Clinical CASE REport 143

Medicina (Kaunas) 2013;49(3):143-7

Bilateral Endogenous Bacterial Panophthalmitis

Lina Krėpštė, Reda Žemaitienė, Valerijus Barzdžiukas, Arūnas Miliauskas
Department of Ophthalmology, Medical Academy, Lithuanian University of Health Sciences, Lithuania

Key Words: endogenous endophthalmitis; bacterial panophthalmitis; Streptococcus pneumo-

niae; intravitreal antibiotic; meningitis.

Summary. We present a case of meningitis with bilateral endogenous bacterial panophthalmi-

tis 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. Func-
tional 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.

Introduction sive Care Unit due to cerebral edema, meningitis,

Infectious endophthalmitis is a potentially blind- and bilateral vision loss. He received ceftriaxone
ing eye condition when intraocular spaces with struc- at a dosage of 2 g twice a day intravenously and
tures from the anterior and posterior segments are 0.3% tobramycin drops 3 times a day to both eyes.
involved. Exogenous endophthalmitis is caused by A cerebral spinal fluid (CSF) specimen was taken
microorganisms entering the intraocular space due on the first hospitalization day in the Clinic of In-
to the eye wall defect after trauma, ocular surgery, or fectious Diseases, and the CSF culture was positive
cornea ulcer. The rates of postoperative endophthal- for Streptococcus pneumoniae sensitive to penicillin,
mitis are reported to be 0.05%–0.29% (1). Endog- erythromycin, cefotaxime, and trimethoprim with
enous endophthalmitis (EE) occurs in approximately sulbactam. Despite a systemic recovery without a
5% of endophthalmitis cases (2) and indicates the neurologic deficit, bilateral vision loss and ocular
hematogenous spread of an infective agent to an eye pain remained severe.
from another site in the body. The incidence of EE On admission to the Clinic of Eye Diseases,
in bacteremic patients is 0.06%–0.44% (3). The fi- the right eye showed the visual acuity of no light
nal visual outcome is worse than counting fingers in perception, and the left eye, visual acuity of light
69% (4), and the mortality rate due to this condition perception with incorrect projection. The proptoses
is 30%–50% since it usually develops in chronically were considerable, more significant in the right eye.
ill patients (4, 5). Despite the severity and miserable Ocular hypertension was present in both eyes (4+ by
outcomes of the condition, the best management is palpation). The eyelids of both the eyes were swol-
still unclear. len with marked ptosis and significant conjunctival
We present a case of severe meningitis and con- hyperemia and chemosis. The right eye was immo-
current bilateral endogenous panophthalmitis – the bile, and there was no adduction in the left eye. The
most advanced form of EE – in a young, previously slit-lamp examination of the right eye revealed the
healthy individual. infiltrated, melting cornea with total hypopyon (Fig.
1). There was hypopyon (0.5 mm), exudative pu-
Case Report pillary membrane, iris hyperemia at the pupillary
A 41-year-old Caucasian man presented to the border, seclusio pupillae, and no red reflex or view
Clinic of Eye Diseases, Hospital of Lithuanian Uni- of the fundus in the LE, but the cornea was clear
versity of Health Sciences, following a 9-day treat- (Fig. 2). Ultrasound sonography of this eye showed
ment in the Clinic of Infectious Diseases, Kaunas numerous membranous vitreous opacities and the
Clinical Hospital, including 3 days in the Inten- thickened retina, choroid, sclera, and optic nerve
(Fig. 3) but no vitreous or retinal detachment.
Computed tomography of the head revealed in-
Correspondence to L. Krėpštė, Department of Ophthalmology, flammatory changes of the eyeballs (more signifi-
Medical Academy, Lithuanian University of Health Sciences,
Eivenių 2, 50028 Kaunas, Lithuania cant in the right eye) involving the walls, moderate
E-mail: [email protected]

Medicina (Kaunas) 2013;49(3)

