Nguyen et al. Int J Ophthalmol Clin Res 2017, 4:066 International Journal of DOI: 10.23937/2378-346X/1410066 Volume 4 | Issue 1 Ophthalmology and Clinical Research ISSN: 2378-346X Case Report: Open Access Haemophilus Influenzae Endophthalmitis Associated with a Glau- coma Drainage Implant in an Adult Bac T Nguyen1, Patricia Chevez-Barrios1,2, Robert E Coffee1 and Benjamin J Frankfort1

1Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, USA 2Department of Pathology and Genomic Medicine, The Methodist Hospital, Houston, USA

*Corresponding author: Benjamin J Frankfort, MD, PhD, Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, 6565 Fannin, NC205, Houston, TX 77030, Tel: 713-798-3453, Fax: 713-798-4364, E-mail: [email protected]

Introduction completing a taper of topical prednisolone acetate 1%, the patient developed iritis. This was treated with topical prednisolone acetate Tube shunt surgery with glaucoma drainage implants (GDI) is 1% with improvement but not resolution. The iritis worsened two a commonly-performed procedure in the surgical management of months later (five months after tube shunt surgery), and the patient glaucoma, and utilization of the procedure has steadily increased was switched from topical prednisolone acetate 1% to difluprednate in frequency over the past two decades [1]. Endophthalmitis is ophthalmic emulsification 0.05% and bromfenac ophthalmic solution recognized as a serious but uncommon complication of tube 0.09%. One month later (six months after surgery), the patient shunt surgery, and endophthalmitis associated with Haemophilus returned with worsening pain and vision for one day. The patient’s influenzae is noted to have particularly devastating visual outcomes visual acuity was light perception with projection, and intraocular [2-9]. Multiple case series and reports have evaluated the organisms pressure was 25 mmHg. There was no tube erosion or exposure, and causing endophthalmitis after tube shunt surgery with a GDI and the patient had a 2 mm hypopyon with 4+ cell and flare. There was no only four distinct cases were associated with Haemophilus influenzae. view to the posterior pole, and B-scan ultrasonography demonstrated All of these cases occurred in pediatric patients, with the oldest being hypermobile vitreous debris. A diagnostic vitreous paracentesis six years of age [2,7-9]. We present the first reported case of tube was performed and intravitreal ceftazidime and vancomycin were shunt-associated endophthalmitis caused by Haemophilus influenzae injected. The patient’s vitreous culture grewHaemophilus influenzae in an adult. that was pan-sensitive. Case Description Five days after presentation, the patient underwent anterior A 65-year-old male with primary open-angle glaucoma underwent chamber washout, pars plana vitrectomy and tube shunt removal. tube shunt surgery with an Ahmed Glaucoma Valve FP-7 (New World During surgery, vancomycin was injected intravitreally, and cefazolin Medical, Rancho Cucamonga, CA) in the left eye for uncontrolled and dexamethasone were injected subconjunctivally. Three weeks intraocular pressure, worsening visual field defects, and advanced later, the patient returned with a tractional retinal detachment and glaucomatous optic neuropathy. In that eye, the patient had previously underwent a repeat pars plana vitrectomy with silicone oil. One undergone selective laser trabeculoplasty, phacoemulsification year later, the patient’s visual acuity was hand motions, intraocular with posterior chamber intraocular lens placement, and pars plana pressure was 7 mmHg, and early phthisis bulbi was noted. vitrectomy for rhegmatogenous retinal detachment. The patient also Discussion had a history of recurrent iritis, which was first diagnosed three years prior to surgery and treated as needed with topical corticosteroids. Endophthalmitis is a rare but serious complication after tube The patient did not require topical corticosteroid therapy at the time shunt surgery with a GDI. A low rate of endophthalmitis has been of presentation. The patient’s past medical history included diabetes confirmed by several recent randomized controlled clinical trials. mellitus, hyperlipidemia, hypertension, and squamous cell carcinoma In the Ahmed Versus Baerveldt Study one case of endophthalmitis of the neck that was treated with chemotherapy six years prior to tube occurred from a study population of 238 [4]. Similarly, in the Ahmed shunt surgery. The GDI was placed in the superior temporal quadrant Baerveldt Comparision Study only two cases of endophthalmitis using a limbal-based conjunctival flap and covered anteriorly with a occurred from a study population of 276 [5]. Lastly, the Tube Versus split thickness corneal patch graft. The patient’s initial post-operative Trabeculectomy Study reported one case of endophthalmitis from the course was uncomplicated and at two months post-operatively, 107 patients in the tube shunt group [3]. Retrospective studies have the patient’s visual acuity was 20/400 (preoperative 20/100) and also found low rates of endophthalmitis, and one large study found an intraocular pressure was 18 mmHg without the use of any glaucoma endophthalmitis rate of 1.7% [8]. medication. Endophthalmitis after tube shunt surgery with a GDI can have Three months after tube shunt surgery and two months after a range of visual outcomes. In a case series by Gedde, et al. tracking

