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Case Reports and Small Case Series
July 1999

Clostridium perfringens Endophthalmitis Following Cataract Surgery

Arch Ophthalmol. 1999;117(7):978-979. doi:

Clostridium perfringens, an anaerobic gram-positive bacillus, is an infrequent pathogen in endophthalmitis, causing rapid destruction of ocular tissues. It typically develops after penetrating injury with soil-contaminated foreign bodies1 or, less commonly, endogenously,2,3 usually in an immunocompromised patient. To our knowledge, there are no previously reported cases of clostridial endophthalmitis following intraocular procedures. We present a case of C perfringens endophthalmitis after cataract surgery in a patient who was later diagnosed with metastatic cancer.

Report of a Case

A 78-year-old white man underwent an uncomplicated extracapsular cataract extraction of his left eye with a posterior chamber intraocular lens implant and subconjunctival injections of gentamicin and dexamethasone. His medical history was significant only for hypertension, and review of systems was negative for weight loss, malaise, pain, and other potential signs and symptoms of chronic or malignant disease. On postoperative day 1, the patient had a visual acuity of light perception OS and severe ocular discomfort. Examination revealed moderate conjunctival injection and chemosis, diffuse corneal edema with a large epithelial defect, superior iris bowed forward, coffee-colored aqueous, and moderate anterior chamber reaction. The surgical wound appeared intact, and there was no hypopyon. The intraocular lens was not visible, and the intraocular pressure was 34 mm Hg. Reduction of intraocular pressure with acetazolamide permitted viewing of the fundus 6 hours later, showing no retinal or choroidal detachments and the intraocular lens dislocated inferiorly in the vitreous, presumed to be due to zonular dehiscence. The patient underwent pressure patching with gentamicin ointment and returned the following morning with visual acuity of light perception, increased conjunctival chemosis, diffusely opaque cornea, wound dehiscence, shallow anterior chamber, and an intraocular pressure of 0 mm Hg. B-scan ultrasonography revealed choroidal detachments and diffuse vitreous debris.

"Open-sky" deep anterior vitrectomy was performed on postoperative day 2 with intravitreal injections of 1 mg of vancomycin, 1 mg of clindamycin, and 200 µg of gentamicin. The corneal wound was repaired, and 25 mg of vancomycin and 40 mg of gentamicin were injected subconjunctivally. A Gram stain of the wound revealed gram-positive bacilli. Postoperatively the patient was given intravenous clindamycin (900 mg) and gentamicin (90 mg) every 8 hours and topical fortified vancomycin and gentamicin drops.

On postoperative day 3, the patient's visual acuity was no light perception OS, and there was further decompensation of the globe. Vitreous and wound cultures grew C perfringens, and intravenous metronidazole was added to the patient's regimen. The eye showed no improvement during the next 3 days (Figure 1) and enucleation was performed on postoperative day 7. Serial blood cultures demonstrated no bacterial growth.

Postoperative day 5, with hemorrhagic necrosis, corneal decompensation, and wound dehiscence.

Postoperative day 5, with hemorrhagic necrosis, corneal decompensation, and wound dehiscence.

One month after enucleation, the patient was admitted to the hospital with ascites, was diagnosed with metastatic carcinoma of the colon, and died.

C perfringens is a rare cause of endophthalmitis but, when established, almost always results in loss of the globe. Classic signs and symptoms include rapid onset (within 24 hours) with severe pain, brawny eyelid edema, early elevated intraocular pressure, bloody or coffee-colored aqueous, gas bubbles in the anterior chamber, and rapidly progressive total visual loss.3 Most reported cases have occurred following penetrating injury to the globe, with or without retained intraocular foreign body. Frantz et al2 reported the first case of endogenous C perfringens endophthalmitis in a patient with a perforated gangrenous gallbladder, and few other cases of metastatic clostridial endophthalmitis have since been reported.4 To our knowledge, ours is the first reported case of C perfringens endophthalmitis following intraocular surgery, perhaps endogenously seeded but undeniably temporally related to the surgical procedure. It further exemplifies the rapidly destructive nature of this organism despite early diagnosis and treatment.

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Article Information

Reprints: Diane P. Romsaitong, MD, Department of Ophthalmology, Catholic Medical Centers of Brooklyn and Queens, 158-40 79th Ave, Fourth Floor, Flushing, NY 11366 (e-mail: romsaitong@aol.com).

References
1.
Leavelle  RB Gas gangrene panophthalmitis. Arch Ophthalmol. 1955;53634- 642Article
2.
Frantz  JFLemp  MAFont  RLStone  REisner  E Acute endogenous panophthalmitis caused by Clostridium perfringensAm J Ophthalmol. 1974;78295- 303
3.
Crock  GWHeriot  WJJanakiraman  PWeiner  JM Gas gangrene infection of the eyes and orbits. Br J Ophthalmol. 1985;69143- 148Article
4.
Nangia  VHutchinson  C Metastatic endophthalmitis caused by Clostridium perfringensBr J Ophthalmol. 1992;76252- 253Article
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