Sir,

When a patient is referred with a sticky, painful eye soon after an operation on a region of the body remote from the eye, and they are systemically unwell, a diagnosis of endogenous endophthalmitis should be considered. If after examining the eye endophthalmitis seems possible then blood cultures should be taken.

Case report

A previously healthy 62-year-old woman with no past ocular history was admitted with abdominal pain and red, painful eyes 2 days following a routine hysteroscopy for investigation of postmenopausal bleeding. The visual acuities were hand movements in each eye and the conjunctivae were injected with an accompanying pseudomembrane formation. Both corneas were opaque and the left was necrotic inferiorly.

Bilateral hypopyons were present, iris detail was obscured and no red reflex could be seen in either eye (Figures 1 and 2). On systemic examination, the patient was confused, pyrexial, septicaemic, and hypovolaemic. A B-haemolytic group A streptococcus was isolated on blood culture and a diagnosis of streptococcal bilateral endogenous endophthalmitis was made.

Figure 1
figure 1

Right eye 1 day after presentation.

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Figure 2
figure 2

Left eye 1 day after presentation.

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Treatment was commenced with topical ofloxacin and cefuroxime 5%, and oral ciprofloxacin 750 mg bd. Intravitreal amikacin 0.4 mg and vancomycin 1 mg was administered twice within the first 72 h. No organism was identified from the vitreous biopsy specimens. At 3 months following presentation, the right eye had become phthisical and the left eye recovered to 3/60 with anterior-segment reconstructive surgery (Figure 3).

Figure 3
figure 3

Left eye following anterior segment reconstruction. (For online use: Figure 1 has been uploaded in colour as Figure 4 and Figure 3 has been uploaded in colour as Figure 5).

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Comment

B-Haemolytic group A streptococcus has been reported to cause endophthalmitis following ocular surgery1, 2 but there are only three other reported cases in the literature of Group A endogenous infection.3, 4 In the largest review of endogenous bacterial endophthalmitis (EBE), 2 out of 267 cases were due to Group A streptococcus infection.4 Infection occurs haematogenously and blood culture rather than vitreous biopsy is the most frequent means of establishing the diagnosis, which is initially mistaken in the majority of cases.

This is a rare case of streptococcal Group A EBE and the first case of endogenous endophthalmitis to follow gynaecological surgery. We recommend that EBE should be considered in patients who present with painful, red eyes following a surgical procedure and that blood cultures should be taken.

Figure 4
figure 4

Right eye 1 day after presentation.

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Figure 5
figure 5

Left eye following anterior segment reconstruction.

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