sclerosed. Superior retinal detachment was noted with two breaks superionasally, which was managed intraoperatively.
Figure 3: Anterior segment photo of the right eye shows severe lid edema, mucopurulent discharge, diffuse conjunctival chemosis, diffuse corneal cloudiness with subtotal epithelial defect, organized hypopyon, posterior chamber intraocular lens in place and no red reflex (a). One day post pars plana vitrectomy anterior segment photos of right eye shows corneal cloudiness with overlying corneal abrasion (b)

Click here to view


On postoperative day 1, the patient was comfortable, with minimal pain, VA OD was still LP only temporally. Anterior segment examination showed lid edema, conjunctival chemosis, corneal cloudiness, total epithelial defect, AC formed, no further details, sutures adapted, IOP digitally normotensive [Figure 3]b. The patient was started on moxifloxacin eye drops hourly, oral acetazolamide (250 mg every 6 h), and intravenous ciprofloxacin.

Over the course of admission, AC and vitreous samples showed Gram-negative bacilli-Enterobacter cloacae, which was sensitive to amikacin, gentamycin, meropenem, and tazobactam. Infectious disease team was consulted, intracameral amikacin (125 microgram/0.1 ml) was given as well as intravenous meropenem 1 g every 8 h was started and continued for a total 10 days. Two doses of intravitreal meropenem (0.5 mg/0.1 ml) were given OD under local anesthesia 5 days apart. Concurrently, fortified meropenem eye drops were started hourly. IOP was maintained on topical timolol and brimonidine eye drops. The corneal epithelial defect was reduced in size over a week. The patient was started on oral prednisolone 30 mg tapering dosage.

The patient was discharged after 13 days of admission, VA on discharge was LP with inaccurate projection of light, healed corneal epithelial defect, formed ac, no hypopyon, no further details could be seen. On the last follow-up, OD was in prepthysical stage, VA OD was NLP, IOP was 2 mmHg, anterior segment examination showed conjunctival diffuse congestion, diffuse moderate-to-severe corneal haze, healed corneal epithelial defect. AC was flat superiorly and shallow inferiorly, no hypopyon seen. No further details could be seen.

Case 3

A 79-year-old-female presented to the emergency room with 1 week history of sudden loss of vision and severe pain OS. She denied any history of recent ocular trauma. Her past ocular history revealed cataract surgery OS 2 years ago. She is known asthmatic on treatment. On presentation, OS VA was NLP and anterior segment examination showed diffuse conjunctival congestion, corneal edema, a broken half buried corneal suture superiorly, AC was formed with significant cells and 2 mm hypopyon with extensive fibrin. There was PCIOL and IOP was 10 mmHg. Further details were not seen due to the hazy media and the absent red reflex. B-scan showed no evidence of retinal detachment but significant vitreous hyperechogenic opacities. The examination of OD revealed VA of counting finger close to face, dense nuclear cataract, and corneal scarring. The patient was admitted and underwent an urgent OS PPV including vitreous sampling and intravitreal antibiotics (amikacin 0.4 mg/0.1 ml and vancomycin 1 mg/0.1 ml).

On postoperative day 1, the patient was symptomatically better with reduced pain. Her VA OS was LP. Anterior segment evaluation showed no hypopyon but severe fibrinous reaction and corneal edema. The red reflex was present but fundus view was obscured. She was started on fortified gentamycin and cefuroxime eye drops every hour and predforte 1% eye drops every 2 h. Oral ciprofloxacin 500 mg twice daily was also initiated. On the 3rd postoperative day, oral prednisolone was started 30 mg daily with a tapering dose. The result of the microbiology culture of the vitreous sample showed a moderate growth of Haemophilus influenza which was sensitive to ciprofloxacin, ampicillin, augmentin, cefuroxime, and tetracycline.

Over the course of admission; the patient showed significant improvement. Up on discharge on day 8 post PPV, VA OS had improved to hand movements (HM). Anterior segment showed congested conjunctiva, cornea was clearer and formed AC. The fundus view was clear and B-scan showed vitreous hyperechogenic opacities and flat retina. The patient was discharged on oral ciprofloxacin for 10 days postoperatively, topical moxifloxacin eye drops every 6 h for 3 weeks and topical predforte eye drops 1% every 4 hours with a tapering dose.

