A total of 13 eyes of 13 patients were included in this study. All patients were referred from local clinics, via the emergency room (ER) or outpatient department (OPD). All patients had been using the following antibiotic eye drops before their initial visit: 0.5% levofloxacin (Cravit, Santen, Japan), 0.3% gatifloxacin ophthalmic solution [Gatiflo, Handok, Chungbuk, Korea (preservative-free)], 0.5% moxifloxacin hydrochloride ophthalmic solution [Vigamox, Alcon Laboratories, Inc, Fort Worth, TX, USA (preservative-free)], and 0.5% tobramycin (Tobra, Samil, Korea). The mean age of the patients was 75.0 ± 13.3 years (range, 50 – 89 years). Five patients were men and 8 were women. The diagnosis of CNKE was based on slit-lamp examination: corneal ulcers were diagnosed upon determining a loss of corneal epithelium, accompanied by underlying infiltration of the corneal stroma. Endophthalmitis was defined as hypopyon with vitreous inflammation.
Hypopyon was observed in every patient with endophthalmitis. B-scan ultrasonography revealed vitreous inflammation in all patients. All 13 eyes were diagnosed with exogenous endophthalmitis. Of the 13 eyes with exogenous endophthalmitis, 2 eyes had secondary keratitis, which was caused by previous trauma, while the remaining 11 eyes had primary keratitis, without clear etiologies for the inflammation. All 13 patients diagnosed with exogenous endophthalmitis underwent corneal biopsy. Among the risk factors for poor visual outcomes, 10 eyes had visual acuity of light perception or worse, 9 patients were older than 65 years, and 5 patients had diabetes mellitus.
All patients received intravitreal injections of ceftazidime (2.25 mg/0.01 mL) and vancomycin (1 mg/0.01 mL), with vitreous and anterior chamber taps on the day of diagnosis. The mean number of intravitreal injections was 1.23 ± 0.4 (range, 1 – 2) and none of the patients underwent vitrectomy. All patients were simultaneously treated with systemic intravenous and topical antibiotics. Seven eyes were prescribed moxifloxacin, 2 eyes were prescribed levofloxacin, 2 eyes were prescribed gatifloxacin, 1 eye was prescribed levofloxacin and tobramycin, and 1 eye was prescribed moxifloxacin and tobramycin.
The initial visual acuity ranged from no light perception (NLP) to 2/100 and the final visual acuity ranged from NLP to 2/100. Two patients underwent evisceration about 1 week after the intravitreal injection (Table 1). The visual acuity of 3 of the 13 eyes improved compared with the initial visual acuity after treatment. Table 1 summarizes the patients’ clinical information.
[Table 1 near here]
Patient 1
A 58-year-old man presented to the ER of the local ophthalmology clinic with decreased visual acuity and pain on injection in the left eye, about 1 week after symptom onset. However, the symptoms aggravated, and he was referred to our clinic. Ocular examination revealed a BCVA of NLP in the left eye. The intraocular pressure (IOP) was 12 mmHg in the left eye, as measured with a noncontact tonometer. Slit-lamp examination revealed a corneal ulcer with hypopyon and ciliary injection (Figure 1a). We administered an intravitreal injection of ceftazidime and vancomycin and performed a vitreous tap on the day of diagnosis. A second intravitreal injection was administered 1 week later. The inflammation improved after the second injection. However, the final BCVA of the left eye was still categorized as “NLP,” 4 months after the second injection.
[Figure 1 near here]
Patient 2
An 84-year-old woman was referred to our clinic by the ER of a local clinic for the treatment of a corneal ulcer with endophthalmitis in the left eye. Ocular examination revealed a visual acuity of “NLP” and an IOP of 21.0 mmHg in the left eye. Slit-lamp examination revealed corneal infiltration with hypopyon, ciliary injection, and an edematous cornea (Figure 1b). We administered an intravitreal ceftazidime and vancomycin injection and performed a vitreous tap on the day of diagnosis. The inflammation improved after the injection. However, the final BCVA for the right eye was still “NLP” 3 months after the second injection.
Patient 3
A 60-year-old man was referred to the ophthalmology department by a local clinic for ocular pain and ciliary injection in the right eye. Ocular examination revealed a visual acuity of “hand motion” and an IOP of 15 mmHg in the right eye. Slit-lamp examination revealed ciliary injection with corneal infiltration and hypopyon(Figure 1c). We administered an intravitreal injection of ceftazidime and vancomycin and performed a vitreous tap on the day of diagnosis. The inflammation improved after the intravitreal injection. The final BCVA for the right eye was “NLP” 2 months after the injection.
Patient 4
A 50-year-old woman, who wore soft contact lens ordinals, was referred to our clinic for the treatment of endophthalmitis by the local clinic. Ocular examination revealed a BCVA of “hand movement” and an IOP of 23 mmHg in the left eye. Slit-lamp examination revealed ciliary injection, corneal infiltration, and hypopyon in the left eye (Figure 1d). We administered an intravitreal injection of ceftazidime and vancomycin and performed a vitreous tap on the day of diagnosis. A second injection was administered 1 week after the first injection. The inflammation improved after the second injection, but the visual acuity of the left eye was “NLP” 3 months after injection.
