Late-onset bleb-related endophthalmitis is a potentially disastrous
complication of trabeculectomy that may occur months to years after surgery.
The route of infection is believed to involve migration of bacteria across
the conjunctiva, in contrast to early postoperative endophthalmitis, which
results from intraocular inoculation of microorganisms at the time of surgery.1 Late-onset bleb-related infection occurs more frequently
following full-thickness procedures, adjunctive antifibrosis chemotherapy,
or when a late-onset bleb leak is present.2
The disease spectrum ranges from infection limited to the bleb to frank
endophthalmitis.3 We present a case of panophthalmitis
and orbital abscess, which occurred as a late-onset complication of trabeculectomy
with adjunctive 5-fluorouracil (5-FU).
A 69-year-old man had bilateral posterior chamber pseudophakia and a
failed trabeculectomy in his right eye, and a thin-walled, avascular conjunctival
filtering bleb in his left eye. He developed pain, redness, and discharge
in his left eye while vacationing in another country. Examination by a local
ophthalmologist revealed an "eye infection," for which the patient received
eye drops (of an unknown type). When his symptoms worsened, oral amoxicillin/clavulanic
acid potassium was added to his regimen. The patient denied any chronic diseases
or immunodeficient states. His ocular history included bilateral cataract
extraction with posterior chamber intraocular lens insertion and bilateral
trabeculectomies, with adjunctive 5-FU for primary open-angle glaucoma 7 years
prior to presentation. There was no history of bleb leakage in the left eye,
and the patient was not using topical antibiotics as prophylaxis against bleb
infection at the time of the initial infection.
Three weeks following the onset of his initial symptoms, the patient
came to our institution for evaluation. Examination of the right eye was unremarkable
and revealed a visual acuity of 20/50, a flat superior bleb, and a deep and
quiet anterior chamber. The left eye was noted to have severe proptosis and
absence of light perception. Extensive lid ecchymosis and edema were present.
Eye movements were severely restricted in all directions. The conjunctiva
demonstrated extensive chemosis and a superior filtering bleb with pronounced
purulence. The cornea was edematous and there was extensive fibrin and hypopyon
in the anterior chamber. The posterior chamber and the posterior segment could
not be visualized.
The patient was hospitalized and treated with fortified cefazolin sodium
and tobramycin sulfate drops, as well as intravenous vancomycin hydrochloride
and ceftazidime. Computed tomography (CT) scans of the orbits (Figure 1) revealed proptosis of the left eye, with significant periorbital
inflammatory tissue as well as a 1-cm retrobulbar abscess. There was also
diffuse infiltration of the retrobulbar fat, and linear enhancement along
the optic nerve sheath. A diagnosis of infectious panophthalmitis with orbital
abscess was made.
The left eye is proptotic. A 1-cm
retrobulbar abscess is present (arrowhead).
The left eye was enucleated on the basis of the CT scan findings and
the clinical scenario. This was combined with drainage of the orbital abscess.
Histopathological examination (Figure 2)
revealed acute bacterial endophthalmitis with vitreous abscess, acute choroiditis,
and end-stage glaucoma, as well as optic nerve, retinal, and choroidal atrophy
with choroidal effusion. Cultures obtained at the time of enucleation revealed Pseudomonas stutzeri. Blood cultures obtained at the time
of admission were negative for organisms. The patient was treated with intravenous
vancomycin and ceftazidime for 4 days, and was discharged home receiving oral
amoxacillin/clavulanate potassium, topical tobramycin/dexamethasone, topical
neomycin sulfate/polymyxin B sulfate, and dexamethasone ointment.
Panophthalmitis involving the
ciliary body, iris, choroid, and vitreous is present. S indicates sclera;
C, cornea; AC, anterior chamber; I, iris; CB, ciliary body; and VA, vitreous
Late-onset bleb-related endophthalmitis is a serious complication of
filtering surgery. Previously reported risk factors for the development of
this condition include inferior bleb location, blepharoconjunctivitis, contact
lens use, chronic bleb leak, nasolacrimal duct obstruction, young age, male
sex, use of adjunctive antifibrosis agents, and the existence of a cystic,
thin-walled bleb.3 Panophthalmitis occurs
when the intraocular infection extends into and involves the sclera. Our patient
developed late-onset bleb-related panophthalmitis with orbital abscess—a
complication rare enough that we could not find any similar case reports in
the literature. Presumably, the risk factors for development of late-onset
panophthalmitis are similar to those for endophthalmitis, as the former represents
an untreated extraocular extension of the latter.
Pseudomonas stutzeri, the causative organism
in our case, is a nonfermentative, Gram-negative bacteria. The species is
in manure, straw, pond water, sewage, and similar environments. Most patients
in whom the organism has been isolated have been elderly and in poor health.4 Isolation of the organism from eyes is extremely
rare. We found only one case report in the ophthalmic literature, a case of
delayed-onset endophthalmitis after cataract surgery, that mentioned P stutzeri as the infecting organism.5
Our patient was elderly, but his general health status was not poor. He had
recently been abroad (in urban areas only) and it is unclear whether this
contributed to the development of his infection.
The severe course of this case reemphasizes the need for early detection
and rapid, appropriate intervention based on the disease severity and offending
organism. All patients with thin-walled filtering blebs should be urged to
seek immediate attention should symptoms of late-onset bleb-related infection
The authors have no financial interest in any device or technique described
in this article.
Supported by the Oppenheimer Research Fund of the New York Glaucoma
Research Institute, New York, NY.
Reprints: Robert Ritch, MD, Glaucoma Service, Department of Ophthalmology,
The New York Eye and Ear Infirmary, 310 E 14th St, New York, NY 10003 (e-mail: firstname.lastname@example.org).
Lebowitz D, Gürses-Özden R, Rothman RF, Liebmann JM, Tello C, Ritch R. Late-Onset Bleb-Related Panophthalmitis With Orbital Abscess Caused by Pseudomonas stutzeri. Arch Ophthalmol. 2001;119(11):1723-1725. doi: