Endophthalmitis and orbital cellulitis after radial keratotomy

High risk and low prevalence diseases: Orbital cellulitis

INTRODUCTION

Orbital cellulitis is an uncommon but serious condition that carries with it a potential for significant morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of orbital cellulitis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Orbital cellulitis refers to infection of the globe and surrounding soft tissues posterior to the orbital septum. Orbital cellulitis is typically caused by local spread from sinusitis but can also be caused by local trauma or dental infection. It is more common in pediatric patients compared to adults. Emergency clinicians should first assess for and manage other critical, sight-threatening complications such as orbital compartment syndrome (OCS). Following this assessment, a focused eye examination is necessary. Though orbital cellulitis is primarily a clinical diagnosis, computed tomography (CT) of the brain and orbits with and without contrast is critical for evaluation of complications such as abscess or intracranial extension. Magnetic resonance imaging (MRI) of the brain and orbits with and without contrast should be performed in cases of suspected orbital cellulitis in which CT is non-diagnostic. While point-of-care ultrasound (POCUS) may be useful in differentiating preseptal from orbital cellulitis, it cannot exclude intracranial extension of infection. Management includes early administration of broad-spectrum antibiotics and ophthalmology consultation. The use of steroids is controversial. In cases of intracranial extension of infection (e.g., cavernous sinus thrombosis, abscess, or meningitis), neurosurgery should be consulted.

CONCLUSION

An understanding of orbital cellulitis can assist emergency clinicians in diagnosing and managing this sight-threatening infectious process.

Concurrent Pseudomonas Periorbital Necrotizing Fasciitis and Endophthalmitis: A Case Report and Literature Review

(1) Background: Necrotizing fasciitis (NF) is an infection involving the superficial fascia and subcutaneous tissue. Endophthalmitis is an infection within the ocular ball. Herein we report a rare case of concurrent periorbital NF and endophthalmitis, caused by Pseudomonas aeruginosa (PA). We also conducted a literature review related to periorbital PA skin and soft-tissue infections. (2) Case presentation: A 62-year-old male had left upper eyelid swelling and redness; orbital cellulitis was diagnosed. During eyelid debridement, NF with the involvement of the upper Müller’s muscle and levator muscle was noted. The infection soon progressed to scleral ulcers and endophthalmitis. The eye developed phthisis bulbi, despite treatment with intravitreal antibiotics. (3) Conclusions: Immunocompromised individuals are more likely than immunocompetent hosts to be infected by PA. Although periorbital NF is uncommon due to the rich blood supply in the area, the possibility of PA infection should be considered in concurrent periorbital soft-tissue infection and endophthalmitis.

Preseptal and Postseptal Orbital Cellulitis of Odontogenic Origin

The authors present a case of combined preseptal and postseptal cellulitis of odontogenic origin. The infection started as a dental abscess associated with a first maxillary molar. The infection spread into the paranasal sinus, developed into a pansinusitis, and then spread into the preseptal and postseptal tissues. In addition to extraction of the infected tooth, the patient underwent bilateral nasal endoscopy, maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with balloon dilation. Sinus cultures were positive for 2+ microaerophilic streptococci.

Management of preseptal and orbital cellulitis

Orbital cellulitis describes an infection involving the soft tissues posterior to the orbital septum, including the fat and muscle within the bony orbit. This condition may be associated with severe sight and life-threatening complications. Despite significant advances in antimicrobial therapies and diagnostic technologies, the management of orbital cellulitis often remains challenging, and rapid diagnosis and prompt initiation of therapy are important in minimizing complications and optimizing outcomes. This review summarizes the distinctive characteristics of preseptal and orbital cellulitis, with a focus on anatomic considerations, predisposing conditions, approaches to evaluation, and management strategies.

