Taiwan Journal of Ophthalmology xxx (2015) 1e3 Contents lists available at ScienceDirect Taiwan Journal of Ophthalmology journal homepage: www.e-tjo.com Case Report Methicillin-resistant Staphylococcus aureus buckle infection complicated by endophthalmitis and presumed choroidal abscess in a patient with ulcerative colitis * Kuan-I. Wu a, Kwan-Rong Liu a, b, c, Hsiang-Wen Chien b, a Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan b Department of Ophthalmology, Cathay General Hospital, Taipei, Taiwan c Department of Ophthalmology, Taiwan Adventist Hospital, Taipei, Taiwan article info abstract Article history: This patient presented with excessive pain, lid swelling, erythema, heat and limitations of extraocular Received 25 October 2014 movement (OD) nine days after a scleral buckle (SB) and pneumopexy surgery. Complicated buckle Received in revised form infection with endophthalmitis was impressed. Bacterial culture yielded methicillin-resistant Staphylo- 10 May 2015 coccus aureus. A choroidal abscess was identified 1 week after the episode. Complete visual recovery from Accepted 15 July 2015 hand motion to 20/30 (OD) was achieved with buckle removal, subconjunctival and intravitreal antibi- Available online xxx otics. Endophthalmitis and choroidal abscess formation after SB surgery is extremely rare. Host factors including ulcerative colitis may play a role in causing the severe buckle infection of this patient. Keywords: © choroidal abscess Copyright 2015, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights endophthalmitis reserved. methicillin-resistant Staphylococcus aureus, scleral buckle ulcerative colitis 1. Introduction 2. Case Presentation Scleral buckle (SB) surgery is a conventional repair procedure for A 46-year-old male with baseline visual acuity of 20/30 in both rhegmatogenous retinal detachment. The reported incidence of eyes (OU), had history of high myopia (spherical equivalent À12.0 buckle infection ranges 0.2e5.6%.1 Infective endophthalmitis after diopters; OU), retinal break postfocal laser treatment (OU), and scleral buckling surgery is even lower (0.02e0.19%).2,3 Management open angle glaucoma (OU) under regular follow up at our clinic. He typically requires prompt SB removal, which carries the risk of moreover had ulcerative colitis (UC), which was well controlled recurrent retinal detachment. Thus, the visual outcome of buckle with mesalamine. He presented to our clinic and had experienced infection may be poor because of retinal damage or recurrent floaters in the right eye (OD) for 1 week and an inferior visual field detachment. In this paper, we present the clinical course of a pa- defect for 3 days. An examination revealed superior rhegmatoge- tient with complicated methicillin-resistant Staphylococcus aureus nous retinal detachment from the 10 o'clock to 2 o'clock direction (MRSA) buckle infection and discuss the possible host factors without macular involvement. Lattice with atrophic holes from the associated with the disease. 12 o'clock to 1 o'clock positions was identified. He underwent segmental SB surgery with scleral diathermy for retinal break localization and an intravitreal injection of perfluoropropane (C3F8). A Mira silicon sponge-507 was fixated at the superonasal sclera. Postoperative examination showed a well-attached retina, and the patient was discharge under stable condition. fl fl Con icts of interest: None of the authors has any con icts of interest to report Nine days postoperation, the patient presented to our clinic with with regard to this article. No financial support was received for this work. * Corresponding author. Department of Ophthalmology, Cathay General Hospital, excessive pain, chills, and headache. Erythema, lid swelling, heat, 280 Renai Road, Section 4, Taipei, 106, Taiwan. and limitation of extraocular movement were present. Visual acuity E-mail address: [email protected] (H.-W. Chien). http://dx.doi.org/10.1016/j.tjo.2015.07.002 2211-5056/Copyright © 2015, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved. Please cite this article in press as: Wu K-I, et al., Methicillin-resistant Staphylococcus aureus buckle infection complicated by endophthalmitis and presumed choroidal abscess in a patient with ulcerative colitis, Taiwan Journal of Ophthalmology (2015), http://dx.doi.org/10.1016/ j.tjo.2015.07.002 2 K.