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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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Year : 2017  |  Volume : 24  |  Issue : 2  |  Page : 116-118  

Endophthalmitis due to Proteus vulgaris after pars plana vitrectomy with devastating outcome

Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication7-Sep-2017

Correspondence Address:
Abdullah S Al-Kharashi
Department of Ophthalmology, College of Medicine, King Saud University, P. O. Box 245, Riyadh 11411
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/meajo.MEAJO_134_15

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Postoperative infectious endophthalmitis is rare, yet devastating loss of vision or loss of the eye can occur due to a highly purulent microorganism or uncontrolled endophthalmitis that may spread to all coats of the eye. We report, herewith, a case of rapidly progressive postoperative endophthalmitis after pars plana vitrectomy which ended up with enucleation. The isolated microorganism was Proteus vulgaris which has not been reported as causative bacteria of postoperative infections following pars plana vitrectomy.

Keywords: Endophthalmitis, outcome, Proteus vulgaris, vitrectomy

How to cite this article:
Al-Kharashi AS, Al-Kharshi AS, Al-Faky YH. Endophthalmitis due to Proteus vulgaris after pars plana vitrectomy with devastating outcome. Middle East Afr J Ophthalmol 2017;24:116-8

How to cite this URL:
Al-Kharashi AS, Al-Kharshi AS, Al-Faky YH. Endophthalmitis due to Proteus vulgaris after pars plana vitrectomy with devastating outcome. Middle East Afr J Ophthalmol [serial online] 2017 [cited 2021 Oct 26];24:116-8. Available from: http://www.meajo.org/text.asp?2017/24/2/116/214171

   Introduction Top

Infectious endophthalmitis can be a devastating complication after ophthalmic surgery due to the risk of complete loss of vision or loss of the eye. In some cases, endophthalmitis can progress to panophthalmitis. Most simply, panophthalmitis is defined as an inflammation of all coats of the eye. The incidence of postoperative endophthalmitis varies between 0.06% and 0.20%.[1],[2] However, the incidence is even lower after pars plana vitrectomy as it varies from 0.02% to 0.05%.[3]

The microbial spectrum in infectious endophthalmitis may vary based on the geographic location.[4] In addition, immunocompromised patients have a greater susceptibility to develop postoperative endophthalmitis[5] that may further progress to panophthalmitis. Endophthalmitis due to Enterobacteriaceae such as Proteus species has been previously reported.[6] However, to the best of our knowledge, endophthalmitis after pars plana vitrectomy due to Proteus vulgaris has not been reported in the English peer reviewed literature. In this case report, we present a case of postoperative endophthalmitis due to P. vulgaris after pars plana vitrectomy.

   Case Report Top

A 75-year-old female presented to the emergency room complaining of severe lid swelling and pain in the left eye for the previous 3 days. The patient had undergone left eye uneventful pars plana vitrectomy, membrane peeling, endolaser photocoagulation with silicone oil tamponade for chronic tractional retinal detachment at Ophthalmology Department, King Abdul Aziz University Hospital, King Saud University, Riyadh, KSA 1 week before presentation. Medical history included diabetes which was not well controlled for 13 years and hypertension that was being medically treated. Previous ophthalmic history included uncomplicated cataract surgery 6 months before presentation in the right eye and 8 months before presentation in the left eye.

On examination at presentation, visual acuity in the right eye was 20/100 and in the left eye was no light perception. Examination of the right eye showed pseudophakic globe with flat retina with a good panretinal photocoagulation. Examination of the left eye showed severe lid swelling with difficulty to open the eye [Figure 1]a, the cornea was opaque with a hypopyon, conjunctival chemosis and hyperemia and the globe was frozen. The patient was diagnosed with endophthalmitis progressed into panophthalmitis, and computed tomography (CT) scan was done and showed proptosed left eye, increased density of orbital fat and preseptal edema [Figure 1]b.
Figure 1: (a) Severe lid swelling with difficulty to open the left eye. (b) Computed tomography-scan shows proptosed left eye, increased density of orbital fat and preseptal edema

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The patient received systemic intravenous antibiotics in the form of ceftriaxone and clindamycin. An oculoplastic consultation was performed on the same day, and left eye was enucleated that day. Interestingly, pale tissues with minimal bleeding were noticed throughout the procedure [Figure 2]a,[Figure 2]b,[Figure 2]c. Culture samples were positive for P. vulgaris and were negative for microbes at the margin where the optic nerve was cut during enucleation.
Figure 2: (a and b) Very minimal bleeding with pale tissues during lateral canthotomy to widen the palpebral fissure for better surgical field exposure. (c) Pale medial rectus muscle

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Postoperatively, during hospitalization, the patient settled with a quiet socket. At last visit, 2-month postenucleation, the visual acuity was 20/200 in the right eye, and the left eye socket was quiet, and inflammation was well controlled.

