Sir,

Case report

A 61-year-old male presented with a history of floaters, blurred vision and discomfort for 1 week in his left eye and 2 days in his right. He had recently been polyuric and had lost 10 kg in weight. He was treated for a urinary tract infection 2 weeks prior to presentation.

Examination found best-corrected visual acuity (BCVA) of 6/60 in each eye. There was bilateral panuveitis, and intraocular pressures were 4 mmHg bilaterally. Retinal haemorrhages were present in the right fundus. The left fundus was not visible; a B-scan showed an attached retina. Blood tests showed raised blood glucose (43.5 mmol/l), and marked neutrophilia (29.8 × 109/l).

A diagnosis of bilateral endogenous bacterial endophthalmitis (EBE) was made. The patient was admitted and intravenous insulin started. Bilateral anterior chamber and vitreous biopsies were performed under local anaesthesia and intravitreal vancomycin, ceftazidime, and dexamethasone administered. Intravenous flucloxacillin and ciprofloxacin, topical ciprofloxacin, and both topical and oral steroids were given. Urine and blood cultures revealed Staphylococcus aureus. Further investigation showed benign prostatic hyperplasia (BPH), urinary retention, and bilateral hydronephrosis. Microscopy and culture of the ocular samples was negative.

At 3 weeks later, hypotony of the right eye resolved and BCVA in the right eye improved to 6/9. The left eye remained hypotonous for 2 months, and BCVA improved to 6/18.

Comment

EBE is rare, occurring in 0.24% of bacteraemic patients. Patients often have predisposing conditions such as diabetes (35%), and in this case BPH.1

The visual prognosis in EBE is worse than in other forms of endophthalmitis. Jackson et al1 report that only 32% of patients are left with visual acuity of counting fingers or better. Given that in cases of endophthalmitis the presence of severe vitritis, retinal haemorrhages,2 and infection with a virulent organism3 are associated with a worse prognosis, it is noteworthy that this patient's visual outcome was good.

This case illustrates that even in the presence of poor prognostic factors, EBE may have an acceptable outcome if treated promptly and aggressively. It is likely that earlier diagnosis of diabetes and BPH might have prevented this incident.