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Sir,

Endophthalmitis is an uncommon but serious complication of intraocular surgery, often resulting in severe visual loss.1 The endophthalmitis may progress to panophthalmitis if medical or surgical therapy cannot control the infection.

Strains of the Morganella genus are a rare cause of panophthalmitis following trauma and cataract surgery.2 We describe a patient who developed fulminant Morganella morganii panophthalmitis following vitrectomy with resultant loss of vision. To our knowledge, this is the first reported case of M. morganii panophthalmitis.

Case report

A 46-year-old Taiwanese male had sudden loss of vision in right eye for a day due to vitreous haemorrhage. On day 1 after pars plana vitrectomy, the fundus was visible and the retina was well attached. Unfortunately, his visual acuity decreased to no light perception, and severe ocular pain with eyelid swelling developed rapidly within 2 days after the operation. He was transferred to our hospital on day 4. On presentation, the patient eyelid appeared to be severely swollen and haemorrhagic chemosis was noted. Mucopurulent pus exuded from the right eye. Acute postoperative panophthalmitis was diagnosed. Haemogram revealed leukocytosis (16 700/μl) with neutrophils predominant by 80.9%. Pars plana vitrectomy with anterior chamber irrigation and intravitreal delivery of vancomycin and ceftazidime was performed on day 5. Profuse pus was noted during the operation. Vitreous specimens were obtained for smear and culture. Intravitreal injections of vancomycin (1 mg/0.1 ml) and ceftazidime (2 mg/0.1 ml) and subconjunctival injections of vancomycin (50 mg/0.5 cm3) and ceftazidime (125 mg/0.5 cm3) were given at the end of the operation. Diffuse retinal whitening and hyperemic disc were noted intraoperatively.

The patient's postoperative treatment regimen consisted of: (1) subconjunctival vancomycin (50 mg/0.5 cm3) and ceftazidime (125 mg/0.5 cm3) every other day (2) intravenous cefazolin (1 g every 8 h) and gentamicin (80 mg every 12 h) and (3) topical fortified vancomicin (50 mg/cm3) and ceftazidime (50 mg/cm3) every 1 h.

However, his eye became more inflamed with mucopurulent discharge, and the ophthalmic examination was difficult to perform due to severe periorbital swelling (Figure 1). Gram stain of vitreous specimens revealed numerous Gram negative rods (Figure 2), and culture of the anterior chamber aspirates and vitreous specimens grew many Morganella morganii colonies that were resistant to ampicillin and cefazolin using the disk diffusion method. The extraocular extension was noted by computed tomography. The systemic antibiotic was then shifted to intravenous ceftriaxone (2 g every 12 h) 1 week after operation. Periorbital swelling with mucopurulent discharge decreased dramatically after intravenous ceftriaxone use. His eye appeared quiet after a 2-week course of systemic and topical antibiotics with third-generation cephalosporin. Unfortunately, the patient did not regain any vision despite this aggressive treatment.

Figure 1
figure 1

The external eye of the patient. The conjunctiva was haemorrhagic and necrotic with mucopurulent greenish pus discharge. The cornea was oedematous and opacified.

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Figure 2
figure 2

The Gram stain of vitreous specimens shows numerous Gram negative bacilli.

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Comment

M. morganii is a Gram negative bacillus that belongs to the Enterobacteriaceae family. Within the Enterobacteriaceae, the genus Morganella is one member of the tribe Proteeae, which includes also the genera Proteus and Providencia.3 M. morganii is highly resistant bacillus susceptible only to β-lactamase inhibitors. Strains are often resistant to first-generation cephalosporins.3 M. morganii is a rare but usually devastating cause of postoperative endophthalmitis.4, 5

In our patient, the clinical picture was fulminating. Even though the early intervention was performed, panopthalmitis with extraocular extension still developed rapidly. The inflammation did not subside even with aggressive treatment till the third-generation cephalosporin was given intravenously.

To our knowledge, this is the first reported case of M. morganii panophthalmitis. M morganii is a rare aetiologic infectious agent. Very early intensive treatment including systemic antibiotic therapy with the third-generation cephalosporin is the most important factor in the possible success of avoiding an eye with M. morganii panophthalmitis from evisceration/enucleation.