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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 59  |  Issue : 3  |  Page : 280-282

Management of post glaucoma drainage device-related endophthalmitis: To retain or to remove?


Department of Glaucoma, Aravind Eye Hospital, Puducherry, India

Date of Submission27-Jun-2020
Date of Acceptance21-Sep-2020
Date of Web Publication09-Sep-2021

Correspondence Address:
Dr. Srinivasan Kavitha
Department of Glaucoma, Aravind Eye Hospital, Puducherry - 605 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_80_20

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  Abstract 


Glaucoma drainage devices (GDD) play important role in the management of intractable glaucoma. Endophthalmitis in such cases though is a rare occurrence, could still be a vision threatening complication. We report a case of patient with refractory glaucoma who was managed with GDD implantation presenting with delayed endophthalmitis. Here, we discuss the approach to the diagnosis and modalities of intervention keeping the GDD in situ as removing the GDD can jeopardize the intraocular pressure control in such a case of advanced glaucoma.

Keywords: Aurolab aqueous drainage implant, core vitrectomy, endophthalmitis, glaucoma drainage device


How to cite this article:
Tejaswini S U, Kavitha S. Management of post glaucoma drainage device-related endophthalmitis: To retain or to remove?. TNOA J Ophthalmic Sci Res 2021;59:280-2

How to cite this URL:
Tejaswini S U, Kavitha S. Management of post glaucoma drainage device-related endophthalmitis: To retain or to remove?. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Sep 21];59:280-2. Available from: https://www.tnoajosr.com/text.asp?2021/59/3/280/325743




  Introduction Top


Glaucoma drainage devices (GDDs) create an alternate pathway channeling the aqueous from anterior chamber (AC) to the subconjunctival space. GDDs are often used for controlling intraocular pressure (IOP) in patients with refractory glaucoma not responding to maximal medical therapy or trabeculectomy or following a failed Trabeculectomy.[1],[2] The early postoperative complications include Choroidal effusion, shallow AC, wound leak, aqueous misdirection, and suprachoroidal hemorrhage. Late complications include persistent diplopia, tube erosion, endophthalmitis/blebitis, chronic or recurrent iritis, and tube obstruction.[1],[3]

Endophthalmitis is a rare but vision threatening complication of any intraocular surgical procedure which can occur within days or weeks postoperatively.[1] Late-onset endophthalmitis after GDD has been reported as late as 2 years' postoperatively.[2],[3] Exposed tube was found to be a major risk factor in these cases.[2] Most of these cases are managed by explanting the GDD, as the tube is often considered as the route of entry of infectious organisms.[4] We report a case of endophthalmitis following Aurolab Aqueous Drainage Implant (AADI) which was managed without removing the implant.


  Case Report Top


A 51-year-old female presented with severe pain, redness in her right eye since 10 days. She had undergone Aurolab Aqueous Drainage Implant (AADI) 1 year ago for intractable secondary glaucoma following cataract surgery and IOL exchange. She was on regular follow-up, was maintaining a visual acuity of 6/12, had near total cup and well controlled IOP in the range of 10–12 mm Hg.

On examination her vision was 6/60 in the right eye. Anterior segment had ciliary congestion, AADI bleb in supero-temporal quadrant. There was no tube or plate exposure. AC had cells and hypopyon of 0.5mm, infiltrates noted around entry site of the tube at 11o'clock position [Figure 1]a. Fundus examination showed advanced cup. Her left eye was pseudophakic with visual acuity of 6/6, fundus was normal. Initial B scan showed moderate dot echoes with optic nerve cupping. Severe inflammation was suspected, topical moxifloxacin with loteprednol and homatropine started.
Figure 1: (a) Diffuse congestion, infiltrates surrounding the tube and trace hypopyon. (b) A quite eye, complete resolution of exudates surrounding the tube post core vitrectomy

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After a week vision in the right eye dropped to hand movements with accurate projection of rays, infiltrates progressed toward tip of the tube. Fundus examination revealed vitreous haze secondary to exudates. B scan revealed vitreous exudates with normal retinochoroidal complex confirming endophthalmitis.

The patient was immediately taken up for vitreous tap with intravitreal Vancomycin (1 mg/0.1 ml) and Ceftazidime (2.25mg/0.1ml) with dexamethasone (0.4 mg/0.1 ml).

POD 1 AC was more shallow with tube touching the endothelium and increasing vitreous exudates on B scan. Core vitrectomy was done immediately with repeat dose of intravitreal antibiotics.

Postsurgery AADI bleb was intact, exudates around the tube reduced significantly along with clearing of vitreous exudates. Patient received topical Moxifloxacin with Tobramycin eye drops 2nd hourly, cycloplegics, topical and oral steroids in weekly tapering dose. Vitreous tap did not show any organism on grams and KOH staining, no growth noted after 1 week of incubation in blood agar, chocolate agar, and thioglycolate broth.

Three weeks' postsurgery her best-corrected visual acuity BCVA was 6/12, IOP 9mm Hg. Congestion resolved completely with intact AADI bleb, tube was free of exudates [Figure 1]b. Vitreous exudates cleared completely. During her recent follow-up visit which was 8 months post core vitrectomy her vision was 6/24 and IOP was maintained well below 15 mm Hg without anti-glaucoma medications.


