Pan-endophthalmitis and Orbital Cellulitis:

89-year-old female with a history of gradual redness and proptosis OD over 3 weeks

Pan-endophthalmitis and Orbital Cellulitis:

89-year-old female with a history of gradual redness and proptosis OD over 3 weeks

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Chief Complaint: 89-year-old female with a history of gradual redness and proptosis OD over 3 weeks.

History of Present Illness: Redness and proptosis OD worsened on 10 days of IV vancomycin & ceftriaxone.

PMH/FH/POH: mitral valve regurgitation, advanced Alzheimer's disease, heart disease, glaucoma, schizophrenia, diabetes, and myopia.

Patient has had trabeculectomies OD and OS.

EXAM

• Best corrected visual acuities: NLP OD and 20/125 OS.
• Pupils: large RAPD OD by reverse
• Confrontational VF: unable to assess
• EOM: underaction in all directions of gaze OD.
• IOP: 29 mmHg OD, 8 mmHg OS
• Anterior segment: see photos, OS normal with superior trabeculectomy bleb.
• DFE: no view OD, OS normal.
• Hertel: 16 mm OD, 10 mm OS (marked proptosis OD)

Figure 1

OD	OD
Face photo denoting marked proptosis OD with purulent discharge and periorbital erythema.	Photograph of right eye: fibrin in anterior chamber with consolidated hypopyon, marked conjunctival injection and chemosis, and purulent discharge.

Figure 2: Axial CT Scans

CT scan: marked proptosis OD with thickened sclera OD	A different view demonstrating thickened sclera OD wth adjacent areas of possible abscess and/or inflammation.

Figure 3: Globe after Enucleation

Area of globe perforation from pan-endophthalmitis.	The optic nerve separated from the globe during enucleation. There is a rim of necrotic tissue at the lamina cribrosa.

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Discussion

Pan-endophthalmitis and Orbital Cellulitis

This patient presented with periorbital swelling, erythema, proptosis, loss of vision, and ophthalmoplegia of the right eye. She developed an endophthalmitis, likely due to trabeculectomy blebitis, which evolved into a pan-endophthalmitis because of her declined mental function and delay to seek medical attention. The pan-endophthalmitis resulted in globe perforation and spread of the infection resulting in an orbital cellulitis. On CT scan, there was marked scleral thickening and inflammation around the globe. The original scans were worrisome for a possible orbital abscess, which requires emergent surgical exploration and intervention. During surgery, we encountered purulent discharge and inspection of the globe revealed an area of perforation due to necrosis and infection. At this point, the decision was made to perform an enucleation of the right eye.

The presence of a trabeculectomy bleb increases the incidence of infection and endophthalmitis. It is estimated that the incidence of endophthalmitis following trabeculectomy surgery occurs at a rate of less than 1:1000 for early and 1:500 for late endophthalmitis, but can be as high as 1:100 cases. Risk factors for infection following trabeculectomy surgery include: an inferior or nasally located bleb; presence of a high bleb or blepharitis; development of a late-onset bleb leak; use of antifibrotic agents; chronic antibiotic use; and performance of a trabeculectomy alone versus a combined procedure. The use of antifibrotic agents, e.g. mitomycin-C and 5-fluorouracil, have been implicated in increasing the incidence of post-trabeculectomy endophthalmitis due to thin, cystic blebs; however, some studies have not observed a statistically significant increase in the rates of infections with antifibrotic agents during trabeculectomy surgery.

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Diagnosis: Endophthalmitis after trabeculectomy surgery

EPIDEMIOLOGY 1:100 - 1:1000 cases following trabeculectomy surgery. Risk factors: an inferior or nasally located bleb; presence of a high bleb or blepharitis; development of a late-onset bleb leak; use of antifibrotic agents; chronic antibiotic use; and performance of a trabeculectomy alone versus a combined procedure.	SIGNS Blebitis: WBCs in the bleb Anterior chamber WBCs Vitritis Hypopyon (layered WBCs in anterior chamber) Keratic precipitates Conjunctival injection Pain Decreased vision
SYMPTOMS Pain Redness Decreased vision Tearing	TREATMENT Topical broad-spectrum antibiotics for blebitis without endophthalmitis. Tap and inject of broad-spectrum antibiotics If there is bleb leak, then repair of leak after infection controlled. Steriods may be added with careful follow-up to help reduce inflammation after the patient has been covered with antibiotics.

Differential Diagnoses

• Non-infectious uveitis or iritis
• Blebitis
• Endophthalmitis
• Orbital abscess
• Orbital cellulitis
• Advanced orbital tumor