Summary1
Panophthalmitis, a severe ocular infection, risks evisceration if not treated promptly. Typically resulting from endogenous sources, such as urinary tract infections, this report describes a rare case of a 61-year-old patient of Malay descent with panophthalmitis in the left eye. Surprisingly, the ocular culture revealed Escherichia coli (E. coli), while systemic tests ruled out septicemia. With a delayed presentation and concerns about an immunocompromised state, a subsequent diabetes mellitus diagnosis was made. The patient’s eye was saved through a treatment regimen involving intravitreal antibiotics and systemic antibiotics. This report underscores the critical need for swift intervention to prevent evisceration in cases of panophthalmitis.
Introduction
Panophthalmitis is a severe infection that affects all ocular structures and the surrounding orbital tissues.2 This condition progresses rapidly and is associated with a bleak prognosis. 3 Typically, it arises from multiplying pyogenic organisms within the eye, which can occur when bacteria breach the blood-ocular barrier during sepsis or bacteremia. Immunocompromised patients are particularly susceptible to panophthalmitis. Managing this condition is challenging, and evisceration is often the unfortunate outcome.1
Case Presentation: Endogenous Escherichia coli Panophthalmitis1
A 61-year-old Malay woman with no known medical issues presented with a one-week history of progressive swelling and redness in her left periorbital area. This was accompanied by blurred vision, discomfort, and eye discharge. Strikingly, the patient did not complain of severe eye pain. A week before these ocular symptoms appeared, she had experienced a low-grade fever and urinary frequency for five days. She sought care from a general practitioner for what seemed to be a urinary tract infection and was treated with oral moxifloxacin. There was no history of ocular trauma or insect bites.
Upon examination, the patient showed no signs of fever, cough, runny nose, dysuria, or urinary frequency, and no suprapubic pain. Her ocular examination revealed a perception of light as visual acuity in the left eye, an intraocular pressure of 54 mmHg, restricted extraocular movements, and a positive relative afferent pupillary defect (RAPD). The anterior-segment examination displayed proptosis, ptosis, severe chemosis of the conjunctiva, corneal edema, a shallow anterior chamber, hypopyon, and a cataractous lens. A B-scan ultrasound of the left eye revealed dense vitreous loculation and diffuse scleral thickening.
Figure 1: Limited facial photograph showing left eye proptosis, ptosis, and severe conjunctival chemosis.
Figure 2: Ultrasound B-scan showing dense vitreous loculation and diffuse scleral thickening (T-sign).
In light of the gravity of the infection, an immunocompromised state was suspected, and laboratory tests confirmed diabetes mellitus with an HbA1C level of 7.8%. Further investigations, including blood cultures, urine analyses, and an abdomen ultrasound, yielded negative results. Referrals to an ENT team to investigate sinus-related sources of infection were also inconclusive.
Figure 3: Intravitreal tapping performed under aseptic technique.
Figure 4: Vitreous tap showing thick purulent yellowish vitreous fluid.
Figure 5: CT scan of the brain and orbit showing left globe proptosis
Surprisingly, the vitreous fluid culture came back positive for Escherichia coli. The patient was treated with intravitreal injection and a complete course of systemic antibiotics. This treatment approach led to significant improvements, although the final visual acuity remained at “no light perception,” evisceration was successfully avoided.
Discussion
Panophthalmitis, a severe ocular and orbital condition, often results in the need for evisceration. 2 It is most commonly caused by post-traumatic or postoperative endophthalmitis, and endogenous sources within the body can also be responsible. Diabetes is a major risk factor for panophthalmitis; in this patient’s case, diabetes played a significant role. 1,2
The primary treatment goal in this case was to preserve the globe rather than visual recovery, as the optic nerve had suffered irreversible damage. Globe preservation is crucial for improved cosmetic and physiological results and the psychological well-being of patients. 3
Timely intervention in panophthalmitis is essential to prevent anatomical damage and the spread of infection to the brain. Surgical management options include evisceration, enucleation, and pars plana vitrectomy, depending on the patient’s clinical condition. 1
Intravitreal tapping served a dual purpose: obtaining samples for testing and mechanically removing the causative agent. Intravitreal antibiotic injections allowed for precise delivery of medications to the site of infection. 1
Conclusions 1,2,3
This unique case underscores the importance of swift diagnosis and treatment in panophthalmitis, particularly in immunocompromised patients. The infection was successfully resolved by implementing intravitreal and systemic antibiotics, and evisceration was averted despite poor visual outcomes.
References
- Nadhirah Ahmad Fauzi, Abdul-Hadi Rosli, Aidila Jesmin Jabbari. A Rare Occurrence of Isolated Endogenous Escherichia coli Panophthalmitis: A Case Report. Cureus. 2023 Oct 15
- Jackson TL, Paraskevopoulos T, Georgalas I. Systematic review of 342 cases of endogenous bacterial endophthalmitis. Survey of Ophthalmology [Internet]. 2014 Nov 1 [cited 2021 Jun 20];59(6):627–35. Available from: https://pubmed.ncbi.nlm.nih.gov/25113611/
- Hassanin FF, Elkhamary S, Al Thaqib R, Strianese D. A Case of Escherichia coli Endogenous Panophthalmitis and Orbital Cellulitis With Normal Workup for Primary Focus. Cureus. 2021 May 18
About Docquity
Docquity is an AI-based state-of-the-art private & secure continual learning network of verified doctors, bringing you real-time knowledge from thousands of doctors worldwide. Today, Docquity has over 400,000 doctors spread across six countries in Asia.
Meet experts and trusted peers across Asia where you can safely discuss clinical cases, get up-to-date insights from webinars and research journals, and earn CME/CPD credits through certified courses from Docquity Academy. All with the ease of a mobile app available on Android & iOS platforms!
