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Endophthalmitis: A Case Presentation

A patient's journey demonstrating how the prompt diagnosis and treatment of endophthalmitis can still ensure a positive outcome


on 17 January 2015

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Transcript of Endophthalmitis: A Case Presentation

A patient's journey demonstrating how the prompt diagnosis and treatment of endophthalmitis can still ensure a positive outcome.
Endophthalmitis: A case presentation
Jonathan Lazari BSc (hons)
5th year medical student at Barts and The London

Name: M.M | Gender: F | Age: 69
Patient Details
Medical/Surgical History
1) T2DM
2) Hypercholesterolaemia
* No personal or family ophthalmological history of note
Drug History
1) Metformin 550mg 2x noct, 1x mane
2) Simvastatin 40mg 1x noct
3) Calcium carbonate and colecalciferol 1.5mg + 10mcg ods
Serattia Marcescens
Referral by GP (via optician)
For reduced VA (6/12 in BE) due to bilateral cataract
Seen in Ms Patra's clinic
C/o reduced VA and night glare

VA: 6/12 | 6/7.6 (w/pinhole)

IoP: 15 | 16

Lens: C++ NS+ no NVI | C+ NS+ no NVI

All other examination findings normal [cornea: normal and clear. AC: deep and quiet. Vit: clear. Fundus: normal with no diabetic changes bilaterally]

PLAN: Rt phaco. + IoL, before Lt phaco. + IoL
Rt phaco + IoL
Uncomplicated procedure

Fitted with "Rayner 970C Aspheric". Power: +23.5D. Length: 12.0mm

Discharged as normal
Rt phaco follow-up
Uneventful recovery. Normal examination

Patient happy with results

Added to waiting list for Lt phaco + IoL
Lt phaco + IoL
Uncomplicated procedure

Fitted with "Rayner 970C Aspheric". Power: +23.5D. Length: 12.0mm

Discharged as normal
Timeline of Events
**Presents to A&E**
Awoke in the morning with no vision, a white discharge and a painful, gritty sensation in Lt eye

On Maxidex and chloramphenicol eye drops qds

VA: 6/9 | cf
IoP: 16 | 10
Red reflex present
AC: Hypopyon and cells+++
Iris: Plastic irits with fibrinous exudates on pupillary margin
No fundal view (B-Scan showed flat retina with no vit. opacities)
IMPRESSION: endophthalmitis
Vitreous tap with intravitreal ABx
Tapped for culture

Intravitreal injection of ABx
Vancomycin 2mg in 0.1ml
Gentamicin 200mcg in 0.1ml
Provided good Gram +ve and -ve cover

Tap results (on 15/08/11)
Microbiology: no organisms seen
Wound culture: growth of serratia marcescens (R: amoxicillin & co amoxiclav. S: trimethoprim & gentamicin)
This was therefore noted as a "sterile" endophthalmitis
Follow up: Day 1
LVA now 6/95

RE: normal examination

LE: no hypopyon, plastic iritis, bombe. No view of posterior of eye

IMPRESSION: improvement

Treat with intensive dilatation of pupil with cyclopentolate, atropine and phenylephrine every 10mins for 1hr
Follow up: Day 2
Had episode of epistaxis whilst in waiting room - BP: 154/97. Tx with ice packs until it stopped

Small opening at lateral aspect of central cornea

Pupil still small

AC: cells+, no hypopyon

Tx: dexamethasone, oflox and atropine 1% eye drops hourly
Follow up: Day 4
VA now 6/6 | 6/24

AC: cells+

Iris: fibrinous pupillary membrane contracting slowly

Lens: psuedophakic

Vit: 2+ inflammation

PLAN: intravitreal vancomycin 2mg/0.1ml
Intravitreal ABx and orbital floor TA: Day 5

1) Intravitreal vancomycin 0.2mg in 0.1ml

2) Orbital floor triamcinolone acetonide 20mg in 1ml

Follow up in 1m with following eye drops:
Maxidex 2hrly (1/52) --> qds (2/52) --> bds (2/52)
Levofloxacin qds (2/52)
Atropine tds (2/52)
Follow up: 1 month since presentation
VA: 6/7.5 | 6/12 (6/9 w/PH)
IoP: 18 | 18
AC: quiet, no cells BE
Lens: pseudophakic BE
Posterior: no diabetic retinopathy or maculopathy

