Spontaneous Corneal Perforation and Endophthalmitis in Pseudomonas Aeruginosa Infection in a Ventilated Patient: a Case Report

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SPONTANEOUS CORNEAL PERFORATION AND ENDOPHTHALMITIS IN PSEUDOMONAS AERUGINOSA INFECTION IN A VENTILATED PATIENT: A CASE REPORT

WYNANTS S.*, KOPPEN C.*, TASSIGNON M.J.*

SUMMARY voies respiratoires supérieures chez un patient ven- tilé mécaniquement. Chez ces patients la colonisa- We report a case of Pseudomonas keratitis and en- tion des voies respiratoires par des pathogènes ré- dophthalmitis after inoculation from the respiratory sistants est bien connue. Ils peuvent être responsa- tract in a mechanically ventilated patient. In these ble d’une inoculation des yeux chez des patients pré- (semi)comatose and more vulnerable patients, col- sentants une cornée compromise. Il est très impor- onisation of the upper respiratory tract by Pseudomo- tant de reconnaître la pathologie très tôt vu le dan- nas occurs frequently, and this can lead to inocula- ger d’une progression rapide et d’instituer tion of the eyes. Emphasis lies on careful preven- immédiatement une thérapie agressive dès l’appa- tion of ocular inoculation and aggressive therapy as rition d’une kératite. soon as keratitis is noticed. MOTS CLÉS SAMENVATTING Pseudomonas aéruginé, kératite, We stellen een casus voor van Pseudomonas kera- endophtalmie, ventilation mécanique. titis en endoftalmitis na besmetting vanuit de bo- venste luchtwegen bij een kunstmatig beademde pa- KEY WORDS tiënt. Bij deze patiënten treedt vaak een colonisatie Pseudomonas aeruginosa, keratitis, van de luchtwegen op door Pseudomonas aeruginosa. In combinatie met de verminderde oculaire af- endophthalmitis, mechanically ventilated weermechanismen bij semi-comateuze patiënten, patients. kan dit leiden tot een agressief evoluerende keratitis. RÉSUMÉ Nous présentons un cas de kératite et d’endophtalmie à Pseudomonas dûe à une inoculation par les zzzzzz * Department of Ophthalmology, University Hospital Antwerp, Belgium.

received: 31.01.00 accepted: 10.04.00

Bull. Soc. belge Ophtalmol., 276, 53-56, 2000. 53 INTRODUCTION: ment with a lubricant. Repeated fundoscopic examinations revealed no signs of endogenous The development of corneal ulcers by patho- infection. At the day of transfer to a rehabili- gens of the respiratory tract as a complication tation centre, the ophthalmological examina- of mechanical ventilation has been described tion showed a healthy right eye and a well healed since the early 1970’s(7). evisceration wound at the left eye. Pseudomonas aeruginosa can cause very viru- lent corneal infections which can quickly lead to hypopion formation and destruction of the DISCUSSION corneal stroma. Perforation of the eye can occur within 48 hrs (1,3,9,17,23). The corneal ulcer caused by Pseudomonas We present a case of Pseudomonas aeruginosa aeruginosa has several characteristics: it is usu- keratitis in a mechanically ventilated patient, ally centrally located, almost always second- leading to ulceration, perforation, and finally ary to corneal injury and has a fulminant pro- evisceration. gression. The cornea gets involved within 48 to 72 hours after inoculation. A hypopyon of un- usual size can be present early in the disease. CASE REPORT Pus, mucous in consistency and greenish in co- An ophthalmological consultation was request- lour, appears in copious amounts. Unless spe- ed for a 49-year-old polytraumatized, coma- cific adequate treatment is initiated immedi- tose man, mechanically ventilated in the inten- ately, panophthalmitis can develop (1,4,8). sive care unit for two months, because of mul- At first, when evaluating this case, the diagno- tiple fractures, multiple organ failures, a torn sis of a postsplenectomy syndrome (PSS), which liver, a splenoraphy and sepsis. The reason for is an endogenous endophtalmitis due to sepsis the ophthalmological referral was the sudden after splenectomy, was considered (5). How- appearance of a red eye with discharge on the ever, this is more likely to occur after splenec- left side. tomy and not after splenoraphy. Spleen insuf- It was known that the patient’s upper respira- ficiency after splenoraphy was improbable in tory tract was colonised with Pseudomonas our patient since the counting of thrombocytes a aeruginosa. He had been treated with fusidine remained normal ( 400.000) instead of be- acid one month earlier for a corneal erosion in ing increased. Moreover, Streptococcus pneu- the left eye. The treatment had been stopped moniae is the predominant organism found in and replaced by an eye gel lubricant one week PSS and not Pseudomonas aeruginosa. before the requested examination. In one patient, reported by Ommeslag et al (11), At the time of examination, the eyelids were Pseudomonas aeruginosa was found in several swollen, sticking to each other and a purulent blood cultures, suggesting that his keratitis orig- discharge was present. While opening the eye- inated from sepsis. The hypothesis of an en- lids for further evaluation, the cornea perfora- dogenous dissemination was found unlikely by ted spontaneously, a drop of anterior chamber the authors because of the absence of retinal fluid squirted out of the eye and immediately emboles on fundoscopy in the undamaged as hereafter the intraocular lens dropped onto the well as in the damaged eyes. So they conclud- cheek, followed by vitreum. An evisceration was ed that his keratitis originated from an exoge- performed the next morning. nous source. Cultures of the cornea and vitreum revealed the In our patient, the undamaged eye remained presence of Pseudomonas aeruginosa as was ophthalmoscopically clean before and after the found in the patient’s sputum. corneal perforation of the left eye despite sev- The patient was closely monitored ophthalmo- eral episodes of sepsis with Pseudomones aeru- logically: his right eye presented repetitively ginosa. with sticky eyelids and mucous discharge, white The hypothesis of an exogenous autoinocula- dots and strands on the corneal surface. Cul- tion of the eye with organisms of the respira- tures of this right eye remained negative how- tory tract seems more likely in our patient whose ever, and all symptoms disappeared after treat- bronchotracheal aspirates had been found pos-