  Discussion Top


AADI is a Baerveldt type, non-valvular GDD, which shunts the aqueous humor from the anterior or posterior chamber through a tube to an episcleral plate located in the equatorial region. Aqueous pools in the space between plate and surrounding capsule which is later absorbed by periocular lymphatics and capillaries. This bleb has thick, fibrous capsule, is remote from the limbus, making it less prone to develop bleb leak/infection compared to thin-walled bleb after a trabeculectomy, especially with anti-metabolite use.[2]

Although endophthalmitis is a rare complication after GDD surgery, the exact incidence is unclear. In Trabeculectomy versus-Tube study, endophthalmitis developed in 1 of 107 eyes in the GDD group and 5 of 105 in the Trabeculectomy group over 5 years.[3] Majority of GDD related endophthalmitis is commonly late onset,[1],[3],[5],[6] can also follow tube repositioning, needling or bleb revision.

Erosion of the tube seems to be a major risk factor of late Endophthalmitis as it forms a conduit for the passage of host flora in to the eye. Exposure of Molteno tube was noted in all four patients in series published by Gedde et al. and both cases reported by Krebs et al.[2],[7] Tube erosion generally develops close to the limbus. The use of donor sclera/corneal patch graft to cover anterior portion of the tube significantly reduces the likelihood of erosion.

It is unclear whether GDDs should be removed or left in place during the course of treatment for endophthalmitis. In case series published by Gedde et al., Perkins and Malik explanation of the GDD for the purpose of removing the contaminated foreign body was advised.[2],[4],[5] Others have reported successful treatment with intravitreal antibiotics while the GDD remains in place.[7],[8] However, outcome following removal of GDD remains ambiguous.

In our case, the presentation was 1 year post-GDD implantation with no signs of tube erosion/exposure of footplate. As medical treatment failed to show any response surgical intervention in the form of intravitreal antibiotics followed by timely core vitrectomy was done keeping tube in situ. Postsurgery exudates resolved completely with good visual recovery.

Gram stain and culture results were negative for bacterial and fungal microbes. Cytology analysis indicated an acute inflammatory response. Symptoms improved with core vitrectomy followed by topical steroids and antibiotics. These observations indicate sterile endophthalmitis as the possible diagnosis. Sterile endophthalmitis is an acute intraocular inflammation that either resolves without antibiotics or is culture-proven negative.[9] However, even in culture-proven negative cases, empirical treatment with antibiotics covering potential microbes may be judicious.[10]

Majority of such cases are managed by tube removal considering it to be the reservoir of infection. A trial of core vitrectomy alone can be considered especially when there is no exposure of the tube or footplate. Meticulous evaluation of signs and timely intervention can avoid unnecessary tube explantation in such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Al-Torbak AA, Al-Shahwan S, Al-Jadaan I, Al-Hommadi A, Edward DP. Endophthalmitis associated with the Ahmed glaucoma valve implant. Br J Ophthalmol 2005;89:454-8.  Back to cited text no. 1
    
2.
Gedde SJ, Scott IU, Tabandeh H, Luu KK, Budenz DL, Greenfield DS, et al. Late endophthalmitis associated with glaucoma drainage implants. Ophthalmology 2001;108:1323-7.  Back to cited text no. 2
    
3.
Gedde SJ, Herndon LW, Brandt JD, Budenz DL, Feuer WJ, Schiffman JC, et al. Postoperative complications in the tube versus trabeculectomy (TVT) study during five years of follow-up. Am J Ophthalmol 2012;153:804-14.  Back to cited text no. 3
    
4.
Perkins TW. Endophthalmitis after placement of a Molteno implant. Ophthalmic Surg 1990;21:733-4.  Back to cited text no. 4
    
5.
AlHadlaq A, AlMalki S, AlShahwan S. Late onset endophthalmitis associated with unexposed glaucoma valved drainage device in Saudi J Ophthalmol 2016;30:125-7  Back to cited text no. 5
    
6.
Francis BA, DiLoreto DA, Chong LP, Rao N. Late-onset bacterial endophthalmitis following glaucoma drainage implantation. Ophthalmic Surg Lasers Imaging 2003;34:128-30.  Back to cited text no. 6
    
7.
Krebs DB, Liebmann JM, Ritch R, Speaker M. Late infectious endophthalmitis from exposed glaucoma setons. Arch Ophthalmol 1992;110:174-5.  Back to cited text no. 7
    
8.
Ellis BD, Varley GA, Kalenak JW, Meisler DM, Huang SS. Bacterial endophthalmitis following cataract surgery in an eye with a preexisting Molteno implant. Ophthalmic Surg 1993;24:117-8.  Back to cited text no. 8
    
9.
Kim JH, Chen TC. Delayed sterile endophthalmitis after glaucoma drainage implantation. Semin Ophthalmol 2011;26:290-4.  Back to cited text no. 9
    
10.
Arıkan Yorgun M, Mutlu M, Toklu Y, Cakmak HB, Cağıl N. Suspected bacterial endophthalmitis following sustained-release dexamethasone intravitreal implant: A case report. Korean J Ophthalmol 2014;28:275-7.  Back to cited text no. 10
    


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