IMPRESSION: endophthalmitis resolved
PLAN: discharged from care, no further follow up. To continue annual community diabetic screening
There was a remarkable recovery from this potentially devastating complication
Thank you
Any questions?
A: Corneal haze. B: Fibrinous exudate and hypopyon. C: Vitreous haze and impaired fundus view. D: Severe iritis.
Treatment Overview of Endophthalmitis
Intravitreal ABx
Ceftazidime and vancomycin are a common combination in order to cover most Gram -ve (inc. Pseudomonas A.) and coagulase -ve & +ve cocci (inc. MRSA) respectively. (2, 3)
Periocular ABx
Probably of limited benefit if intravitreal ABx have been given. (2)
Topical ABx
Achieve good anterior chamber, but not vitreal concentrations. Therefore, of limited benefit other than to cover any fresh/open wounds. (2, 3)
Oral ABx
Fluoroquinolones penetrate the eye well. 400mg of moxifloxacin is capable of achieving 90% minimal inhibitory concentrations against most Gram +ve and -ve pathogens associated with endophthalmitis. (2, 3)
Oral Steroids
Once fungal infx has been ruled out, steroids may prevent the destructive aspect of inflammation. E.g. Prednisolone 1mg/kg. Beware of contraindications, provide gastric protection and monitor blood tests/levels. (2, 3)
Periocular Steroids
May be used if systemic steroids are C/I'd. E.g. Triamcinolone. (2)
Topical Dexamethasone
0.1% 2hrly initially for anterior uveitis. (2)
Topical Mydriatic
E.g. Atropine 1% bd. (2)
Intravitreal Steroids
Whilst there is short term reduction in inflammation, there is limited demonstrated long term improvements in visual outcome. (2, 3)
Pars Plana Vitrectomy
Complex. The "Endophthalmitis Vitrectomy Study" (EVS) showed benefit for PPV only if the VA in the eye was to light perception or worse at presentation. (2, 3)
1) Ania, B.J. (2011). Serratia. eMedicine: http://emedicine.medscape.com/article/228495-overview [accessed 23/09/2012]

2) Kanski, J.J. & Bowling, B. (2011). Clinical Ophthalmology: A Systematic Approach (7th ed.). Elsevier Saunders.

3) Lemley, C.A. & Han, D.P. (2007). Endophthalmitis: a review of current evaluation and management. Retina, 27:6, p.662-680.

4) Equi, R.A. & Green, W.R. (2001). Endogenous serratia marcescens endophthalmitis with dark hypopyon: a case report and review. Survey of Ophthalmology, 46:3, p.259-68.

5) Samonis, G., Vouloumanou, E.K., Christofaki, M., Dimopoulou, D., Maraki, S., Triantafyllou, E., Kofteridis, D.P. & Falagas, M.E. (2011). Serratia infections in a general hospital: characteristics and outcomes. European Journal of Clinical Microbiological Infectious Diseases, 30:5, p.653-660.

6) Hazzaa, S.F.Al., Tabbara, K.F. & Gammon, J.A. (1992). Pink hypopyon: a sign of serattia marcescens endophthalmitis. British Journal of Ophthalmology, 76, p.764-765.

7) Cohen, S.M., Flynn, H.W.Jr. & Miller, D. (1997). Endophthalmitis caused by serratia marcescens. Ophthalmic Surg Lasers, 28:3, p.195-200.

8) Kappstein, I., Schneider, C.M., Grundmann, H., Scholz, R. & Janknecht, P. (1999). Long-lasting contamination of a vitrectomy apparatus with serratia marcescens. Infection Control and Hospital Epidemiology, 20:3, p.192-195.
Whether a truly sterile case or not, an appropriate treatment protocol was followed which no doubt aided the patient's prompt and impressive recovery
M.M presented within 48hrs of uncomplicated cataract surgery with signs and symptoms of endophthalmitis

This was either a case of sterile endophthalmitis or due to infection with serratia marscecens
A Gram -ve, opportunistic pathogenic bacteria. (1, 4)

Tends to colonize the respiratory and urinary tracts, and capable of producing "outbreaks" of nosocomial infections, especially in ITU. (1)

May present with a pink hypopyon. (1, 4, 6)

Naturally resistant to ampicillin, macrolides and 1st gen. cephalosporins. (1)

Suggested treatment is with an aminoglycoside plus an anti-pseudomonal beta-lactam. (1, 5)

Capable of long-term contamination of hospital/surgical equipment. (8)
Was It A "Sterile" Endophthalmitis?
Serratia is capable of being a causative pathogen of endophthalmitis, both endogenously and exogenously. (1, 4, 5)

In 77 hospitalised patients with serattia infections, the 2nd most common site of infection was the eye (20.8%). (5)

However, serratia is a common contaminant from the skin surface and only rarely produces significant human infection. (6)

Exogenous serratia endophthalimitis tends to run a longer, more severe course, with very poor outcomes. (7)

Either an extremely well treated case of serratia marcescens endophthalmitis, or a sterile endophthalmitis that resolved well
Anterior View
Posterior View
Anterior View
Posterior View
LE Anterior View

1) Be aware of the long-term contamination potential of s.marscecens. If warranted, possibly audit the endophthalmitis cases?

2) Be familiar with treatment principles of endophthalmitis to ensure a prompt response to a presentation
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