Orbital cellulitis as complication of endophthalmitis after cataract surgery

A 74-year-old man presented with light perception and presumed early bacterial endophthalmitis in the left eye after cataract surgery. Vitreous tap biopsy and core vitrectomy were performed immediately, along with injection of antibiotic agents (ceftazidime and vancomycin). Culture of the vitreous tap revealed Pseudomonas aeruginosa sensitive to ceftazidime. The eye remained inflamed despite 2 additional intravitreal ceftazidime injections. Orbital cellulitis with perforation of the globe was suspected and confirmed on magnetic resonance imaging, and enucleation was performed. Endophthalmitis due to P aeruginosa is associated with poor visual outcomes despite prompt treatment with appropriate intravitreal antibiotic agents. Progression to orbital cellulitis in immunocompetent patients is extremely rare. Careful monitoring of patients with endophthalmitis after cataract surgery is recommended. .

Rupture of Radial Keratotomy Incisions by Blunt Trauma 6 Years After Combined Photorefractive Keratectomy/Radial Keratotomy

PURPOSE

To report a case of traumatic corneal rupture that occurred 6 years previous, following combined radial keratotomy (RK) and photorefractive keratectomy (PRK).

METHODS

A 28-year-old man experienced a severe direct trauma to the right eye. Upon initial examination, a ruptured globe was diagnosed. Four of the eight radial incisions were ruptured with extrusion of intraocular tissues. The patient was also diagnosed with a fracture of the medial wall of the right orbit. The patient received immediate surgery during which the radial incisions that had been torn were stitched with a suture.

RESULTS

Following the postoperative period, the patient had visual acuity of light perception.

CONCLUSION

PRK, carried out on a cornea already treated with RK, may increase the likelihood of rupture in blunt trauma.

Hypopyon uveitis

Hypopyon uveitis has inflammatory, infective, and neoplastic causes and a high association with systemic disease. Careful questioning of the patient and detailed examination of the eye for other signs is necessary to guide the differential diagnosis and relevant investigations. Because the underlying causes require very different types of investigation and, if missed, can have serious sequelae for the patient, a rational approach based on the understanding of the causes of hypopyon uveitis is imperative. In this review, hypopyon uveitis is considered in the context of the associated ocular and systemic diseases that cause it.

Necrotising orbital cellulitis

PURPOSE

To report 2 cases of severe necrotising orbital cellulitis which illustrate the need for aggressive surgical management to prevent blindness.

METHODS

The case records of 2 patients with necrotising orbital cellulitis were reviewed.

RESULTS

Both patients had orbital cellulitis associated with sinusitis. Each case was characterised by the rapid development of severe systemic toxicity, extensive soft tissue necrosis and abscess formation. One patient developed panophthalmitis and the eye had to be eviscerated. The other patient underwent repeated surgical drainage of multiple orbital abscesses. This led to resolution of the infection and preservation of vision.

CONCLUSIONS

Atypical rapidly progressive necrotising orbital cellulitis may occasionally be encountered. In such cases, aggressive surgical drainage of orbital abscesses is crucial to prevent blindness and death.

Early- versus late-onset infectious keratitis after radial and astigmatic keratotomy: clinical spectrum in a referral practice

PURPOSE

To compare the clinical characteristics of early- versus late-onset keratitis after radial keratotomy (RK) and astigmatic keratotomy (AK).

SETTING

Referral subspecialty practice.

METHODS

This retrospective review comprised 19 patients with infectious keratitis after RK and AK. Early- versus late-onset groups were analyzed for predisposing conditions; infiltrate location, size, and depth; microbiologic data; and final visual outcome.

RESULTS

Ten patients in the early-onset group developed keratitis within a mean of 7.4 days after surgery (range 3 to 14 days). Nine patients in the late-onset group developed keratitis a mean of 5.4 years after surgery (range 1.5 to 15.0 years). Staphylococcus aureus was the predominant organism in the early-onset group and Pseudomonas aeruginosa in the late-onset group. In the early-onset group, most infiltrates occurred in the paracentral aspect of the RK incision and extended to the middle or posterior stroma. In the late-onset group, most infiltrates occurred in the peripheral portion of the RK incision and were localized to the superficial stroma. A hypopyon was present in 7 of 10 ulcers in the early group and in 1 of 9 in the late group. Two patients in the early group developed endophthalmitis. Most patients in the late-onset group had incisional pseudocysts; 2 had other risk factors for keratitis. Final visual acuity was 20/40 or better in 7 of 10 patients in the early group and in 8 of 9 patients in the late group.

