A 43-year-old male, Borneo native, with no known medical illness presented with pain and blurred vision of his left eye after being poked with a wire. He worked as a gardener at a nursery within the vicinity of a makeshift lavatory, which is a common structure found in rural Borneo where there is scarcity of modern lavatory and sewage systems. While he was ploughing the garden, a piece of metallic wire accidentally sprang from the ground and poked into his left eye and immediately dislodged. The patient was not using any protective eye gear at that time. He rushed to the casualty of the nearest rural clinic, was given an eye shield and was referred to the nearest hospital (3 hours away) for further management.
Upon presentation to the ophthalmology unit 5 hours later, the visual acuity was 6/6 on the right eye and Counting Fingers 3 feet with severe pain of the left eye (Figure 1). Anterior segment examination of the left eye showed a mildly injected conjunctiva, with a jagged partial thickness laceration wound measuring about 3mm on the surface of the cornea with pupil peaking at the same spot. Cornea was slightly edematous at the site of penetration. Siedel leaking test was negative. Anterior chamber showed 3+ cells, with absence of hyphema level. Pupil was irregular but reactive. Fundoscopy showed a slightly hazy posterior segment, but the optic disc and vessels were both visible. A gentle B scan was done which showed no vitreous loculations nor retinal abnormalities. The patient was treated as a self-sealing partial thickness corneal laceration and was admitted for close observation. Meanwhile, intensive Gutt Moxifloxacin eyedrops two hourly around the clock was commenced to the affected eye.
The next day however, despite the pain score remaining the same, the left visual acuity had dropped to No Perception of Light (NPL). The eyelids were swollen and the conjunctiva was severely chemosed. The cornea was opaque with no visibility of the anterior segment (Figure 2). A diagnosis of endophthalmitis was made and the patient underwent urgent cleaning and suturing of the corneal wound. Intraoperatively, intravitreal vancomycin 1mg/0.1ml and ceftazidime 2.2mg/0.1ml injections were given. Vitreous tap was taken and sent for culture and sensitivity. Systemic broad-spectrum antibiotics (Intravenous Ciproflocxacin 750mg bd) and analgesia for pain management was added. Topical moxifloxacin eyedrops were continued intensively as before.
On the third day after injury, the left eye did not show any improvement. The vision was still NPL. The left eyelids became more chemosed and swollen and there was purulent yellowish substance extruding from the sutured cornea laceration site.
At this juncture, the patient was counselled for evisceration. He was informed of the risks of systemic spread of infection and agreed for the procedure. Post evisceration, there was less pain and the left eyelids swelling had markedly reduced. The evisceration site healed well with no wound breakdown or discharge.
Culture results from the vitreous tap yielded florid growth of Bacillus cereus species on the blood agar plate (Figure 3). The patient was sent home three days later with Gutt Moxifloxacin 4 hourly and a 10-days course of oral Ciprofloxacin 500mg bd. Subsequent follow-ups showed the left adnexa remaining quiet (Figure 4).