Fulminent Streptococcal Endophthalmitis Progressing to Evisceration Within Hours of Presentation
Purpose
To describe a patient with a history of multiple corneal graft failures and advanced glaucoma who underwent evisceration for endophthalmitis within 2 days of combined Baerveldt glaucoma implant with pars plana vitrectomy.
Methods
A 78-year-old male presented with a history of cataract surgery and 5 penetrating keratoplasties. Pre-operatively, BCVA was 20/80 and IOP was 24 mmHg despite maximal medical therapy. Combined Baerveldt glaucoma implant and pars plana vitrectomy (for posterior tube placement) was performed. Examination on post-operative day 1 was unremarkable with clear corneal graft and deep anterior chamber. 24-36 hours after surgery, the patient experienced onset of severe pain, bloody discharge and decreased vision. Examination on post-operative day 2 revealed an opacified melting corneal graft, copious purulent discharge, hypotony, and NLP vision. Ultrasound revealed dense non-mobile vitreous opacities consistent with endophthalmitis.
Results
Vitreous tap could not be performed due to appositional hemorrhagic choroidal detachment. Conjunctival cultures grew Serratia marcenscens (presumed contaminent). Due to the fulminant anterior segment melt and poor visual prognosis (NLP), evisceration was performed the following day. Pathologic examination of the evisceration specimen revealed extensive infiltration with gram positive cocci (consistent with Streptococci) throughout the vitreous, along with diffuse disorganization and necrosis secondary to a fulminant inflammatory response to the organism. One month postoperatively, the patient is pain-free with conformer in place.
Conclusion
In a patient with multiple ocular comorbidities and an extensive surgical history, a presumed Streptococci infection can manifest as a rapidly progressive corneal melt post-operatively resulting in endophthalmitis, ultimately necessitating emergent evisceration.