54 itive for Pseudomonas aeruginosa several times. eyes. It is generally agreed that the relative re- It is therefore more likely that the cause of this sistance of the healthy cornea to direct bacte- endophthalmitis was exogenous rather than en- rial invasion is multifactorial: an intact epithe- dogenous. lial layer, an optimal outer eye defence mech- The autoinoculation in ventilated patients by in- anism such as the lower temperature of the tubation can be the result of an enhanced bac- open eye, correct whipping and washing effect terial adherence to bronchial mucosal cells of the lids and tears, the presence of a certain (15,16,18), leading to inoculation of the eye concentration of secretory IgA, tear lysozymes when aspiration of the intubation tube is per- and betalysins and the phagolytic activity of formed with uncovered or open eyes. conjunctival mucosal and polymorphonuclear The normal respiratory tract efficiently removes cells (10,19,20,22). Pseudomonas aeruginosa bacteria that have been aspirated into the air- adheres little, if at all, to the normal cornea sur- ways. It is extremely difficult to experimentally face but collects in areas of damaged basal cells induce respiratory disease in animals by the as- and the sites of injured epithelium (12, 14). piration of micro-organisms alone. Injury of the The combination of colonisation of the respi- respiratory tract is also required. Viral infec- ratory tract in intubated patients, the auto-in- tions, endotracheal intubation and chemical inoculation through suctioning of the respiratory jury are factors that favor the induction of bac- tract and the more vulnerable cornea in (semi) terial respiratory infections. Endotracheal intu- comatose patients makes it clear that these pa- bation induces trauma to the mucous mem- tients should be closely monitored. branes so that micro-organisms can adhere to desquamated or desquamating epithelial cells CONCLUSION and to the basement membrane if this is ex- posed, leading to the colonisation of the respi- Patients who are intubated should be followed ratory tract with micro-organisms. Pseudomo- and nursed carefully. They are definitely more nas aeruginosa is frequently found as this bac- at risk for developing an infectious keratitis be- terium is all too often present in intensive care cause of a decreased corneal resistance and a units. higher concentration of micro-organisms present A highly significant association has been found in the respiratory tract. between copious sputum production and high Special precautions must be taken in case of colony count scores after suctioning the respi- proven colonisation with Pseudomonas aeru- ratory tract, suggesting that bacteria from the ginosa since this organism is known to cause a respiratory secretions were dispersed about the very rapid and very destructive corneal ulcer patients’ eyes during suctioning (6). Observa- (13,21). Possible prevention is by means of tions of nurses carrying out the withdrawal pro- special attention by the nursing staff while clean- cedure of endotracheal tubes revealed that pa- ing and suctioning the respiratory tract. Gen- tients’ eyes were frequently uncovered and found erous lubrication of the eyes is mandatory from open during the nursing procedure, allowing the beginning on and a vigorous and prompt bacteria to be directly inoculated into the eye. treatment is needed as soon as clinical symp- Hilton et al (6) have analysed why the left eye toms, suggestive for keratitis appear. was most commonly affected: right handed nurses tended to withdraw the catheter diagonally across the left side of the patient’s face. A study emphasised that the eyes should be covered and the catheter not withdrawn across the patient’s face after suctioning. The eyes of critically ill patients are more ex- posed to injury (6). The absence of normal eye- lid action and diminished tear production com- bined with the fact that the patients’ eyes are often uncovered during nursing procedures, may contribute to the increased vulnerability of these

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