A 61-year-old man presented with pain, redness, floaters and decreased vision in his right eye for two days. It was diagnosed as anterior uveitis at a local clinic and treated with prednisolone acetate eye drops combined with intravenous drip of dexamethasone and cephalosporin for seven days. Two weeks later, the patient’s visual acuity decreased to light perception, so he was referred to us eighteen days after his initial onset of symptoms. The patient had no previous history of systemic diseases or infectious diseases, no trauma or surgery before, no chronic medication used. He had a history of heavy drinking and chronic peptic discomfort, and he had been diagnosed suffering from peptic ulcer by agastroscopytwo weeks prior to the onset of symptoms. He had loss of appetite after abstinence from alcohol and reduced 15 kg of weight during the previous one month.
At presentation, vision was light perception in the right eye and 6/6 in the left. The slit-lamp examination of the right eye revealed mild injection, anterior chamber cells of 2+ with a hypopyon of 1.4 mm, pupillary hypopyon, posterior iris synechia, and fibrinous exudates covering the anterior lens capsule (Fig. 1). Fundus of the right eye was invisible due to the vitreous opacity and the left eye was normal. Intraocular pressure was normal in both the eyes. The color ultrasound examination revealed dense vitreous opacities and a avascular homogeneous hyperechoic mass (Fig. 2).
The vital parameters were in normal range, with the blood pressure of 132/80 mmHg, pulse 76/min and a temperature of 36.7° Celsius. Physical examination did not show any abnormalities. Systemic investigations including blood routine examination, liver and renal function tests, computed tomography scan of the lung and abdominal were all unremarkable. Serologic tests that included human immunodeficiency virus antibody, antibodies for toxoplasma, varicella zoster virus, herpes simplex virus and the treponemal antibody-absorption test yielded negative results. Laboratory result for fasting blood glucose was 9.07 mmol/l (normal range: 3.88~ 6.1). The patient was diagnosed as diabetes mellitus after many blood glucose tests and was treated with Metformin. No specific site of systemic infection was found. Presumptive diagnosis of right EE was made, but intraocular lymphoma could not be ruled out.
Vitreous and anterior chamber taps of the right eye were performed, aqueous and vitreous aspirations were sent for cultures and histopathology examination. The patient was treated with intravitreal injection of vancomycin 1 mg/0.1 ml and ceftazidime 2 mg/0.1 ml, topical levofloxacin 0.5% and prednisolone 1% acetate eye drops six times a day, atropine 1%ointment at night in the right eye, concurrent with intravenous drip of cefoperazone.
Three days after the intravitreal injection, the results of vitreous samples cultures and histopathology examination were all negative. The anterior chamber inflammation improved, and fundus of the right eye was still invisible. B-scan ultrasound showed increased vitreous debris and extensive thickening of the retina and choroid layer. Therefore, a pars plana vitrectomy (PPV) combined with phacoemulsification was performed. After a complete vitrectomy, a white elevated fluffy mass with the overlying retinal whitening and necrosis was revealed in superior periphery (Fig. 3a). In addition to this, extensive retinal hemorrhages and five adjacent subretinal whitish masses with exudative retinal detachment were observed in the posterior pole and inferior quadrants which were suggestive of extensive subretinal abscess with intense overlying retinal inflammation (Fig. 3b). Intraoperatively, we carefully cleared the white fluffy mass in superior and peripheral vitreous without retinal break formation. A white fluffy cotton-like substance was excised from the superior mass (Fig. 3c) and finally left a 4-disc diameter retinal defect (Fig. 3d). The vitreous and cotton-like substance were sent for culture, histopathology examination, and polymerase chain reaction (PCR) testing. Retinotomy and aspiration of extensive subretinal abscess in the posterior pole and inferior were not performed. Laser photocoagulation around the retinal defect site and gas or oil intraocular tamponade were not performed either. No intravitreal or intravenous antibiotics were used for we were not sure if the infection arose from fungal, bacterial, mycobacterial or a different aetiology. Post-operative administration remained topical levofloxacin 0.5%, prednisolone 1% acetate eye drops six times a day and atropine 1% ointment once a day.
On post-operative day 1, slit-lamp examination showed anterior segment moderate inflammatory reaction and no posterior segment view because of vitreous opacities. B-scan ultrasound of the right eye showed vitreous opacities and an extensive retinal detachment with sub-retinal exudates (Fig. 4a). On post-operative day 4, the inflammatory reaction subsided significantly and the media started clearing. A blurry fundus was observed. B-scan ultrasound showed slight vitreous opacities and shallow retinal detachment (Fig. 4b). The result of vitreous samples PCR was positive for Klebsiella pneumonia (KP). The results of cultures and histopathological examination were again negative. Clinical examination along with PCR testing confirmed the diagnosis of EE caused by KP. An intravitreal injection of ceftazidime 2 mg/0.1 ml on the right eye was performed. On post-operative day 9, the anterior chamber and vitreous cavity were clear, the retina reattached with lots of yellowish subretinal precipitates and a scar at the superior region (Fig. 5). B-scan ultrasound showed retina reattached except localized shallow retinal detachment (Fig. 4c). Corrected visual acuity improved to hand motions and intraocular pressure was normal. Intravitreal injection of ceftazidime 2 mg/0.1 ml was repeated in the right eye. The patient was discharged for follow-up as an outpatient with levofloxacin 0.5% and prednisolone 1% acetate eye drops administered topically for one week. He was in a stable condition at subsequent visit two months later. Fundus and B-scan ultrasound examination revealed the retina remained attached with some yellowish subretinal precipitates, a large fibrotic scar superiorly, an epiretinal membrane presented in the posterior pole (Fig. 6). At eight months, his eye remained quiescent with a corrected visual acuity of hand motions.