144 Lina Krėpštė, Reda Žemaitienė, Valerijus Barzdžiukas, Arūnas Miliauskas

Fig. 1. The right eye at presentation: significant conjunctival Fig. 2. The left eye at presentation: conjunctival hyperemia and
hyperemia and chemosis, infiltrated, melting cornea, and total chemosis, clear cornea, exudative pupillary membrane, iris
hypopyon hyperemia at the pupillary border, and seclusio pupillae

Fig. 3. Ultrasound sonography of the left eye: membranous Fig. 4. Computed tomography: inflammatory changes
opacities in the undetached vitreous with edema of the retina, in the preseptal and retrobulbar spaces and both eyeballs
the choroid, the sclera, and the optic nerve

signs of retrobulbar cellulitis, and shaded but not ratory tests and electrocardiography were normal.
enlarged contours of the optic nerves (Fig. 4). The diagnosis of endogenous bilateral panoph-
On the first day at our clinic (the ninth day of ill- thalmitis was made on the first day of arrival to the
ness), the findings from the CSF examination were clinic after the abovementioned tests, and a prompt
normal, and a complete blood count test showed treatment was started. Before the intravitreal injec-
leukocytosis (15.4×109/L) with polymorphonuclear tions of vancomycin, the specimens from the an-
leukocytes accounting for 70.9%. The C-reactive terior chamber, the vitreous, and the conjunctivas
protein level was 45.37 mg/L, which was substan- were cultured, which were negative to bacteria. The
tially decreased compared with that on the first day treatment is outlined in Table.
of the illness (238 mg/L). The results of other labo- Despite the treatment, vision in the right eye did

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 Bilateral Endogenous Bacterial Panophthalmitis 145

Table. Conservative Treatment of Bilateral Panophthalmitis

Medications Doses/Regimens Notes

Intravitreal
Vancomycin 1 mg/0.1 mL 0.1 mL on alternate days Possible after paracentesis due to ocular hypertension
Intravenous
Ceftriaxone 2 g × 2/d
Metronidazole 500 mg × 3/d
Vancomycin 1 g × 2/d
Per os
Acetazolamide 500 mg × 2/d
KCl 750 mg × 20/d
Intracameral
Epinephrine Once Posterior synechiae were immediately broken
Subconjunctival
Dexamethasone 0.1% ×1/d
Vancomycin ×1/d
Epinephrine ×1/d
Topical
Ciprofloxacin drops 0.3% ×5/d
Tobramycin ointment 0.3% ×2/d
Diclofenac drops 0.1% ×3/d
Cyclopentolate 1% ×2/d
Timolol 0.5% ×2/d
Dorzolamide 2% ×2/d

not recover, and pain in the eye intensified. After visual acuity (BCVA) of the left eye was 0.07, and
the 5-day treatment, intermittent left bundle branch the adduction was incomplete; there were slight
block was observed in the electrocardiogram, and signs of band keratopathy and no signs of inflam-
infectious vegetations of the aortic valve were sus- mation, and the retina was attached with a grayish
pected, which hastened the enucleation of the right change in the macula inferonasally from the fovea
eye. The histological examination of the enucleated (Fig. 5). BCVA was the same after the next 4 weeks,
eye revealed vast neutrophilic infiltration of all the but keratopathy was developing further, and the sili-
ocular structures, including the fibers of the ex- cone oil had to be removed. Two weeks after the re-
traocular muscles and a purulent exudate in all the moval of silicone oil, visual acuity decreased to light
intraocular spaces. perception due to hypotony and significant swelling
The left eye responded immediately to intravit- of the retina and the choroid, which were suggestive
real vancomycin. On the next day, pain in the eye, of developing phthisis bulbi. A 5-month follow-up
hyperemia, and chemosis of the conjunctiva de-
creased and hypopyon disappeared. Two days later,
vision acuity of hand movements was documented,
but adduction was still limited.
Pars plana vitrectomy (PPV) and lensectomy
were performed, when the left eye stopped improv-
ing, and the intraocular pressure normalized. The
vitreous was white, organized with no signs of ac-
tive disease, and undetached. After core vitrecto-
my, necrosis of the retina at 2- to 7-o’clock posi-
tion reaching the macula was found, and the fovea
looked altered. Retinectomy at 2- to 7-o’clock po-
sition sparing the macula was performed (the ne-
crotized retina did not bleed); the retina was fixed
by cryocoagulation. At the end of the operation, an
intravitreal injection of vancomycin and tamponade
with silicone oil (Oculentis 5000) were made. An
intraocular lens was not implanted.
On the next day, the patient was transferred to
the Clinic of Cardiac, Thoracic, and Vascular Sur- Fig. 5. Fundus of the left eye after 13 weeks following pars pla-
gery for prosthesis of the aortic valve. na vitrectomy: remaining retina attached, green-grayish macula
After 13 weeks following PPV, best-corrected parafoveal and nearby chorioretinal scars from cryocoagulation

