Sir,

Postoperative bacterial endophthalmitis is usually confined to the eye. Metastatic spread to the meninges is very rare and could have a devastating outcome.

Case report

An 87-year-old man presented with one day history of severe pain and reduced vision in his left eye 3 days following uneventful cataract surgery under topical anaesthesia. He previously had successful right cataract surgery and bilateral ptosis correction. His medical history included Hypertension and Aortic Valve replacement.

His visual acuity was 6/60 in the affected eye. Examination revealed corneal epithelial and stromal oedema, +3 cells in the anterior chamber and raised intraocular pressure (45 mm Hg). A red reflex was present but no fundus details were visible.

Intravitreal injections of Tiecoplanin (1 mg) and Ciprofloxacin (0.2 mg) were administered. Oral Ciprofloxacin and topical Tiecoplanin, Ciprofloxacin, Dexamethasone, Ketorolac, and Atropine were commenced.

The AC tap and vitreous tap grew Streptococcus pneumoniae, which was sensitive to Chloramphenicol but resistant to Ciprofloxacin. Hence topical Ciprofloxacin was substituted by Chloramphenicol.

Two days later, he developed tonic-clonic seizures and reduced GCS (10/15). An urgent CT of Head did not reveal any intracranial haemorrhage. His bloods showed WBC 26.5, Neutrophils 24.4, and CRP 168. A lumber puncture showed RBCs 1600 × 106/l, WBCs 2500 × 106/l (Neutrophils 95%, Lymphocytes 5%); pneumococcus was positive on PCR.

He was diagnosed with pneumococcal meningitis. Intravenous Ceftriaxone 2 gm BD given for 2 weeks resulted in resolution of meningitis. His final visual acuity dropped to 3/60.

Comment

Postoperative endophthalmitis is a dreaded complication of cataract surgery. Prompt diagnosis and treatment with intravitreal and intensive topical antibiotics is required to salvage vision.1 Systemic antibiotics may have a role in prevention of systemic spread of infection. Systemic spread to involve meninges has been reported2 once but is extremely rare.

Our patient developed meningitis despite receiving oral Ciprofloxacin because the offending organism was resistant to this drug. He was successfully treated under guidance of microbiology results.

Patients with endophthalmitis should be observed closely for signs or symptoms of metastatic spread. Although postoperative bacterial endophthalmitis is typically confined to the eye, this case report indicates that the infection can spread to the central nervous system. The treatment of endophthalmitis (including systemic antibiotics) should be guided by microbiology to ensure that the antibiotics administered are effective.