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 Table of Contents  
CASE SERIES
Year : 2021  |  Volume : 59  |  Issue : 4  |  Page : 368-371

Clinico-etiological profile and drug sensitivity patterns in endophthalmitis due to Bacillus species: A case series


1 Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed To Be) University, Bhubaneswar, Odisha, India
2 Department of Microbiology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed To Be) University, Bhubaneswar, Odisha, India

Date of Submission07-May-2021
Date of Decision24-Jul-2021
Date of Acceptance04-Aug-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
Dr. Pradeep Kumar Panigrahi
Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed To Be) University, 8-Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_55_21

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  Abstract 


Endophthalmitis due to Bacillus species can be associated with devastating consequences. In the present case series, two-each cases of postoperative and traumatic endophthalmitis were included. Prompt surgical intervention was done in all cases. Bacillus cereus and Bacillus subtilis were isolated in 3 cases and 1 case, respectively. All isolates showed 100% sensitivity to vancomycin, ciprofloxacin, and clindamycin. In spite of early intervention, final functional and anatomical outcomes were poor in all four cases.

Keywords: Bacillus, endophthalmitis, intravitreal injection, vitrectomy


How to cite this article:
Panigrahi PK, Bhoi P, Minj A, Satapathy J. Clinico-etiological profile and drug sensitivity patterns in endophthalmitis due to Bacillus species: A case series. TNOA J Ophthalmic Sci Res 2021;59:368-71

How to cite this URL:
Panigrahi PK, Bhoi P, Minj A, Satapathy J. Clinico-etiological profile and drug sensitivity patterns in endophthalmitis due to Bacillus species: A case series. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2022 Dec 10];59:368-71. Available from: https://www.tnoajosr.com/text.asp?2021/59/4/368/333175




  Introduction Top


Endophthalmitis is a vision-threatening ocular condition. It is usually associated with poor prognosis in majority of cases. Bacillus endophthalmitis following intraocular surgery and trauma has been reported in the literature.[1],[2],[3],[4] Although few studies have reported good visual outcomes, the final prognosis following Bacillus endophthalmitis tends to remain poor.[5] In the present case series, we have aimed to study the etiology, clinical profile, and drug sensitivity patterns in endophthalmitis due to Bacillus species.


  Case Reports Top


Case 1

A 61-year-old nondiabetic male presented with pain, redness, and decreased vision in the left eye (LE) 2 days following phacoemulsification and trabeculectomy done elsewhere. Best-corrected visual acuity (BCVA) in the LE was light perception (LP) positive with defective projection of rays (PR). Slit lamp examination of anterior-segment showed superior filtering bleb, corneal edema, hypopyon, and brownish exudates in anterior chamber (AC) [Figure 1]a. Intraocular pressure (IOP) was 28 mm of Hg using Goldmann applanation tonometer. There was no view of fundus. Ultrasound (USG) examination showed plenty of moderate reflective dot and membranous echoes with T-sign positive [Figure 1]b. The patient underwent pars plana vitrectomy (PPVIT) with intraocular lens (IOL) removal. Intravitreal vancomycin (1 mg/0.1 ml) and ceftazidime (2.25 mg/0.1 ml) were injected at the end of the procedure. Vitreous aspirate sent for microbiological examination showed Gram-positive bacilli in Gram stain [Figure 2]a. Bacillus cereus growth was obtained on culture [Figure 2]b. The patient was started on systemic ciprofloxacin (500 mg twice a day), topical moxifloxacin (0.5%, 3 hourly), prednisolone eye drops, and a combination of timolol maleate and brimonidine to reduce the IOP. The antibiogram showed sensitivity to vancomycin, amikacin, and ciprofloxacin. The patient received two more doses of intravitreal vancomycin on days 3 and 6 following surgery. In spite of all treatment measures, there was clinical worsening and the eye had to be eviscerated.
Figure 1: (a) Clinical photograph of the left eye of case 1 showing a shallow superior filtration bleb, corneal edema, hypopyon, and exudates in anterior chamber. (b) Ultrasound image of the left eye of case 1 showing moderate reflective dot and membranous echoes with T-sign positive

