Bilateral corneal ulcers and endophthalmitis after eyelid surgery due to multi-drug resistant mixed infections

Radhika Natarajan; Muna Bhende; Divya Giridhar

doi:10.4103/tjosr.tjosr_42_22

PHOTO ESSAY

Year : 2022 | Volume : 60 | Issue : 4 | Page : 321-322

Bilateral corneal ulcers and endophthalmitis after eyelid surgery due to multi-drug resistant mixed infections

Radhika Natarajan¹, Muna Bhende², Divya Giridhar¹
¹ Department of Cornea and Refractive Surgery, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
² Department of Vitreoretinal Services, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Submission	18-Apr-2022
Date of Decision	01-Sep-2022
Date of Acceptance	02-Sep-2022
Date of Web Publication	19-Dec-2022

Correspondence Address:
Radhika Natarajan
Department of Cornea and Refractive Surgery, Sankara Nethralaya, Medical Research Foundation, 18, College Road, Chennai - 600 006, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_42_22

Abstract

Exogenous infective endophthalmitis is extremely rare after eyelid surgery. A 65-year-old lady presented with bilateral corneal infiltrates and severe anterior chamber exudation after bilateral senile entropion correction. There were multiple fluffy exudates in both the anterior chambers. The left eye was pseudophakic, with yellowish fundal glow. Ultrasonography revealed moderately reflective dot echoes in both eyes. Corneal scraping showed yeast in the right eye. Culture grew Pseudomonas aeruginosa resistant to all drugs except imipenem. Systemic tests for endogenous endophthalmitis were negative. She was started on 5% natamycin and 0.5% imipenem eye drops hourly in both eyes, as well as intravenous imipenem twice a day for five days with supportive treatment. Complete resolution of infection was achieved at one month. The rare bilateral presentation of extra and intraocular infection after entropion surgery, mixed and resistant causative organisms and anterior chamber exudates being disproportionately more than corneal involvement are the unique features of this case.

Keywords: Bilateral infection, corneal infiltrates with endophthalmitis, entropion surgery, multi-drug resistance

How to cite this article:
Natarajan R, Bhende M, Giridhar D. Bilateral corneal ulcers and endophthalmitis after eyelid surgery due to multi-drug resistant mixed infections. TNOA J Ophthalmic Sci Res 2022;60:321-2

How to cite this URL:
Natarajan R, Bhende M, Giridhar D. Bilateral corneal ulcers and endophthalmitis after eyelid surgery due to multi-drug resistant mixed infections. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2023 Feb 8];60:321-2. Available from: https://www.tnoajosr.com/text.asp?2022/60/4/324/364246

Introduction

Exogenous infective endophthalmitis is extremely rare after eyelid surgery. Infectious keratitis progressing to endophthalmitis is an uncommon event, occurring in less than 1% of culture positive corneal ulcers.^[1]

We report a case of bilateral corneal infiltrates progressing to endophthalmitis following eyelid surgery caused by mixed and multi-drug resistant infection.

Case Report

A 65-year-old lady without any comorbidities presented with bilateral corneal infiltrates and severe anterior chamber exudation after bilateral senile entropion correction, done elsewhere two months ago. She had undergone cataract surgery in the left eye five years ago. Vision was counting fingers, corneal epithelial defect with infiltration in both eyes, and dense exudation in the anterior chamber disproportionate to corneal infiltrates [Figure 1] and [Figure 2]. Both eyes had yellowish fundal glow and moderately reflective dot echoes on ultrasonography.

Figure 1: (a and b) Right eye - Corneal ring infiltrate with fluffy AC exudates

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Figure 2: Left eye - Corneal infiltration, vascularisation and dense AC exudates

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Corneal scraping showed yeast. Culture grew Pseudomonas aeruginosa resistant to all drugs except imipenem. Anterior chamber tap could not be performed due to dense media haze. A provisional diagnosis of corneal mixed infection with significant anterior chamber involvement and endophthalmitis was made. Systemic tests for endogenous endophthalmitis were negative.

She was started on 5% natamycin and 0.5% imipenem eye drops hourly. As infection was bilateral and view poor for intravitreal injection, intravenous imipenem, known for good ocular penetration, was given 500 mg twice a day for five days. Cyanoacrylate glue and bandage contact lens were applied to the corneal melt in the left eye.

The corneal infiltrates started reducing, and the anterior chamber exudates started consolidating after one week [Figure 3] and [Figure 4] with gradual reduction in the vitreous echoes. Complete resolution of infection was achieved at one month and the patient is currently awaiting visual rehabilitation.

Figure 3: Right eye - Resolving exudates after treatment

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Figure 4: Left eye - Response to treatment after tissue adhesive for corneal melt. *AC - anterior chamber

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Discussion

Involutional entropion is a relatively common problem in the elderly. Lateral tarsal strip dehiscence, lateral canthal dystopia, conjunctivochalasis, stitch abscess, and pyogenic granuloma are the common complications following trans-conjunctival entropion correction.^[2] Exogenous infective endophthalmitis is extremely rare after eyelid surgery.

This case highlights bilateral extensive anterior chamber exudates after correction of senile entropion. Though such presentation is more commonly associated with endogenous endophthalmitis,^[3] there was a precipitating exogenous cause in our patient. The mixed bacterial and yeast infection with multi-drug resistant nature of the Pseudomonas species isolated, pointed to a hospital-acquired source of organisms.^[4]

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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2.	Erb MH, Uzcategui N, Dresner SC. Efficacy and complications of the transconjunctival entropion repair for lower eyelid involutional entropion. Ophthalmology 2006;113:2351-6.
3.	Sadiq MA, Hassan M, Agarwal A, Sarwar S, Toufeeq S, Soliman MK, et al. Endogenous endophthalmitis: Diagnosis, management, and prognosis. J Ophthalmic Inflamm Infect 2015;5:32.
4.	Raman G, Avendano EE, Chan J, Merchant S, Puzniak L. Risk factors for hospitalized patients with resistant or multidrug-resistant Pseudomonas aeruginosa infections: A systematic review and meta-analysis. Antimicrob Resist Infect Control 2018;7:79.