Medicina (Kaunas) 2013;49(3)

146 Lina Krėpštė, Reda Žemaitienė, Valerijus Barzdžiukas, Arūnas Miliauskas

showed the same visual acuity, but eyeball shrinkage Our patient was severely ill from the onset of the
was observed. disease as it is in many septic patients. Meningitis
could have been just another pyogenic metastasis
Discussion as Streptococcus pneumoniae is capable of spread-
Endogenous bacterial endophthalmitis (EBE) is ing rapidly. Still we consider it as a primary focus
the result of bacterial multiplication within the eye due to the fact that bacterial meningitis is mainly
after bacteria cross the blood-ocular barrier dur- caused by Streptococcus pneumoniae (8), and no
ing bacteremia. Associated conditions are related other infectious focus was found except endocar-
to an immune-compromised state, such as chronic ditis 2 weeks after the onset of the disease. Theo-
diseases, especially diabetes mellitus, malignan- retically, the bacteria could have spread to the eyes
cies, therapy, long-term catheters, intravenous drug through the meningeal layer, but bacteremia and
abuse, or invasive surgery. Predisposing factors for hematogenous spread were proven by the presence
the condition were indicated in 40%–100% of EBE of endocarditis.
cases (3, 4, 6). The ocular presentation of EE in the present
The source and the most frequent causative case was typical and met all the criteria for pano-
agents of the infection vary greatly comparing the phthalmitis according to the classification proposed
Asian and Caucasian populations. In the latter, by Greenwald et al. (9). The prognosis of EBE of
gram-positive bacteria dominate (60.7% of EBE such a grade is very poor. For instance, all the bacte-
cases with Staphylococcus aureus and Streptococcus rial panophthalmitis cases observed by Greenwald et
pneumoniae being the most common); in the Asians, al. resulted in blindness and phthisis bulbi or were
gram-negative microorganisms dominate with Kleb- enucleated (9). Bilateral cases are more commonly
siella species in 77.4% of cases (4). Pyogenic me- caused by EE of fungal than bacterial origin, i.e.,
tastases besides endophthalmitis include arthritis, 33%–45% vs. 13%–25% (6, 9).
endo­carditis, pneumonia, meningitis, infection of Delay in recognizing EBE occurs mainly for 2
the hepatobiliary (common for Klebsiella), renal, or reasons: a severe systemic state deterring early de-
urinary tracts, and skin infection, which all could be tection or diagnostic errors. The most frequently
a primary focus of bacteremia (3–5, 7). Microorgan- (37.5%) reported misdiagnosis was noninfectious
isms are cultured from intraocular fluids, blood, or uveitis as an acutely inflamed eye with hypopyon
relevant sites. A negative blood or vitreous culture mimics Behcet’s disease and involvement of mul-
does not exclude EBE as a positive blood culture is tiple joints suggests the diagnosis of Reiter’s syn-
observed in 33%–75% and a positive vitreous cul- drome (3, 5). The diagnosis is facilitated by septic
ture in 56% of EBE cases (3). appearance and panophthalmitis. Extreme eyelid
The period from systemic to ocular signs in EBE swelling, as in the case of our patient, may suggest
is short. The reported range is from a simultaneous cavernous sinus thrombosis or orbital cellulitis (3).
presentation to 35 days with the mean varying from Despite the rapid systemic improvement due to
4.4 to 6.7 days (3, 4, 7). The rapid manifestation of treatment with intravenous antibiotics, the condi-
ophthalmic symptoms from the onset of sepsis is as- tion of our patient was deteriorating, and the left
sociated with a poorer prognosis (4) and may serve eye improved only after the administration of in-
as a marker of a high virulence of the bacteria. In travitreal vancomycin. Such a case suggests that
our case, the virulence of the microorganisms was the therapeutic levels of systemic antibiotics were
also the foremost factor for concurrent severe bilat- not reached within the vitreous regardless of the
eral endophthalmitis and meningitis since the indi- damaged blood-ocular barrier. The administration
vidual without any possible predisposing condition of systemic antibiotics may be insufficient for the
was suddenly affected. treatment of EBE despite their good ocular pen-
According to the literature sources, 53.1%– etration (penicillin or cephalosporins). Data show
63.6% of EBE cases result in no light perception, an improvement in visual outcomes and a reduc-
phthisis bulbi, and evisceration or enucleation, and tion in evisceration/enucleation rates with intravit-
in 69%, the final visual acuity is worse than counting real antibiotics (3). The time from the onset to the
fingers (3, 4, 7). The suggested prognostic factors efficacious treatment (intravitreal vancomycin) in
for poorer outcomes are different and contradictory. our case was 9 days, which is consistent with the
The possible factors include a delay in diagnosis, reported mean of a 9.5-day delay in misdiagnosed
time to ocular symptoms, use of inappropriate an- EBE cases (3). We did not treat with intravitreal
tibiotics, infection with virulent organisms, namely steroids since they are associated with a worse vis-
gram-negative bacteria and group B Streptococcus ual outcome (10).
pneumoniae, diffuse infection/panophthalmitis, hy- The role in saving the vision function and the
popyon, and opaque media (3,4, 7). timing of PPV in EBE are not as clear as it is in