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Figure 2: (a) Gram stain mount showing Gram-positive bacilli in case 1. (b) Blood agar plate showing growth of Bacillus cereus in case 1

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Case 2

A 90-year-old hypertensive male presented with severe pain and decreased vision in the right eye (RE) 1 day following cataract surgery done elsewhere. BCVA in the RE was LP positive with PR defective. Anterior-segment examination showed a gaping superior scleral wound, corneal edema, brownish hypopyon in AC, and exudative membrane on IOL. IOP was 26 mm of Hg. USG showed plenty of moderate reflective dot and membranous echoes. The patient underwent PPVIT and IOL removal. Intravitreal vancomycin and ceftazidime were injected at the end of the procedure. B. cereus growth was obtained from vitreous aspirate, and the organism was sensitive to vancomycin. The patient received two more doses of intravitreal vancomycin 48 h apart on days 3 and 5 following surgery. The patient developed total retinal detachment on day 7 following surgery and was advised vitrectomy with silicone oil injection. The patient refused further intervention and was lost to follow-up.

Case 3

A 41-year-old male presented with pain, redness, and decrease in vision in the LE 7 days following a penetrating injury. BCVA in the LE was query LP. Anterior-segment examination showed a 4-mm corneal tear with overhanging edematous edges superior to the pupillary axis, hypopyon in AC, and total cataract. USG showed moderate reflective dot and membranous echoes and high reflective echo with posterior shadowing in the mid vitreous suspicious of an intraocular foreign body (IOFB) [Figure 3]a. The patient underwent corneal tear repair, lensectomy, PPVIT, and removal of IOFB. The eye was injected with vancomycin, ceftazidime, and amphotericin at the end of the procedure. B. subtilis growth was obtained from vitreous aspirate. The antibiogram showed sensitivity to vancomycin, and the patient received three more doses of intravitreal vancomycin. In spite of all treatment measures, the patient developed total corneal abscess and had to be ultimately eviscerated [Figure 3]b and [Figure 3]c.
Figure 3: (a) Ultrasound image of the left eye in case 3 showing a high reflective echo in mid-vitreous suggestive of retained intraocular foreign body (white arrow). (b) Clinical photograph of the left eye of case 3 showing total corneal abscess. (c) Clinical photograph of the left eye of case 3 postevisceration

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Case 4

A 40-year-old male presented with loss of vision and pain in the LE 5 days following a penetrating injury at his place of work. The patient had undergone corneal tear repair elsewhere. BCVA in the LE was LP positive with defective PR superiorly. Slit lamp examination showed a repaired corneal tear 5 mm in dimension at 3'o clock position 2 mm away from limbus. An iris entry wound could be seen below the corneal wound. There was hypopyon in the AC with total cataract. IOP was 10 mmHg. USG showed vitreous echoes, IOFB in mid-vitreous and inferior retinal detachment. The patient underwent lensectomy, PPVIT, IOFB removal, and silicon oil injection. Intravitreal vancomycin, ceftazidime, and amphotericin were injected at the end of the procedure. B. cereus growth was obtained both from the vitreous and IOFB. There was slow clinical improvement in the case, and the patient received three more doses of intravitreal vancomycin at 48 h interval. Three months following primary surgery, BCVA was LP positive with pale optic disc and attached retina. Salient clinical characteristics and antibiogram are presented in [Table 1] and [Table 2], respectively.
Table 1: Salient clinical details of the cases

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Table 2: Microbiology details and antibiotic sensitivity patterns

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  Discussion Top


Bacillus species are a group of ubiquitous, Gram-positive, spore-bearing soil-inhabiting rods which are commonly associated with food poisoning. Ocular manifestations include conjunctivitis, keratitis, dacryocystitis, and iridocyclitis.[6] Bacillus endophthalmitis commonly occurs following open globe injuries.[7],[8] Postoperative Bacillus endophthalmitis is very rare and usually signifies a breach in sterilization and aseptic measures. The present case series has included two cases of postoperative and two cases of traumatic endophthalmitis. All two postcataract cases had a fulminant onset and developed symptoms within a few hours of the initial surgery. By the time the patients reached us, both cases had poor vision (LP+), corneal edema, and brownish exudates, and hypopyon in AC. A common finding in both cases was the raised IOP and brownish exudates at presentation. Early PPVIT was done in both cases. The vitreous aspirate obtained was brownish in color. In spite of early treatment, the affected eye in case 1 had to be ultimately eviscerated. Cases 3 and 4 presented with endophthalmitis following open globe injury. Metallic IOFB was extracted from vitreous in both cases. Case 3 developed panophthalmitis and had to be eviscerated. Case 4 had a relatively better final structural outcome with attached retina, pale optic disc, and BCVA of LP+ at final follow-up.

