Sir,

Enterococccus casseliflavus infection has been rarely implicated in ophthalmic infections. We report a case of E. casseliflavus exogenous endophthalmitis due to a metallic intraocular foreign body (IOFB).

Case report

A healthy 54-year-old male presented with a 3-day history of left eye pain and blurred vision after a metal chip entered his left eye during hammering. As the accident occurred overseas, there was a 3-day interval from injury to presentation.

Visual acuity of the left eye was hand movement with a left grade 4 reverse relative afferent pupillary defect. Slit lamp examination findings are shown in Figure 1. Computed tomography of orbits confirmed a 3 × 6 mm metallic IOFB impacted in the retina inferiorly.

Figure 1
figure 1

Slit lamp examination of the left eye showed conjunctival chemosis, corneal oedema, and an inferonasal corneoscleral laceration with iris prolapse. The anterior chamber was shallow with a fibrinous reaction and a 1.6-mm hypopyon.

Full size image

He underwent left corneoscleral laceration repair, phacoemulsification (with no intraocular lens implanted), 20G vitrectomy, IOFB removal through the corneal incision with the aid of an intraocular magnet, intravitreal vancomycin (1 mg/0.1 ml) and ceftazidime (2.25 mg/0.1 ml), and silicone oil injection. Postoperatively, topical cefazolin, gentamicin, and atropine were commenced. Vitreous culture grew E. casseliflavus susceptible to penicillin (demonstrable synergism with aminoglycoside) and linezolid but resistant to vancomycin. He completed 6 weeks of systemic antibiotics therapy, which consisted of 19 days of intravenous amoxicillin, linezolid, and gentamicin, followed by oral amoxicillin. At postoperative month 2, visual acuity in his left eye improved to 6/90.

Comment

E. casseliflavus is commonly found in the gastrointestinal tract of livestock.1 Although it has been implicated in a variety of human infections, we found no previous report of E. casseliflavus endophthalmitis due to IOFB. Two cases of E. casseliflavus endophthalmitis have been reported: an endogenous endophthalmitis due to enterococcal bacteraemia2 and an endophthalmitis associated with a horse tail injury; however, no entry site was found.3 In exogenous endophthalmitis, the success of treatment is dependent on adequate vitreous clearance during vitrectomy and appropriate antibiotic therapy postoperatively. Cephalosporins and quinolones have good eye penetration but are ineffective against E. casseliflavus. Vancomycin and high-dose penicillins may penetrate the eye during active inflammation, but the concentration achievable is not previously studied. The E. casseliflavus in our patient showed low-level vancomycin resistance, but remained susceptible to penicillins.4 Previous reports of E. casseliflavus endophthalmitis were treated with vitrectomy with intravitreal vancomycin and ceftazidime2, 3 and topical gentamicin.2 Our patient had a reasonably good outcome with the postoperative use of appropriate triple systemic antibiotics. We added linezolid as it has satisfactory eye penetration.5 Early diagnosis, prompt surgical intervention, and sensitivity-guided systemic antibiotics can result in an improved visual outcome in this otherwise devastating condition.