   Discussion Top

Postoperative infectious endophthalmitis can be caused by all groups of microbes. However, the most common causative organisms from recent studies in the Middle East are Gram-positive microorganisms followed by Gram-negative microorganisms and least frequently, fungi.[4],[7] The most common Gram-negative isolates are generally Pseudomonas species and Haemophilus. Proteus related endophthalmitis is rare. In Saudi Arabia, systemic Proteus infections are most commonly due to P. mirabilis (89%), P. vulgaris (6%), and other Proteus species (5%).[8] Those typically associated with endophthalmitis are P. mirabilis in 90% of the cases.[6] P. vulgaris is an opportunistic human pathogen that is isolated in individuals with underlying disease or those who are immunocompromised.[9],[10],[11] P. vulgaris is susceptible to fluoroquinolones, cephalosporins, beta-lactams, and aminoglycosides. Recently, some Proteus isolates in Saudi Arabia have exhibited resistance to expanded-spectrum beta-lactam antibiotics.[8]

Risk factors for postoperative endophthalmitis include the lack of subconjunctival antibiotics, leaking sclerotomies resulting in postoperative hypotony, vitreous wick after sclerotomy, wound construction, bacterial inoculum into the vitreous in immune-compromised patients such as diabetics and the elderly.[5] In our case, the patient was a diabetic which is also known risk factor for endophthalmitis.[7],[8] However, the endophthalmitis vitrectomy study (EVS) has reported that postoperative infectious endophthalmitis is more likely due to Gram-positive bacteria in diabetics.[9] Notably, the EVS reported results after cataract surgery rather than pars plana vitrectomy. Wykoff et al. have reported that the incidence of endophthalmitis after pars plana vitrectomy is significantly lower compared to other intraocular procedures.[10] The aggressive nature of the isolated microorganism and the immune-comprised state of this patient combined with the multiple surgeries in the left eye may have allowed progression to panophthalmitis.

P. vulgaris infections are highly purulent, which was consistent with the finding of hypopyon in this case. In addition, the presentation was consistent with previous literature that described more severe initial presentation in Gram-negative cases.[1] Visual acuity after endophthalmitis following pars plana vitrectomy is typically worse than following anterior segment surgery.[11] P. vulgaris infections can cause occlusive vasculitis and even symmetric peripheral gangrene which could explain the notably minimal bleeding and pale tissues during enucleation procedure.[12]

Our search engine could not find a case of postoperative panophthalmitis due to P. vulgaris in the PubMed literature, Google, and Google Scholar. This is a relatively rare entity, yet should be included in the differential diagnosis of any suspected cases of postoperative infections following pars plana vitrectomy.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Sheng Y, Sun W, Gu Y, Lou J, Liu W. Endophthalmitis after cataract surgery in China, 1995-2009. J Cataract Refract Surg 2011;37:1715-22.  Back to cited text no. 1
Du DT, Wagoner A, Barone SB, Zinderman CE, Kelman JA, Macurdy TE, et al. Incidence of endophthalmitis after corneal transplant or cataract surgery in a medicare population. Ophthalmology 2014;121:290-8.  Back to cited text no. 2
Wallin Ö, Al-ahramy AM, Lundström M, Montan P. Endophthalmitis and severe blebitis following trabeculectomy. Epidemiology and risk factors; a single-centre retrospective study. Acta Ophthalmol 2014;92:426-31.  Back to cited text no. 3
Wu L, Berrocal MH, Arévalo JF, Carpentier C, Rodriguez FJ, Alezzandrini A, et al. Endophthalmitis after pars plana vitrectomy: Results of the Pan American Collaborative Retina Study Group. Retina 2011;31:673-8.  Back to cited text no. 4
Shi XY, Zhao HS, Wei WB. Analysis of post-operative endophthalmitis after pars plana vitrectomy: A 10-year experience at a single center. Chin Med J (Engl) 2013;126:2890-3.  Back to cited text no. 5
Falavarjani KG, Nekoozadeh S, Modarres M, Parvaresh MM, Hashemi M, Soodi R, et al. Isolates and antibiotic resistance of culture-proven endophthalmitis cases presented to a referral center in Tehran. Middle East Afr J Ophthalmol 2012;19:361-3.  Back to cited text no. 6
[PUBMED]  [Full text]  
Kaiser RS, Prenner J, Scott IU, Brucker AJ, Flynn HW Jr., Williams GA, et al. The microsurgical safety task force: Evolving guidelines for minimizing the risk of endophthalmitis associated with microincisional vitrectomy surgery. Retina 2010;30:692-9.  Back to cited text no. 7
Leng T, Flynn HW Jr., Miller D, Murray TG, Smiddy WE. Endophthalmitis caused by proteus species: Antibiotic sensitivities and visual acuity outcomes. Retina 2009;29:1019-24.  Back to cited text no. 8
Al-Turki TA, Al-Shahwan S, Al-Mezaine HS, Kangave D, Abu El-Asrar AM. Microbiology and visual outcome of bleb-associated endophthalmitis. Ocul Immunol Inflamm 2010;18:121-6.  Back to cited text no. 9
Hassan MI, Alkharsah KR, Alzahrani AJ, Obeid OE, Khamis AH, Diab A, et al. Detection of extended spectrum beta-lactamases-producing isolates and effect of AMPC overlapping. J Infect Dev Ctries 2013;7:618-29.  Back to cited text no. 10
Okumoto M, Smolin G, Belfort R, Kim HB, Siverio CE. Proteus species isolated from human eyes. Am J Ophthalmol 1976;81:495-501.  Back to cited text no. 11
Scott IU, Flynn HW Jr., Dev S, Shaikh S, Mittra RA, Arevalo JF, et al. Endophthalmitis after 25-gauge and 20-gauge pars plana vitrectomy: Incidence and outcomes. Retina 2008;28:138-42.  Back to cited text no. 12


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