-I. Wu et al. / Taiwan Journal of Ophthalmology xxx (2015) 1e3 was limited to seeing hand motion only at 10 cm. The active cellular reaction was 4þ in the anterior chamber. A dilated fundus exami- nation showed inferior vitreous opacities with an attached retina and an intraocular gas bubble of ~30%. The orbital computed to- mography scan revealed a significant thickening of the right eyelid and the right superior rectus and levator palpebrae superioris muscles (Figure 1). Buckle infection complicated with orbital cellulitis and endophthalmitis was impressed. Empirical intrave- nous antibiotics of cefazolin and gentamicin were administered. The patient was started on hourly topical ciprofloxacin. Emergent buckle removal surgery was arranged. During the operation, a peritomy was performed 120 superonasally. Purulent discharge was spontaneously drained from the superonasal quad- rant. After removing the sponge implant and the underlying pus, the sclera beneath the buckle appeared soft and necrotic. Intra- vitreal vancomycin (1 mg/0.1 mL) and ceftriaxone (2 mg/0.1 mg) were injected, followed by subconjunctival injections of vanco- mycin (25 mg/0.5 mL) and ceftriaxone (100 mg/0.5 mL). The buckle and swab culture both yielded MRSA that was resistant to all an- tibiotics except vancomycin and teicloplanin. Hence, systemic an- tibiotics were shifted to teicloplanin and topical antibiotics were shifted to vancomycin. The anterior chamber reaction subsequently subsided. However, the fundus view remained impaired because of vitreous opacities. An elevated subretinal lesion located at the former buckle area over the superonasal region was identified 1 week postbuckle removal. An ultrasound B-scan (Figure 2A) revealed a dome-shaped elevation in the area. A choroidal abscess was also impressed. Intravitreal and subconjunctival injections of vancomycin were repeated every 2 days for a total of eight times to control the infection. The patient responded well to vancomycin treatment. The vit- reous opacities subsided and the choroidal abscess gradually flat- tened over an 8-week period, as shown by fundus examination and ultrasound B-scan in Figure 2B. Subsequent bacterial cultures of the eye discharge remained negative. Visual acuity of the patient improved dramatically to the baseline value of 20/30 at the 2- month follow up. The retina remained attached thereafter without any focal laser treatment. The patient underwent cataract surgery 48 months later, and visual acuity improved to 20/25. Follow-up optical coherence tomography (OCT) postcataract surgery showed a thin epiretinal membrane formation over the macular area of the right eye (Figure 2C). Figure 2. (A) Ultrasound B-scan of the right eye shows a dome-shaped choroidal elevation at the previous location of the removed buckle. Vitreous opacities are pre- sent. (B) At the 8-week follow up, the choroidal lesion (asterisk) has gradually flattened and the vitreous opacities are markedly decreased, which is consistent with resolution of the inflammatory process. (C) Optical coherence tomography reveals a thin epi- retinal membrane over the right eye. 3. Discussion Our patient had MRSA infection that was associated buckle infection with endophthalmitis and presumed choroidal abscess. Scleral necrosis also occurred underneath the silicon sponge. Figure 1. Orbital computed tomography without contrast of the right eye shows Staphylococcus species are one of the most common organisms swelling of the periorbital tissue and fat stranding next to the buckle (arrow). An fi 4,5 intraocular gas bubble from pneumatic retinopexy of right eye is also evident on the identi ed from an explanted SB and necrotic sclera. Methicillin- computed tomography image. resistant Staphylococcus aureus ophthalmic infections are Please cite this article in press as: Wu K-I, et al., Methicillin-resistant Staphylococcus aureus buckle infection complicated by endophthalmitis and presumed choroidal abscess in a patient with ulcerative colitis, Taiwan Journal of Ophthalmology (2015), http://dx.doi.org/10.1016/ j.tjo.2015.07.002 K.-I. Wu et al. / Taiwan Journal of Ophthalmology xxx (2015) 1e3 3 increasing. In a review by Blomquist,6 orbital cellulitis with Apart from aforementioned factors, pathological changes in endophthalmitis accounted for 4% of all MRSA ophthalmic in- highly myopic eyes include thinning of the sclera. Our patient had fections. Apart from Staphylococcus aureus, other causative organ- open angle glaucoma (OU) for years. This may provide indirect isms in buckle infection include Staphylococcus epidermidis, Proteus evidence that our patient had weakened biomechanical properties mirabilis, and Pseudomonas aeruginosa.7 of the sclera. This predisposed our patient to increased suscepti- The possible route of bacterial entry in our patient may have bility of deeper bacterial invasion through the sclera, which resul- been via contamination of the buckle implant or suture material. ted in the formation of the choroidal abscess and 14 Ocular penetration during intravitreal injection of C3F8 may also endophthalmitis. In addition, the application of