Patient 5
A 57-year-old man was referred to our clinic for the treatment of endophthalmitis by the local clinic, via the OPD. Ocular examination revealed a BCVA of “light perception” (LP) and IOP of 19 mmHg in the left eye. Slit-lamp examination revealed corneal infiltration, ciliary injection, and hypopyon in the anterior chamber (Figure 1e). We administered an intravitreal injection of ceftazidime and vancomycin and performed a vitreous tap on the day of diagnosis. The BCVA of the left eye was “hand movement” 1 month after intravitreal injection.
Patient 6
An 87-year-old man was referred to our clinic for the treatment of endophthalmitis, via the OPD of the local ophthalmology clinic. Ocular examination revealed that visual acuity was “NLP” and the IOP was 10 mmHg in the right eye. Slit-lamp examination revealed ciliary injection, corneal ulceration, and hypopyon. We administered an intravitreal injection of ceftazidime and vancomycin and performed a vitreous tap for the right eye on the day of diagnosis. The BCVA of the right eye was “NLP”, and the inflammation in the anterior chamber resolved 1 month after the intravitreal injection.
Patient 7
An 89-year-old man, who was referred to our clinic via the OPD of the local ophthalmology clinic, presented with pain on injection in the right eye. Ocular examination revealed a BCVA of “NLP” in the right eye. Noncontact tonometry revealed an IOP of 5 mmHg in the right eye. Slit-lamp examination revealed a corneal ulcer, hypopyon, and ciliary injection (Figure 1f). We administered intravitreal injection of ceftazidime and vancomycin and performed a vitreous tap on the day of diagnosis. The inflammation improved 3 months after the injection. Moreover, the final BCVA for the right left eye improved to “hand movement” 3 months after the intravitreal injection.
Patient 8
A 74-year-old woman was referred to our clinic by the local clinic, via the OPD, for the treatment of a corneal ulcer with endophthalmitis in the right eye. Ocular examination revealed a visual acuity of “NLP” and an IOP of 5 mmHg in the right eye. Slit-lamp examination revealed corneal infiltration, hypopyon, and ciliary injection (Figure 1g). We administered intravitreal injection of ceftazidime and vancomycin and performed a vitreous tap on the day of diagnosis, Another intravitreal injection was administered 1 week later. The inflammation improved after the second injection. The final BCVA of the right eye was “hand movement” 2 months after the second injection .
Patient 9
An 82-year-old Korean woman was referred to the ophthalmology department, via the ER of the local clinic, for ocular pain and ciliary injection in the right eye. Ocular examination revealed a visual acuity of “LP” and an IOP of 46 mmHg in the right eye. Slit-lamp examination revealed ciliary injection, corneal infiltration, and hypopyon (Figure 1h). We administered intravitreal injection of ceftazidime and vancomycin and performed a vitreous tap on the day of diagnosis. The inflammation improved after the intravitreal injection. The final BCVA for the right eye was “NLP” and the IOP was 34 mmHg, 3 months after the injection.
Patient 10
An 88-year-old woman was referred to our clinic for the treatment of endophthalmitis by the local clinic. Ocular examination revealed a BCVA of “NLP” and an IOP of 27 mmHg in the left eye. Slit-lamp examination revealed ciliary injection, corneal infiltration, and hypopyon in the left eye. We administered intravitreal injection of ceftazidime and vancomycin and performed a vitreous tap on the day of diagnosis. The inflammation improved after the intravitreal injection, but the visual acuity in the left eye was “NLP” 3 months after treatment.
Patient 11
An 83-year-old woman was referred to our clinic for the treatment of endophthalmitis by the local clinic, via the OPD. Ocular examination revealed a BCVA of “NLP” and an IOP of 28 mmHg in the right eye. Slit-lamp examination revealed a corneal ulcer, ciliary injection, and hypopyon in the anterior chamber. We administered intravitreal injection of ceftazidime and vancomycin and performed a vitreous tap on the day of diagnosis. Subsequently, the patient underwent evisceration 5 days after the injection, due to disease exacerbation.
Patient 12
A 76-year-old woman was referred to our clinic for the treatment of endophthalmitis, via the OPD of the local ophthalmology clinic. Ocular examination revealed a visual acuity of “NLP” and an IOP of 21 mmHg in the right eye. Slit-lamp examination revealed ciliary injection, corneal infiltration, and hypopyon. We performed an intravitreal ceftazidime and vancomycin injection and a vitreous tap on the day of diagnosis. Subsequently, the patient underwent evisceration 1 week after the injection, due to disease exacerbation.
Patient 13
An 86-year-old woman was referred to our clinic by the local clinic via the OPD for the treatment of a corneal ulcer with endophthalmitis in the right eye. Ocular examination revealed a visual acuity of 2/100 and an IOP of 16 mmHg in the right eye. Slit-lamp examination revealed ciliary injection with corneal infiltration, and hypopyon, We performed an intravitreal injection of ceftazidime and vancomycin and a vitreous tap on the day of diagnosis. The inflammation improved after intravitreal injection. The final BCVA of the right eye was 2/100, 6 months after injection.