The patient was re-evaluated 3 weeks later where VA OS remained HM with stable anterior segment and mild corneal haziness. The AC was formed and quiet. PCIOL was in the normal position. The fundus view was hazy due to vitreous debris but optic disc and retina was visualized. She was posted for secondary vitrectomy to remove the residual vitreous debris but the patient lost follow-up.


   Discussion Top


Infectious endophthalmitis is one of the serious adverse events that can occur after intraocular procedures or ocular trauma. The Gram-positive (GP) micro-organisms are more common causative agents than the Gram-negative (GN). According to the Endophthalmitis Vitrectomy Study (EVS), the GN postoperative endophthalmitis constituted 5.9% of all culture positive cases. It was found that GN endophthalmitis occurs frequently in developing countries than in developed countries, 26%−42% versus 5.9%−12%, respectively.[2] In another large-cohort study, which was conducted by a research group from Bascom Palmer Eye Institute in Miami USA, a retrospective analysis of all culture-positive endophthalmitis was conducted over a period of 24 years starting from 1990. Results revealed that GN-endophthalmitis occurred in 246 (11.5%) cases from a total of 2134 culture-positive endophthalmitis.[2] This study, also, showed that antimicrobial resistance in GN bacteria did not change over the study period. In a recently published study about endophthalmitis in Oman; 32% of studied eyes were culture-positive in which 75% were GP and 19% were gram-negative bacteria.[3]

Anti-microbial resistance to important drugs is a growing concern. In one study which was conducted between 2010 and 2014 revealed that 24% from all GP endophthalmitis cases were Gram-negative of which more than 40% were resistant to ceftazidime.[4] However, those patients did have a better response and outcome when treated with intravitreal imipenem. GN-microorganisms were also found to be more sensitive to imipenem and ciprofloxacin than ceftazidime in other studies.[5]

Finally, postoperative endophthalmitis has become less with wide use of recommended precautions such as 5% povidone iodine preoperatively and use of intracameral antibiotics at the end of the surgery. Moreover, there are case series studies started to point out the problem of using preoperative broad-spectrum topical antibiotics as prophylaxis as this may increase the risk of multi-drug resistant GN endophthalmitis.[6]


   Conclusion Top


Infectious endophthalmitis remains an important cause of visual morbidity, even with appropriate and prompt management. To minimize the risk of infectious endophthalmitis; treating ophthalmologists should follow the universal preventive protocols, strict use of 5% povidone iodine perioperatively and to consider intraoperative intracameral antibiotics. Finally, immediate recognition, prompt and timely intervention and consideration of substituting ceftazidime antibiotics with more susceptible ones such as amikacin or imipenem antibiotics may yield better outcomes is such devastating condition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mamalis N. Endophthalmitis. J Cataract Refract Surg 2002;28:729-30.  Back to cited text no. 1
    
2.
Wilson BD, Relhan N, Miller D, Flynn HW Jr. Gram-negative bacteria from patients with endophthalmitis: Distribution of isolates and antimicrobial susceptibilities. Retin Cases Brief Rep 2019;13:54-6.  Back to cited text no. 2
    
3.
Al-Abri M, Al-Hinai A, Al Hamar Y, Al-Abri H, Habsi AA, Al-Kaabi A, et al. Endophthalmitis in Oman: A descriptive retrospective multi-center study. Oman J Ophthalmol 2020;13:141-5.  Back to cited text no. 3
  [Full text]  
4.
Dave VP, Pathengay A, Nishant K, Pappuru RR, Sharma S, Sharma P, et al. Clinical presentations, risk factors and outcomes of ceftazidime-resistant Gram-negative endophthalmitis. Clin Exp Ophthalmol 2017;45:254-60.  Back to cited text no. 4
    
5.
Liu C, Ji J, Li S, Wang Z, Tang L, Cao W, et al. Microbiological isolates and antibiotic susceptibilities: A 10-year review of culture-proven endophthalmitis cases. Curr Eye Res 2017;42:443-7.  Back to cited text no. 5
    
6.
Menchini F, Toneatto G, Miele A, Donati S, Lanzetta P, Virgili G. Antibiotic prophylaxis for preventing endophthalmitis after intravitreal injection: A systematic review. Eye (Lond) 2018;32:1423-31.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
   
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Reports
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed150    
    Printed4    
    Emailed0    
    PDF Downloaded27    
    Comments [Add]    

Recommend this journal