Endophthalmitis is an ocular emergency that can have a devastating outcome. The poor prognosis is often related to rapid progression of the disease process and a relative delay in diagnosis due to the wide array of clinical symptoms and signs.1 Although endophthalmitis is most often related to surgical intervention, endogenous sources are identified in 2% to 15% of cases.1 Intravenous drug-related endophthalmitis is most commonly caused by Bacillus cereus.2,3 We report a case of B cereus endophthalmitis secondary to periorbital drug injection that resulted in spontaneous lens subluxation. This case underscores the difficulty in making an expeditious diagnosis when there is an uncertain medical history.
A 29-year-old male prison inmate had a 12-hour history of vomiting associated with pain, redness, and impaired vision of the left eye. The patient denied trauma and drug abuse. Medical history was remarkable for active interferon therapy for hepatitis C. The right eye was normal. The left eye had light perception vision, 360° perilimbal injection, mid-dilated pupil, and dull red reflex. There were no signs of penetrating injury. The angle was closed with an intraocular pressure of 61 mm Hg. A toxicology screen test result was positive for amphetamine. An initial diagnosis of angle-closure glaucoma led to initiation of timolol maleate, brimonidine tartrate, acetazolamide, and isosorbide dinitrate therapy that reduced the intraocular pressure to 40 mm Hg. On the evening of admission, ocular ultrasonography revealed thickening of the choroid and retina, fluid posterior to the sclera, inflamed extraocular muscles, and a nondisplaced lens.
Laser iridotomy, topical cycloplegics, and steroids failed to reduce the intraocular pressure or reverse the ocular inflammation (Figure 1). On the second day, an orbital computed tomography scan demonstrated marked scleral thickening, enlarged extraocular muscles, and subluxation of the lens (Figure 2). Suspicion of endophthalmitis led to vitreous aspiration. The aspirate showed gram-positive rods, and the culture revealed B cereus/Bacillus thuringiensis. Intravenous vancomycin hydrochloride, ceftriaxone sodium, and clindamycin phosphate supplemented intravitreal injections of vancomycin and ceftazidime. A normal echocardiogram ruled out a cardiac source of bacteria. On the fourth day, spontaneous scleral perforation occurred with extrusion of purulent uveal contents. The eye was eviscerated. Weeks later, 2 prison guards reported to a case worker that prior to the episode the patient had been observed injecting drugs into the periocular tissues.
Scleritis (T sign) and normal lens position on day 1 (ultrasound courtesy of Laurie Barber, MD).
Axial (A) and coronal (B) computed tomographic scans show lens subluxation on day 2.
To our knowledge, this is the first reported case of endophthalmitis secondary to presumed illicit periorbital drug injection and the first reported case of lens dislocation associated with B cereus endophthalmitis. Unreliable patient history delayed correct diagnosis and contributed to a poor outcome, but retrospective review of the initial signs and symptoms and subsequent eyewitness reports led us to suspect orbital injection. Inadvertent ocular penetration and intraocular injection may have caused acute angle closure at the patient's initial visit. Periocular injection or direct inoculation of the vitreous body with a dirty needle in turn progressed to B cereus endophthalmitis that rapidly led to lens dislocation. Although other mechanisms may result in endophthalmitis, the lack of systemic sepsis, other infectious sources, or obvious trauma near the globe make these etiologies less probable. Our report emphasizes the virulent nature of B cereus, which typically causes retinal necrosis and retinal detachment1,2 due to the production of multiple toxins and enzymes.2 The orbit should be recognized as a potential site for illicit drug injection, a practice which carries the risk of inadvertent intraocular inoculation. Our report illustrates 3 important aspects of B cereus endophthalmitis: (1) A high index of suspicion is necessary for early detection; (2) B cereus must be considered in an individual who abuses drugs; and (3) The rapid destruction caused by this highly virulent organism in endophthalmitis may result in lens subluxation.
We would like to acknowledge the contributions of Rebecca Martin, MD, and the Infectious Disease Department at the University of Arkansas for Medical Sciences.
Corresponding author: Christopher T. Westfall, MD, Department of Ophthalmology, University of Arkansas for Medical Sciences, 4301 W Markham St, Mail Slot #523, Little Rock, AR 72205 (e-mail: firstname.lastname@example.org).
Blackmon DM, Calvert HM, Henry PM, Westfall CT. Bacillus cereus Endophthalmitis Secondary to Self-inflicted Periocular Injection. Arch Ophthalmol. 2000;118(11):1585-1586. doi: