To present two cases of neonatal endophthalmitis with poor prognosis that were managed with primary evisceration.
Case 1 is a 27-weeks’ gestation neonate who developed Pseudomonas aeruginosa endophthalmitis complicated by globe rupture. Case 2 describes a 34-weeks’ gestation neonate with Serratia marcescens endophthalmitis. Both patients had poor prognosis and thus underwent primary evisceration with good long-term cosmetic outcomes at 15 years and 17 months, respectively.
Conclusions and Importance
Primary evisceration should be considered in neonates with endophthalmitis with a poor prognosis and can result in good long-term cosmesis.
Neonatal endogenous endophthalmitis is one of the feared complications of neonatal sepsis that can result in loss of vision and the eye. This results from the hematogenous spread of microorganisms across the blood-ocular barrier which infect the vitreous or aqueous humor of the eye. Despite advances in neonatal care and antimicrobial therapy, systemic infections remain common among premature infants. Nearly one-third of extremely premature infants, defined as birth before 28 weeks of pregnancy, develop sepsis , with associated high mortality and high risk of long-term complications, including blindness from neonatal endophthalmitis. A premature infant suffering from bacteremia, perinatal infections, or respiratory disorders is twice as likely to get endophthalmitis. In one series examining 4323 infants in the neonatal intensive care unit over five years, among the six patients that developed endophthalmitis all had constitutional signs of infection.
Treatment of endogenous endophthalmitis in the neonate includes, as with adults, control of the systemic infection by intravenous antimicrobials with adjuvant intravitreal injections and pars plana vitrectomy in select patients. However, despite maximal therapy, long term visual outcomes are typically poor with worse outcomes associated with more virulent organisms. In such cases, primary evisceration can be utilized both as a definitive therapy to control the infection locally and to preserve a good cosmetic outcome.
Herein, we report two cases of neonatal endophthalmitis associated with virulent causative organisms managed with primary evisceration with good cosmesis.
The ophthalmology service was consulted to evaluate a 27-weeks’ gestation neonate born to a 23-year-old female via emergent Caesarean section for premature rupture of membranes. The patient’s complicated perinatal course was marked by the development of intraventricular hemorrhages, hydrocephalus, respiratory distress, intussusception, and sepsis. Blood cultures were positive for Pseudomonas aeruginosa and Candida albicans . The patient was started on intravenous vancomycin, gentamicin, ceftazidime, imipenem, and amphotericin B.
On the 35th day of life the patient was transferred to our care due to concern for endogenous endophthalmitis. Ophthalmic examination of the right eye was notable for diffuse injection, a corneal epithelial defect with a large infiltrate, a shallow anterior chamber with a mixed hypopyon and hyphema, and no view to the iris or posterior pole. Ultrasound of the eye ( Fig. 1 ) identified dense infiltrates in the vitreous, choroid, and retina without evidence of shadowing to indicate calcification. Examination of the left eye disclosed no evidence of infection.
A corneal scrape of the right eye was sent for culture. An intravitreal paracentesis was performed but minimal fluid was aspirated. Vancomycin (1mg/0.1ml) and amikacin (0.2g/0.05ml) were injected into the vitreous cavity. Subsequently, the eye developed a marked rise in intraocular pressure, so an intravitreal ceftazidime injection was deferred. Subconjunctival depots of vancomycin and ceftazidime were placed.
The corneal culture later grew Pseudomonas aeruginosa resistant to cefazolin. No organisms were identified in the vitreous sample. Four days later, the cornea had perforated with expulsion of intraocular material. Once the patient was deemed medically stable, the right eye was eviscerated at the bedside and a 16mm acrylic implant placed ( Fig. 2 ). The patient remained admitted to the neonatal intensive care unit for 16 weeks, during which the left eye was treated with laser for Stage 2 retinopathy of prematurity in Zone II ( Fig. 3 ).
The patient underwent acrylic implant exchange at 24 months and again at 9 years of age with placement of a larger 20mm scleral-wrapped MEDPOR porous polyethylene implant (Stryker Corporation, Kalamazoo, Michigan). At the most recent follow up, 15 years later, examination showed a well-formed post-surgical socket and a visual acuity of 20/40 in the seeing eye ( Fig. 4 ).