Citation: Nguyen BT, Chevez-Barrios P, Coffee RE, Frankfort BJ (2017) Haemophilus Influenzae Endophthalmitis Associated with a Glaucoma Drainage Implant in an Adult. Int J Ophthalmol Clin Res 4:066. doi.org/10.23937/2378-346X/1410066 ClinMed Received: June 09, 2016: Accepted: January 25, 2017: Published: January 27, 2017 International Library Copyright: © 2017 Nguyen BT, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. DOI: 10.23937/2378-346X/1410066 ISSN: 2378-346X four separate cases of endophthalmitis after tube shunt surgery, post- tube shunt exposure or erosion. Thus, while tube shunt erosions may infection visual acuity ranged from 20/40 to no light perception [2]. predispose patients to Haemophilus influenzae endophthalmitis, they Al-Torbak, et al. published nine cases of endophthalmitis associated do not appear to be a requirement, especially if patients have other with Ahmed glaucoma valves and found that post-infection visual medical comorbidities that could lead to immunosuppression. acuity ranged from 20/200 to no light perception [8]. Between these In summary, endophthalmitis is a rare complication after tube two series, there were three cases of endophthalmitis associated with shunt surgery with GDI, and while a small subset of cases have been Haemophilus influenzae, all in children, with post-infection visual associated with Haemophilus influenzae in children, this report acuities of light perception or no light perception [2,8]. Trzcinka, indicates that Haemophilus influenzae endophthalmitis is possible in et al. also reported a single occurrence of Haemophilus influenzae an adult. Visual outcomes of patients with Haemophilus influenzae endophthalmitis after tube shunt surgery with a Baerveldt GDI. endophthalmitis following tube shunt surgery with GDIs are very This case was also in a child and the outcome was a phthisical eye poor. It appears that tube shunt erosions through the cornea or [9]. Together, these reports suggest that visual outcomes following conjunctiva are not a requirement for Haemophilus influenzae endophthalmitis caused by Haemophilus influenzae may be worse endophthalmitis. than with other organisms. To our knowledge, the patient presented in this case represents References the first reported case of Haemophilus influenzae endophthalmitis 1. Ramulu PY, Corcoran KJ, Corcoran SL, Robin AL (2007) Utilization of various associated with tube shunt surgery in an adult. Despite prompt and glaucoma surgeries and procedures in Medicare beneficiaries from 1995 to aggressive treatment, and consistent with the published literature, 2004. Ophthalmology 114: 2265-2270. the patient’s visual outcome was poor: hand motions vision and early 2. Gedde SJ, Scott IU, Tabandeh H, Luu KK, Budenz DL, et al. (2001) Late phthisis bulbi. As a whole, the clinical course is consistent with the endophthalmitis associated with glaucoma drainage implants. Ophthalmology 108: 1323-1327. above GDI-associated pediatric cases, as well as with a case series published by Yoder, et al., which showed that visual outcomes, in 3. Gedde SJ, Herndon LW, Brandt JD, Budenza Dl, Feuer WJ, et al. (2012) Postoperative complications in the Tube Versus Trabeculectomy (TVT) study general, were poor in endophthalmitis associated with Haemophilus during five years of follow up. Am J Ophthalmol 153: 804-814. influenza [7]. 4. Christakis PG, Kalenak JW, Tsai JC, Zurakowski D, Kammer JA, et al. Our patient also had a history of recurrent iritis as well as (2016) The Ahmed Versus Baerveldt Study: Five-Year Treatment Outcomes. persistent iritis following GDI placement and preceding a diagnosis Ophthalmology 123: 2093-2102. of endophthalmitis. For several months leading up to presentation 5. Budenz DL, Feuer WJ, Barton K, Schiffman J, Costa VP, et al. (2016) with endophthalmitis the patient was using topical corticosteroids. Postoperative Complications in the Ahmed Baerveldt Comparison Study During Five Years of Follow-up. Am J Ophthalmol 163: 75-82. This clinical scenario and ocular history made the diagnosis of endophthalmitis challenging. Furthermore, our patient’s tube shunt 6. Salim NL, Azhany Y, Abdul Rahman Z, Yusof R, Liza-Sharmini AT (2015) Infected Baerveldt Glaucoma Drainage Device by Aspergillus niger. Case did not erode through the cornea or conjunctiva, which calls into Rep Ophthalmol Med 2015: 249419. question the entry point for the organism. No tube shunt erosions were noted in the report by Trzcinka, et al., but there were erosions 7. Yoder DM, Scott IU, Flynn HW Jr, Miller D (2004) Endophthalmitis caused by Haemophilus influenzae. Ophthalmology 111: 2023-2026. noted in the case of Haemophilus influenzae endophthalmitis reported by Gedde, et al. [2,9]. Similar to the patient presented in Trzcinka, et 8. Al-Torbak AA, Al-Shahwan S, Al-Jadaan I, Al-Hommadi A, Edward DP (2005) Endophthalmitis associated with the Ahmed glaucoma valve implant. Br J al., our patient also had other medical comorbidities, most notably Ophthalmol 89: 454-458. diabetes mellitus and squamous cell carcinoma of the neck that was 9. Trzcinka A, Soans FP, Archer SM, Moroi SE (2008) Late-onset Haemophilus treated with systemic chemotherapy [9]. These comorbidities could influenzae endophthalmitis in an immunized child after Baerveldt implant. J have left our patient relatively immunosuppressed and predisposed AAPOS 12: 412-414. to Haemophilus influenzae endophthalmitis, even in the absence of

Nguyen et al. Int J Ophthalmol Clin Res 2017, 4:066 • Page 2 of 2 •