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Late-Onset Bleb-Related Panophthalmitis With Orbital Abscess Caused by Pseudomonas stutzeri
Arch Ophthalmol. 2001;119:1723-1725.
INTRODUCTION
Late-onset bleb-related endophthalmitis is a potentially disastrous complication of trabeculectomy that may occur months to years after surgery. The route of infection is believed to involve migration of bacteria across the conjunctiva, in contrast to early postoperative endophthalmitis, which results from intraocular inoculation of microorganisms at the time of surgery.1 Late-onset bleb-related infection occurs more frequently following full-thickness procedures, adjunctive antifibrosis chemotherapy, or when a late-onset bleb leak is present.2
The disease spectrum ranges from infection limited to the bleb to frank endophthalmitis.3 We present a case of panophthalmitis and orbital abscess, which occurred as a late-onset complication of trabeculectomy with adjunctive 5-fluorouracil (5-FU).
Report of a Case
A 69-year-old man had bilateral posterior chamber pseudophakia and a failed trabeculectomy in his right eye, and a thin-walled, avascular conjunctival filtering bleb in his left eye. He developed pain, redness, and discharge in his left eye while vacationing in another country. Examination by a local ophthalmologist revealed an "eye infection," for which the patient received eye drops (of an unknown type). When his symptoms worsened, oral amoxicillin/clavulanic acid potassium was added to his regimen. The patient denied any chronic diseases or immunodeficient states. His ocular history included bilateral cataract extraction with posterior chamber intraocular lens insertion and bilateral trabeculectomies, with adjunctive 5-FU for primary open-angle glaucoma 7 years prior to presentation. There was no history of bleb leakage in the left eye, and the patient was not using topical antibiotics as prophylaxis against bleb infection at the time of the initial infection.
Three weeks following the onset of his initial symptoms, the patient came to our institution for evaluation. Examination of the right eye was unremarkable and revealed a visual acuity of 20/50, a flat superior bleb, and a deep and quiet anterior chamber. The left eye was noted to have severe proptosis and absence of light perception. Extensive lid ecchymosis and edema were present. Eye movements were severely restricted in all directions. The conjunctiva demonstrated extensive chemosis and a superior filtering bleb with pronounced purulence. The cornea was edematous and there was extensive fibrin and hypopyon in the anterior chamber. The posterior chamber and the posterior segment could not be visualized.
The patient was hospitalized and treated with fortified cefazolin sodium and tobramycin sulfate drops, as well as intravenous vancomycin hydrochloride and ceftazidime. Computed tomography (CT) scans of the orbits (Figure 1) revealed proptosis of the left eye, with significant periorbital inflammatory tissue as well as a 1-cm retrobulbar abscess. There was also diffuse infiltration of the retrobulbar fat, and linear enhancement along the optic nerve sheath. A diagnosis of infectious panophthalmitis with orbital abscess was made.
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Figure 1. The left eye is proptotic. A 1-cm retrobulbar abscess is present (arrowhead).
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The left eye was enucleated on the basis of the CT scan findings and the clinical scenario. This was combined with drainage of the orbital abscess. Histopathological examination (Figure 2) revealed acute bacterial endophthalmitis with vitreous abscess, acute choroiditis, and end-stage glaucoma, as well as optic nerve, retinal, and choroidal atrophy with choroidal effusion. Cultures obtained at the time of enucleation revealed Pseudomonas stutzeri. Blood cultures obtained at the time of admission were negative for organisms. The patient was treated with intravenous vancomycin and ceftazidime for 4 days, and was discharged home receiving oral amoxacillin/clavulanate potassium, topical tobramycin/dexamethasone, topical neomycin sulfate/polymyxin B sulfate, and dexamethasone ointment.
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Figure 2. Panophthalmitis involving the ciliary body, iris, choroid, and vitreous is present. S indicates sclera; C, cornea; AC, anterior chamber; I, iris; CB, ciliary body; and VA, vitreous abscess.
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Comment
Late-onset bleb-related endophthalmitis is a serious complication of filtering surgery. Previously reported risk factors for the development of this condition include inferior bleb location, blepharoconjunctivitis, contact lens use, chronic bleb leak, nasolacrimal duct obstruction, young age, male sex, use of adjunctive antifibrosis agents, and the existence of a cystic, thin-walled bleb.3 Panophthalmitis occurs when the intraocular infection extends into and involves the sclera. Our patient developed late-onset bleb-related panophthalmitis with orbital abscess—a complication rare enough that we could not find any similar case reports in the literature. Presumably, the risk factors for development of late-onset panophthalmitis are similar to those for endophthalmitis, as the former represents an untreated extraocular extension of the latter.
Pseudomonas stutzeri, the causative organism in our case, is a nonfermentative, Gram-negative bacteria. The species is in manure, straw, pond water, sewage, and similar environments. Most patients in whom the organism has been isolated have been elderly and in poor health.4 Isolation of the organism from eyes is extremely rare. We found only one case report in the ophthalmic literature, a case of delayed-onset endophthalmitis after cataract surgery, that mentioned P stutzeri as the infecting organism.5 Our patient was elderly, but his general health status was not poor. He had recently been abroad (in urban areas only) and it is unclear whether this contributed to the development of his infection.
The severe course of this case reemphasizes the need for early detection and rapid, appropriate intervention based on the disease severity and offending organism. All patients with thin-walled filtering blebs should be urged to seek immediate attention should symptoms of late-onset bleb-related infection appear.
AUTHOR INFORMATION
The authors have no financial interest in any device or technique described in this article.
Supported by the Oppenheimer Research Fund of the New York Glaucoma Research Institute, New York, NY.
Dan Lebowitz, MD;
Rabia Gürses-Özden, MD;
Robert F. Rothman, MD;
Jeffrey M. Liebmann, MD;
Celso Tello, MD;
Robert Ritch, MD
Valhalla, NY
Reprints: Robert Ritch, MD, Glaucoma Service, Department of Ophthalmology, The New York Eye and Ear Infirmary, 310 E 14th St, New York, NY 10003 (e-mail: ritch{at}inx.net).
REFERENCES
1. Wolner B, Liebmann JM, Sassani JW, Ritch R, Speaker M, Marmor M. Late bleb-related endophthalmitis after trabeculectomy with adjunctive 5-fluorouracil. Ophthalmology. 1991;98:1053-1060.
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2. Greenfield DS, Suñer IJ, Miller MP, et al. Endophthalmitis after filtering surgery with mitomycin C. Arch Ophthalmol. 1996;114:943-949.
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3. Waheed S, Liebmann JM, Greenfield DS, et al. Recurrent bleb infections. Br J Ophthalmol. 1998;82:926-929.
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4. Holmes B. Identification and distribution of Pseudomonas stutzeri in clinical material. J Appl Bacteriol. 1986;60:401-411.
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5. Jirásková N, Rozsíval P. Delayed-onset Pseudomonas stutzeri endophthalmitis after uncomplicated cataract surgery. J Cataract Refract Surg. 1998;24:866-867.
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SECTION EDITOR: W. RICHARD GREEN, MD
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