CONCLUSIONS

Early-onset corneal ulcers after incisional refractive keratotomy were usually paracentral and deep, whereas late-onset ulcers were usually peripheral and superficial. Despite the predominance of Staphylococcus and Pseudomonas in the early- and late-onset groups, respectively, a variety of organisms may be responsible for infections in keratotomy incisions.

Use of reverse geometry rigid gas permeable contact lenses in the management of the postradial keratotomy patient: review and case report

Radial keratotomy (RK) is a well-known procedure for reducing myopia. However, the complications associated with the procedure and the development of newer technologies, such as photorefractive keratectomy and laser-assisted in situ keratomileusis, has resulted in the technique of RK falling out of favor. A number of patients who received RK during the 1980s are now experiencing a shift in their prescription and are presenting to primary care practitioners for contact lens fitting. These patients pose a significant challenge to the contact lens practitioner, and novel methods frequently are required to fit corneas that exhibit such abnormal topography. This article reviews the potential problems associated with fitting patients who have received RK and describes a case in which a novel lens design was used to achieve a successful lens fit.

Culture-negative ulcerative keratitis after laser in situ keratomileusis

A 40-year old man, highly myopic in both eyes, had laser in situ keratomileusis (LASIK) in the left eye in November 1996. Corneal melting and ulceration and fine striae-like interface infiltrates were noticed 1 day postoperatively. There was no response to intensive topical antibiotics in the form of hourly ofloxacin 3% (Tarivid), and satellite lesions developed on day 4. Corneal scrapings for gram stain and culture were done twice. No bacterial or fungal organisms were identified. Intensive topical fortified vancomycin (50 mg/mL) was added, and the lesions resolved gradually over the ensuing 2 weeks. Eighteen months after LASIK, refraction was -1.50 - 0.75 x 105 in the left eye, and uncorrected visual acuity was 20/70, correctable to 20/25 with spectacles.

Acute corneal necrosis after excimer laser keratectomy for hyperopia

OBJECTIVE

To describe a new, rare clinical complication after routine excimer laser photorefractive keratectomy to correct hyperopia.

DESIGN

Case report with clinicopathologic correlation.

MAIN OUTCOME MEASURES

Four weeks after treatment with excimer laser, a perforating keratoplasty was performed for persistent corneal opacities. The corneal button was examined using light and electron microscopy. Special immunohistochemical stains were used to detect apoptosis.

RESULTS

The patient developed corneal opacities, endothelial precipitates, and a fibrinous exudate in the anterior chamber after the laser treatment. The changes did not respond to therapy directed against bacteria, fungi, and Acanthamoeba. All examinations and special stains were negative for micro-organisms. By light microscopy, an anterior zone of corneal necrosis was present with a moderate amount of acute inflammatory cells. At the interface between necrotic and viable corneal stroma, keratocytes with typical features of apoptosis were detected by immunohistochemistry and electron microscopy.

CONCLUSION

This is the first full histopathologic report of a case of acute corneal necrosis with signs of apoptosis after excimer laser therapy of the cornea. Surgeons should be aware of this rare but potentially severe complication.

Endophthalmitis

Endophthalmitis is an inflammatory reaction of intraocular fluids or tissues. Infectious endophthalmitis is one of the most serious complications of ophthalmic surgery. Occasionally, infectious endophthalmitis is the presenting feature of an underlying systemic infection. Successful management of infectious endophthalmitis depends on timely diagnosis and institution of appropriate therapy. Recognition of the different clinical settings in which endophthalmitis occurs and awareness of the highly variable presentation it may have facilitate timely diagnosis. Biopsy of intraocular fluid/tissue is the only method that permits reliable diagnosis and treatment. The different presenting clinical settings, a rational approach to diagnosis (i.e., when, what, and how to biopsy), and the treatment of infectious endophthalmitis are reviewed.

