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UNILATERAL ENDOGENOUS ENDOPHTHALMITIS BY ESCHERICHIA COLI NI A DIABETIC

NISHANT KUMAR
SHO Department of Ophthalmology, Royal Gwent Hospital, New Port, UK.

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Endogenous endophthalmitis was thought to be a rare clinical entity. The diagnosis is often difficult to make and the delay often causes loss of the eye.

CASE REPORT

A 76 year old non-insulin dependent diabetic lady presented to the eye department with a painful left eye with reduced visual acuity. She had no systemic complaints at presentation.

She maintained poor glycaemic control, had been recently diagnosed as having myeloma and had a chronic history of renal calculi and recurrent urinary tract infections.

Her visual acuity was reduced to hand movements and examination on slit lamp showed marked circum-corneal congestion with the anterior chamber showing signs of active inflammation with the presence of a hypopyon (pus in the anterior chamber) (Fig. 1).

Fundus examination revealed no red reflex and an ultrasound of the eye showed a pre-retinal abscess with inflammation of the vitreous. (Fig. 2). The above are characteristic signs of endophthalmitis.

The patient was admitted, a vitreous biopsy taken and investigations made to ascertain any other septic focus.

Escherichia coli was grown from both the vitreous sample and the urine that showed the same antibiotic sensitivities leading to the conclusion that this was a endogenous endophthalmitis with the primary septic focus being in the urinary tract.

During her admission the patient became very unwell with electrolyte imbalances and raised blood sugars almost slipping into diabetic keto-acidosis.

She was treated with intensive topical and systemic antibiotics along with a single intra-vitreal vancomycin injection. The eye showed no signs of improvement despite intensive treatment and eventually it was eviscerated. The histo-cytology report confirmed ‘acute suppurative ophthalmitis’.

The right eye remains unaffected till date with a vision of 6/9. She has been started on prophylactic antibiotics for her recurrent urinary tract infections.

Fig.1	Fig.2

				Endophthalmitis
		Exogenous			Endogenous
		Post operative	Post traumatic		Focal	Diffuse			Panophthalmitis

DISCUSSION

In our case the patient presented with all the characteristic signs of endophthalmitis but had no symptoms of the primary septic focus, the urinary tract and this is the fact that makes the diagnosis difficult unless a high index of suspicion exists.

Despite an early diagnosis and rigorous treatment we were not able to save the eye and this is a well-documented problem in endogenous endophthalmitis. In a particular case study out of the 13 affected eyes 10 had to be removed.[1] The only positive prognostic factor is an urgent timely referral to an Ophthalmologist with intense treatment.

Endogenous endophthalmitis accounts for 2-8% of all cases of endophthalmitis.[2] Bilateral endogenous endophthalmitis due to Escherichia coli appears to be exclusive to diabetics.[5] In the Asian community Klebsiella accounts for about 60% of cases but in the Western world escherichia coli makes up more than 50% of the isolates and 30-50% of these strains are resistant to Ampicillin.[3]

Spread of infection to the eye is haematogenous with the primary focus predominantly being the urinary tract in cases of Escherichia coli whereas Klebsiella usually causes suppurative liver disease. In our literature search we found that acute bacterial endocarditis has also been found to cause endophthalmitis.[6] It has been postulated that the diabetic retinopathy may cause breakdown of the blood-ocular barrier facilitating bacterial seeding.[7] It is also known that bacteraemia is a complication in febrile patients with bacteriuria.[5]

Management includes intense topical antibiotics and mydriatics with systemic and intra-vitreal antibiotics. Systematic search for asymptomatic foci of infections should be made.

Dangers of endophthalmitis are that it not only causes a loss of the eye but it also acts as a septic focus which may precipitate diabetic ketoacidosis as was seen in our case. The infection may also spread to cause panophthalmitis, and also cerebral infections.

SUMMARY

Any diabetic with a painful eye and decreased visual acuity must raise an alarm in the mind of the physician and warrants an urgent referral to an ophthalmologist with a systematic search for a primary focus of infection, which may be asymptomatic. If there is any chronic infection prophylactic antibiotics shoud be considered as they may prevent such devastating complications.

Despite the advances in surgery and antibiotics this condition yet carries a very bad prognosis and it is now being realised that this condition is not as rare as it was thought to be. A combined medical-ophthalmic approach is the only way forward.

REFERENCES

1.Park SB, Searl S, Aquavella JV. Endogenous endophthalmitis caused by E Coli. Ann Ophthalmol 1993; 25 : 95-9.

2.Okada AA, Johnson RP, Liles WC, D’Amico DJ, Baker AS. Endogenous bacterial endophthalmitis. Report of a ten-year retrospective study. Ophthalmology 1994; 101 : 832-8.

3.Wong JS, Chan TK, Lee HM, Chee SP, Harris EW, D’Amico DJ, Bhisitkul R, Priebe GP, Petersen R, Emerson PM, Cairncross S, Bailey RJ, Mabey DC. Ophthalmology 2000; 107 (8) : 1483-91.

4.Bilateral endophthalmitis in bacterial endocarditis : Christine L, Burns AJO. 1979; 88 : 909-13.

5.Paul Cohen Jeffrey Krishner. Bilateral endogenous endophthalmitis. Arch Intern Med 1980;140.

6.Bilateral endophthalmitis in acute bacterial endocarditis,

7.Christine Burns, AJO. 1979; 88 : 909-13.

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