Rishi et al.[3] in their case series of postoperative endophthalmitis due to Bacillus cereus have reported fulminant presentation, raised IOP, and brownish exudates in AC and vitreous. All eyes in their case series had poor final prognosis. Similar findings of raised IOP and brownish exudates were noted in both our postoperative cases. The brownish nature of the exudates could represent necrosis of the uveal tissues signifying the high necrolytic properties of the offending organism. In the present series, Bacillus was isolated from vitreous aspirate in all cases. B. subtilis grew in culture in case 3. Bacillus cereus growth was obtained in the remaining three cases. The isolated organism showed 100% sensitivity to vancomycin, ciprofloxacin, and clindamycin. Similar antibiotic sensitivity has been reported in previous studies.[2],[3],[4] Brief summary of previous studies on endophthalmitis due to Bacillus species is summarized in [Table 3]. All patients included in this series had poor visual outcome in spite of early institution of antibiotics to which the isolated organism was sensitive. This highlights the rapid pace with which Bacillus endophthalmitis progresses ultimately, leading to poor visual and structural outcomes in majority of the cases.
Table 3: Comparison of present case series with previous studies on Bacillus endophthalmitis

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  Conclusion Top


Endophthalmitis due to Bacillus species is usually associated with poor outcomes. Most infections have been reported posttrauma. Postoperative infections are usually rare. High IOP and brownish exudates in the early postoperative phase should be followed up carefully keeping in mind a possible Bacillus endophthalmitis. Early institution of therapy can be associated with good prognosis on rare occasions. The present case series adds to the body of literature available on endophthalmitis due to Bacillus species.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/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 their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Das T, Choudhury K, Sharma S, Jalali S, Nuthethi R; Endophthalmitis Research Group. Clinical profile and outcome in Bacillus endophthalmitis. Ophthalmology 2001;108:1819-25.  Back to cited text no. 1
    
2.
Miller JJ, Scott IU, Flynn HW Jr., Smiddy WE, Murray TG, Berrocal A, et al. Endophthalmitis caused by Bacillus species. Am J Ophthalmol 2008;145:883-8.  Back to cited text no. 2
    
3.
Rishi E, Rishi P, Sengupta S, Jambulingam M, Madhavan HN, Gopal L, et al. Acute post-operative Bacillus cereus endophthalmitis mimicking toxic anterior segment syndrome. Ophthalmology 2013;120:181-85.  Back to cited text no. 3
    
4.
Dave VP, Pathengay A, Budhiraja I, Sharma S, Pappuru RR, Tyagi M, et al. Clinical presentation, microbiological profile and factors predicting outcomes in Bacillus endophthalmitis. Retina 2017;38:1-5.  Back to cited text no. 4
    
5.
Barletta JP, Small KW. Successful visual recovery in delayed onset Bacillus cereus endophthalmitis. Ophthalmic Surg Lasers 1996;27:70-2.  Back to cited text no. 5
    
6.
Weber DJ, Rutala WA. Bacillus species. Infect Control Hosp Epidemiol 1988;9:368-73.  Back to cited text no. 6
    
7.
Chhabra S, Kunimoto DY, Kazi L, Regillo CD, Ho AC, Belmont J, et al. Endophthalmitis after open globe injury: Microbiologic spectrum and susceptibilities of isolates. Am J Ophthalmol 2006;142:852-4.  Back to cited text no. 7
    
8.
Thompson JT, Parver LM, Enger CL, Mieler WF, Liggett PE. Infectious endophthalmitis after penetrating injuries with retained intraocular foreign bodies. National Eye Trauma System. Ophthalmology 1993;100:1468-74.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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