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Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 697-698

Subacute postoperative endophthalmitis secondary to sutureless self-sealing corneal wound infection at both main cornea and side port wounds: A case report

Department of Ophthalmology, Hospital Miri, Miri, Sarawak, Malaysia

Date of Submission03-Dec-2020
Date of Acceptance28-Mar-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Ngu D B Michael
Hospital Miri, Jalan Cahaya, Miri, Sarawak 98000
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_3568_20

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Corneal wound infection following cataract surgery is rare. We describe a case of wound infection at both the main wound and the side port wound following uncomplicated phacoemulsification. Candida albicans was isolated, and the condition worsened with progression to endophthalmitis. Vitrectomy was done, and the infection was controlled after 3 months of topical and systemic antifungal medications.

Keywords: Corneal wound infection, endophthalmitis, phacoemulsification

How to cite this article:
Michael ND, Kueh YY. Subacute postoperative endophthalmitis secondary to sutureless self-sealing corneal wound infection at both main cornea and side port wounds: A case report. Indian J Ophthalmol Case Rep 2021;1:697-8

How to cite this URL:
Michael ND, Kueh YY. Subacute postoperative endophthalmitis secondary to sutureless self-sealing corneal wound infection at both main cornea and side port wounds: A case report. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 21];1:697-8. Available from: https://www.ijoreports.in/text.asp?2021/1/4/697/327674

Ocular adnexa such as lids, lacrimal sac, and conjunctiva are the common sources of cataract wound infection.[1] Contaminated surgical instruments have also been reported to be the cause of this pathology.[2] Poor corneal tunnel wound construction or damage caused by instrumentation or prolonged surgery could increase the risk of infection.[3],[4],[5] We report a case of subacute postoperative endophthalmitis secondary to sutureless self-sealing corneal wound infection. The source of infection was believed to be contaminated eye drops as the patient had a fungal nail infection.

  Case Report Top

A 69-year-old gentleman with underlying hypertension, chronic kidney disease, Parkinson's disease, and psoriasis presented with left eye pain, redness, and reduced vision 5 weeks after his uneventful phacoemulsification. He denied any history of trauma after the surgery. Postoperatively, he was on topical dexamethasone 0.1% and moxifloxacin 0.5% 2-hourly for 1 week, then four times per day until his presentation to us.

On examination, his left eye visual acuity was 20/80. Slit-lamp examination showed endothelial plaques at both the main wound and the side port wound [Figure 1]. Anterior chamber cells were 3+, and no hypopyon was noted. There were no giant cells or deposits on the intraocular lens. Fundus examination was unremarkable. He was diagnosed with corneal wound infection and treated with topical cefuroxime 5% and gentamicin 0.9% hourly. Two days after the treatment, he developed vitritis, and vision dropped to 20/125. He was then treated as endophthalmitis secondary to corneal wound infection. Aqueous and vitreous tapping was done, and intravitreal vancomycin 2 mg/0.1 mL, ceftazidime 2 mg/0.1 mL, and amphotericin B 0.005 mg/0.1 mL were given. The aqueous culture showed Candida albicans. Topical fluconazole 0.2% and amphotericin B 0.15% hourly, as well as oral fluconaole 200 mg daily were added. He was referred to a dermatologist for nail changes because the infected nail was believed to be the source of infection, and the culture of the nail showed fungal organisms [Figure 2]. In fact, the moxifloxacin eye drops that our patient was using tested positive for fungal culture.
Figure 1: Endothelial infiltrate at the main wound (black arrow) and smaller infiltrate at the side port wound (red arrow)

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Figure 2: Hand hygiene condition

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Left eye vitrectomy was performed for endophthalmitis. Intrastromal and intracameral amphotericin B 0.005 mg/0.1 mL injections were given to treat the corneal infiltrate. The infection was controlled, and the topical antifungals were tapered over 3 months. His left eye's final best corrected vision was 20/40.

