Unusual case series of Post -operative endophthalmitis due to Mycobacterium tuberculosis

Unusual case series of Post -operative

endophthalmitis due to Mycobacterium

tuberculosisDr. Thiruvengada Krishnan , M.D. , Aravind Eye Hospital

Pondicherry , IndiaCo- Authors – Dr Deeksha ,

MD , Dr R.D. Ravindran , MD

Authors have no financial interest

Case 1• 64 years old male patient presented with

diminution of vision and redness of left eye for 10 days . Underwent uneventful temporal section Phacoemulsification cataract surgery and in the bag intraocular lens implantation , 1 month back .

• On anti- tuberculous ( A.T.T.) treatment for past 2 months and Chest X-ray showed bilateral apical fibrotic changes.

• Ocular examination right eye – B.C.V.A was 6/9 with early nuclear sclerosis .

Left Eye Ocular and Microbiological Examination

V/A at presentation of L/E

6 / 60 B.C.V.A.

Tunnel infiltrate L/E 3 x 3 mm temporally

A. C. Reaction L/E Grade 4 + flare and cells and fibrin membrane

U.S.G. B Scan L/E Suggestive of endophthalmitis

A.C. and vitreous tap L/E Negative for microbiological examination

Tunnel infiltrate scraping specimen L/E

Positive A.F.B. and grew colonies on L.J. medium and P.C.R. positive for

mycobacterium T.B.

Management and clinical course

• Intraocular inflammation responded well to continuation of systemic A.T.T.

• Topically - fortified amikacin , vigamox , ketlur LS and atropine eyedrops were instilled .

• B.C.V.A. left eye stabilized at 6/12 at the end of 3 months .

Case 2• 77 years old female presented with blurred

vision and pain right eye for 2 days . Underwent uncomplicated Phacoemulsification and in the bag intraocular lens implantation via temporal section 2 months back .

• On treatment for Diabetes mellitus Type II for 7 years .

• Ocular examination left eye – B.C.V.A. 6/9 with intraocular lens in the bag and no diabetic retinopathy.

Right eye Ocular and Microbiological Examination

V/A at presentation of R/E

6/12 B.C.V.A.

Tunnel infiltrate R/E 2 x 2 mm temporally

A/C Reaction R/E Grade III flare and cells

U.S.G. B Scan R/E Suggestive of endophthalmitis

A.C. and vitreous tap R/E

Negative for microbiological examination

Tunnel infiltrate scraping specimen R/E

Positive A.F.B. and grew colonies on L.J. medium and P.C.R. positive for

mycobacterium T.B.

Management and clinical course• Intraocular inflammation responded well

with institution of systemic A.T.T. and topically - fortified amikacin , vigamox , ketlur LS and atropine eyedrops were instilled .

• B.C.V.A. right eye stabilized at 6/18 p at the end of 3 months .

Case 3• 57 years old male presented with right eye

redness and pain , 1 month following uncomplicated Phacoemulsification and in the bag intraocular lens implantation , via temporal section .

• Ocular examination left eye – B.C.V.A. 6/12 with nuclear sclerosis .

Right eye Ocular and Microbiological Examination

V/A at presentation of R/E

6 / 24 p B.C.V.A.

Tunnel infiltrate R/E 3 x 3 mm temporally

A/C Reaction R/E Grade IV flare and cells with fibrin membrane and 1mm hypopyon

U.S.G. B Scan R/E Suggestive of endophthalmitis and Tractional Retinal Detachment

A.C. and vitreous tap R/E Negative for microbiological examination

Tunnel infiltrate scraping specimen R/E

Positive A.F.B. and grew colonies on L.J. medium and P.C.R. positive for

mycobacterium T.B.

Management and Clinical course• Intraocular inflammation responded well with institution

of systemic A.T.T. and topically with fortified amikacin , vigamox , ketlur LS and atropine eyedrops .

• Intracameral 0.05 cc Avastin was given for neovascular glaucoma with standard oral and topical anti – glaucoma medications .

• Total Pars plana vitrectomy with intra - vitreal silicone oil was done for tractional retinal detachment .

• B.C.V.A. right eye stabilized at 6/36 at the end of 3 months .

Tunnel Infiltrate : at presentation

Conclusion

• Mycobacterium tuberculosis is a possible etiology in post - operative endophthalmitis cases , especially pertinent in set up of tropical countries , where tuberculosis is endemic .

• A high index of suspicion aids in timely diagnosis and guiding management to salvage the eye and vision restoration .