Intricate treatment of Endophtalmitis - case report

Authors: Dr. Ionela Iosub Coordinator: Dr. Livia Sram Emergency Eye Hospital, Bucharest Case report Personal data: V. E. A., 9 years, girl, hospitalized in Emergency Eye Hospital 26.05.2012, presentation is with blurred vision, photophobia RE for 5 days, without a history of ocular trauma, 25.05.2012 Valcea Hospital: Uveitis with hipopion; General examination: normal ponderal status, AT=100/65 mmHg AF=90 hbm, External examination: RE vision=hand movement RE tension=12 mmHg LE vision=1 LE tension=16mmHg, RE: normal ductions and versions, RE=cellular deposits on the corneal endothelium, hypopyon, fibrinous exudate; Fundus examination: inexplorable; LE: normal external and fundus examination; Special investigation: WBC 13,5 (3,9-9,6/1000/uL); NEUTROPHILS 84,3 (37,0-73,0/%);
LYMPHOCYTES 11,8 (20-55/%); FIBRINOGEN 457 (180-350 mg/dL); VSH 60 (5-15); TOXOCARA CANIS 3,901 NTU (<9=NEGATIV); TOXOPLASMA GONDI <0,13 UI/ml (<1 NEGATIV); Radiology Ocular ultrasound

RE multiple inflammatory vitreous echoes,

Choroidal oedema.

CT - To exclude sarcoidosis, multiple sclerosis and primary intraocular lyphoma

Chest X-ray - To exclude tuberculosis and sarcoidosis

Diagnosis Principal Diagnostic: RE Endophtalmitis Anterior uveitis: keratic precipitates, hypopyon, fibrinous exudate Posterior uveitis: vitreous haze, choroidal oedema.

Differential diagnosis Primary intraocular lymphoma Fuchs uveitis syndrome A peripheral toxocara granuloma Amyloidosis

Etiological: Idiopathic or sistemic associations: Parasitic: toxoplasmosis, toxocariasis Bacterial: TB, syphilis, Lyme disease, brucellosis, endogenous bacterial endophtalmitis, catscratch disease Viral: citomegalovirus retinitis, HIV microangiopathy Fungal: Neurological: multiple sclerosis , Vogt-Koyaagi-Harada syndrome, Behcet syndrome, Rheumatic: spondyloarthropathies, juvenile arthritis Gastro-intestinal: Crohn disease, Whipple disease Sarcoidosis

Treatment 26.05.2012-10.06.2012

Sistemic treatment: 1. Tienam 500 mg i.v. 12 h 2. PDN 30 mg/day- (after 7 days 25 mg) 3. Diflucan 1 cp/day

4. Dicarbocalm 1 tbx3/day Local treatment RE: Nettildex, Edicine, Axetine, Diflucan, Tropicamid, Fenefrin (1 dx6/day). 07.06.2012 RE intravitreal triamcinolone injection.

Discarge: RE vision=hand movements, RE tension=13 mmHg

Course 2.07.2012 RE vision=1/24 RE tension=11 mmHg 9.07.2012 RE vision=0,1 (PDN=12,5 mg) 23.07.2012 RE vision=0,2 pinhole 30.07.2012 RE vision=counter finger at 20 cm

Complication: cataract Surgical treatment 31.07.2012 RE : vitrectomy, EEC , IOL-CP in sulcus. Discharge 01.08.2012 RE vision=1/6 1/4 pinhole 03.09.2012 RE vision=0,8 0,9 with glasses (+0,5sfd -0,75cyld /180 degrees)

Titmus test: fly, ABC +, Lang test +, Worth test +.

Prognosis Functional= high General= favourable, side-effects of systemic medication (PDN)

Bibliographical refences: J. Kanski, Brad Bowling, Clinical Ophtalmology, seventh edition American Academy of Ophtalmology, 2011-2012 P. T. Khsw, ABC of Eyes, fourth edition David A. Quillen, Clinical Retina, 2002