Keratitis complicated by endophthalmitis 3 years after astigmatic keratotomy

Endophthalmitis after keratotomy is rare and usually occurs soon after surgery. A 56-year-old woman with mild dry-eye symptoms developed keratitis complicated by endophthalmitis 3 years after astigmatic keratotomy (AK). The keratitis lasted for less than 1 day in the upper keratotomy incision. Corneal cultures yielded. Pseudomonas aeruginosa. Keratitis progressed to endophthalmitis 1 day after the detection of keratitis. The inflammation was controlled with intravitreal, subconjunctival, topical, and systemic antibiotics. This case demonstrates the potential risk of endophthalmitis developing very shortly after late keratitis of AK incisions. Vigorous early treatment and close follow-up seem justifiable in any keratitis associated with a keratotomy incision.

Diagnostic anterior chamber paracentesis in uveitis: a safe procedure?

BACKGROUND

Differentiation between infectious and non-infectious uveitis is of crucial value for accurate management of patients with uveitis. Tests performed on aqueous humour yield more relevant information than those done in serum. The objective of this study was to evaluate whether the aqueous humour tap for diagnostic purposes is a safe procedure to perform in uveitis patients.

METHODS

In this retrospective study 361 patients with uveitis, who underwent a diagnostic anterior chamber paracentesis in an outpatient clinic, were investigated. 72 of the 361 patients were examined 30 minutes after the puncture. The site of the paracentesis, the depth of the anterior chamber, and cells in the anterior chamber were examined. All 361 patients were evaluated within 2 weeks after the paracentesis was performed. The final follow up period varied from 6 months to more than 3 years. The clinical data were analysed with the emphasis on the occurrence of cataract and a history of corneal infections or endophthalmitis.

RESULTS

In this series no serious side effects such as cataract, keratitis, or endophthalmitis were observed. The depth of the anterior chamber of all evaluated patients was restored after 30 minutes. In five out of 72 cases (three AIDS patients with cytomegalovirus retinitis and two patients with anterior uveitis due to herpes simplex virus) a small hyphaema was observed 30 minutes after the paracentesis took place.

CONCLUSION

Anterior chamber paracentesis appears to be a safe procedure in the hands of an experienced ophthalmologist.

Excimer Laser in situ Keratomileusis for Myopia

PURPOSE

To evaluate the efficacy, safety, and predictability of excimer laser in situ keratomileusis (LASIK) for the correction of myopia.

METHODS

Forty-six consecutive eyes that had LASIK with the VISX 20/20B laser and Chiron corneal shaper were evaluated. Mean spherical equivalent of the preoperative manifest refraction was -9.40 +/- 3.78 diopters (D) (range, -3.50 to -19.75 D). The refractive effect (postoperative refraction minus baseline refraction), residual refractive error (refractive effect minus planned correction) and uncorrected and spectacle-corrected visual acuity were examined.

RESULTS

Mean follow-up was 6.1 months (range, 3 to 9 mo). Spectacle-corrected visual acuity was unchanged in 39 eyes (84.78%), significantly improved in five eyes (10.86%), and worse in two eyes (4.34%). Uncorrected visual acuity was 20/20 or better in 15 eyes (32.6%) and 20/40 or better in 39 eyes (84.78%). Thirteen eyes (28.26%) had a postoperative spherical equivalent refraction within +/- 0.50 D and 36 eyes (78.26%) within +/- 1.00 D of attempted correction. No intraoperative complication occurred. Postoperative complications were few and not severe: three eyes (6.52%) developed regular astigmatism, two eyes (4.34%) had interface deposits, and three eyes (6.52%) had small epithelial cysts in the interface.

CONCLUSION

LASIK with the VISX 20/20B laser is safe, moderately effective, and relatively predictable for correcting myopia from -3.50 to -19.50 D. Predictability decreases with increasing myopia.

Endophthalmitis after radial keratotomy enhancement

A 45-year-old man developed endophthalmitis after a radial keratotomy (RK) enhancement. He developed severe intraocular inflammation, hypopyon, and dense vitreous membranes 4 days after the enhancement surgery. Cultures of the corneal wound yielded a heavy growth of Streptococcus viridans. The inflammation subsided after treatment with intraocular, intravenous, and topical antibiotics. The patient subsequently developed a cataract and retinal detachment. This case demonstrates the risk of endophthalmitis after RK enhancement.