Medicina (Kaunas) 2013;49(3)

 Bilateral Endogenous Bacterial Panophthalmitis 147

cases of postoperative endophthalmitis after the proceeded with vitrectomy only when no improve-
Endophthalmitis Vitrectomy Study. Some reviews ment was observed in the left eye.
show an unrelated visual outcome to the use of PPV
(4, 5); others suggest that eyes after PPV are more Conclusions
likely to retain useful vision and less likely to be Though initially functional vision in the better
eviscerated/enucleated (3). The general rationale eye was restored, phthisis bulbi began to develop af-
for a procedure is obtaining vitreous samples, clear- ter the removal of the silicone oil, proving many fac-
ing the vitreous, and reducing the amount of infec- tors of a bad prognosis in EBE: a delay in diagnosis,
tive organisms, toxins, or inflammatory substances an infection with a virulent organism, simultaneous
in order to prevent retinal necrosis. Nevertheless, systemic and ocular symptoms, panophthalmitis,
an inflammatory response and exotoxins may irre- opaque media at presentation, and hypopyon. Better
versibly damage photoreceptors within 24 hours of outcomes of EBE could be expected if bacteremic,
inoculation (3); so, in case of a virulent organism, especially unconscious, patients were examined rou-
only early PPV could hinder necrosis. There was no tinely by an ophthalmologist and, in case of EBE,
reason for prompt PPV in our case since the patient prompt intravitreal antibiotics were administered.
was admitted to the Clinic of Eye Diseases after 9
days; the bacteria were cultured from the CSF, and Statement of Conflict of Interest
above all, intravitreal vancomycin was effective. We The authors state no conflict of interest.

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Received 4 January 2013, accepted 30 March 2013

Medicina (Kaunas) 2013;49(3)