  Discussion Top

Phacoemulsification with a self-sealing corneal wound incision is the most widely performed technique for cataract extraction. Fungal infection of the corneal wound following surgery is rare with limited case series being reported.[2],[3],[4] The literature review shows that most of the fungal infections were caused by Aspergillus spp.[3],[4] The wound infection could be at the sclerocornea or at the clear cornea either in the main wound or in the side port wound depending on the technique of the surgery.[1],[2],[3],[4],[5],[6] For our patient, the wound infection was caused by Candida albicans and presented at 5 weeks postphacoemulsification. The endothelial plaques were noted at both the main wound and the side port wound, which is rare and different from the existing reported cases.

Because the infection was present at the posterior cornea, it was not amenable for routine corneal scrapping; hence in our case, aqueous tapping was done, and the culture showed Candida infection. The surgery was uneventful, and there were no associated cluster cases. Therefore, the inoculation of infection must have most likely occurred from an external source. Based on the hand hygiene, we postulated that the source of infection could be the fungal nail infection. Furthermore, the topical medication was contaminated and both the nail samples and the moxifloxacin eye drops that our patient was using tested positive for fungal culture. Also, the use of corticosteroids could be the precipitating factor because our patient used topical corticosteroids in the immediate postoperative period until the onset of clinical infection. We did not reuse the keratome, and even different knives were used to make the main corneal wound and side port wound incisions. In addition, the instruments that passed through the main wound were different from that used for the side port wound. Hence, it is unlikely that the infection could be from the instruments.

There is a high risk of developing endophthalmitis in the corneal wound infection following cataract surgery.[3],[4] In fact, endophthalmitis secondary to fungal nail infection has been reported.[7],[8] It was a therapeutic challenge for our case as the endothelial plaques were at the corneal incision wounds, and most of the antifungal medications are fungistatic and have poor penetration through the cornea. The use of corticosteroids before the onset of clinical presentation might cause the fungus to spread diffusely and even gain access to the vitreous resulting in endophthalmitis like in our case. Medical treatment alone often fails and a combined surgical approach can be pursued to control the infection, especially in the case of endophthalmitis. It is important that during preoperative assessment, the patient's hand hygiene and the technique of instilling eye drops should be emphasized apart from the ocular condition.

  Conclusion Top

In conclusion, fungal infection of self-sealing corneal incision can pose a diagnostic and therapeutic challenge. Because the infection is deep seated, corneal biopsy or anterior chamber paracentesis may be used. The goal is to eradicate any source of infection within the eye and in the cornea.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Valenton M. Wound infection after cataract surgery. Jpn J Ophthalmol 1996;40:447-55.  Back to cited text no. 1
Gokhale NS, Garg P, Rodrigues C, Haldipurkar S. Nocardia infection following phacoemulsification. Indian J Ophthalmol 2007;55:59-61.  Back to cited text no. 2
[PUBMED]  [Full text]  
Palioura S, Relhan N, Leung E, Chang V, Yoo SH, Dubovy SR, et al. Delayed-onset Candida parapsilosis cornea tunnel infection and endophthalmitis after cataract surgery: Histopathology and clinical course. Am J Ophthalmol Case Rep 2018;11:109-14.  Back to cited text no. 3
Garg P, Mahesh S, Bansal AK, Gopinathan U, Rao GN. Fungal infection of sutureless self-sealing incision for cataract surgery. Ophthalmology 2003;110:2173-7.  Back to cited text no. 4
Cosar CB, Cohen EJ, Rapuano CJ, Laibson PR. Clear corneal wound infection after phacoemulsification. Arch Ophthalmol 2001;119:1755-9.  Back to cited text no. 5
Kehdi EE, Watson SL, Francis IC, Chong R, Bank A, Coroneo MT, et al. Spectrum of clear corneal incision cataract wound infection. J Cataract Refract Surg 2005;31:1702-6.  Back to cited text no. 6
Tamez-Peña A, González-González LA, López-Jaime GR, Rodríguez-García A. Endoftalmitis endógena por Fusarium spp en un paciente con onicomicosis: Reporte de un caso. Rev Mex Oftalmol 2010;84:122-6.  Back to cited text no. 7
del Pilar Lucena M, Sola FF, Soriano ME, Gerster FA. Postoperative endophthalmitis caused by Candida parapsilosis: A case report. Open J Ophthalmol 2019;9:64-9.  Back to cited text no. 8


  [Figure 1], [Figure 2]


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