Citrobacter diversus endophthalmitis following penetrating keratoplasty

Endogenous endophthalmitis caused by Citrobacter koseri originating from a renal abscess

We present a rare case of endogenous endophthalmitis caused by Citrobacter koseri. A 69-year-old woman with a history of poorly controlled diabetes and a protracted urinary tract infection (UTI) presented with a painful swollen left eye. There was no history of eye surgery or trauma. Imaging revealed an abscess in the right kidney. Although endophthalmitis is very rare in healthy patient, it is more common in the immunocompromised. In this patient, several multiple system illnesses including poorly controlled diabetes appear to have worked synergistically to make endophthalmitis a realistic complication of an otherwise isolated and remote source of infection, in this case pyelonephritis. Endophthalmitis, in the absence of an obvious exogenous cause, should be investigated thoroughly to exclude metastatic microbial spread. In addition, chronic features of UTI in a patient with poorly controlled diabetes or who is otherwise immunosuppressed warrant the exclusion of an underlying renal abscess.

Late-onset Citrobacter koseri endophthalmitis with suture exposure after secondary intraocular lens implantation

A 54-year-old male patient was seen in clinic for ocular pain and decreased vision in the right eye with duration of two days. He underwent a cataract operation for his right eye 12 years ago, then a sclera-fixated secondary intraocular implantation and pars plana vitrectomy three years ago due to intraocular lens dislocation. At the initial visit, his visual acuity was restricted to the perception of hand motion. An edematous cornea, cells, flare with hypopyon, and exposed suture material at were observed at the six o'clock direction by slit lamp. Vitreous opacity was noted from B-scan ultrasonography. The patient was diagnosed with late-onset endophthalmitis and an intravitreal cocktail injection was done. On the next day, the hypopyon was aggravated, and therefore a pars plana vitrectomy was performed. A vitreous culture tested positive for Citrobacter koseri. After 12 weeks, the best corrected visual acuity of the right eye improved to 0.7 and a fundus examination revealed a relatively normal optic disc and retinal vasculature. We herein report the first case of endophthalmitis caused by Citrobacter koseri in Korea. Exposed suture material was suspected as the source of infection in this case and prompt surgical intervention resulted in a relatively good visual outcome.

The role of bacteriologic infection in the etiology of nasolacrimal duct obstruction

BACKGROUND

In patients with nasolacrimal duct obstruction, the inflammation and fibrosis may be secondary to coexisting infectious colonization within the lumen of the lacrimal sac. We examined the bacterial flora within the lacrimal sac at the sac-duct junction to explore the possibility of a primary bacteriologic etiology of the inflammatory response.

METHODS

The study included 114 consecutive patients (132 sides) with epiphora undergoing routine external dacryocystorhinostomy (DCR) at a tertiary care hospital in Toronto between November 1999 and April 2000. A lacrimal sac tissue biopsy specimen was acquired intraoperatively from the inferior posterior lacrimal sac near the sac-duct junction. Microbiologic analysis was carried out to determine the presence and identification of infectious organisms.

RESULTS

Culture gave positive results in 51 patients (44.7%) (41.7% of specimens). A total of 65 isolates were cultured, of which 78.5% were gram-positive bacteria and 21.5% gram-negative bacteria. Of the gram-positive organisms 76.5% were Staphylococcus sp. The presence of a positive culture result was independent of a history of dacryocystitis or the presence of a mucocele.

INTERPRETATION

Using direct biopsy methods, we found culture-positive lacrimal sac specimens in a large proportion of patients undergoing DCR surgery. These organisms were found to be present in patients with and without a history of infection.

Bacterial and fungal endophthalmitis after penetrating keratoplasty

We analyzed 1,010 consecutive penetrating keratoplasties to determine the incidence of postoperative endophthalmitis, the frequency of positive donor rim cultures, and whether a correlation between these two factors exists. There were three cases of bacterial endophthalmitis, all caused by streptococci, and one case of Candida albicans endophthalmitis. In all cases except one case of streptococcal endophthalmitis, the same organism was cultured from the donor rim. We cultured 138 organisms from 128 of 932 donor rims (14%). A remarkable percentage of gram-positive organisms were resistant to gentamicin, the only antibiotic contained in corneal storage media. On the basis of our data and previously published data, we believe that donor material is frequently the source of microorganisms in endophthalmitis after penetrating keratoplasty.