Acute postoperative Bacillus cereus endophthalmitis mimicking toxic anterior segment syndrome

Abstract

Objective: To study the clinicomicrobiologic characteristics and treatment outcomes in eyes with acute postoperative endophthalmitis (APE) owing to Bacillus cereus from a tertiary eye-care center.

Design: Retrospective, interventional case series.

Participants: Case records of all eyes with culture-proven APE attributable to B cereus from January 2000 to May 2011 were identified from a computerized database and evaluated.

Methods: Clinical features at time of presentation, microbiological characteristics, and treatment measures were recorded. A thorough literature search using PubMed and the Cochrane Library databases was done to identify all cases of APE owing to Bacillus species reported to date and clinical characteristics of these eyes was compared with our series.

Main outcome measures: Structural (globe salvage) and functional (visual rehabilitation) outcomes at last follow-up visit.

Results: We found 6 sporadic cases that experienced APE during the study period. All eyes had a fulminant onset within the first 24 hours of cataract surgery with extremely high intraocular pressure (IOP) and corneal edema similar to toxic anterior segment syndrome (TASS). However, these eyes progressed rapidly to develop corneal infiltrates, scleral and uveal tissue necrosis with hyphema, brownish exudates in anterior chamber and necrotizing retinitis within hours despite immediate initiation of intravitreal pharmacotherapy and vitrectomy. All eyes demonstrated gram-positive bacilli from the aqueous and B cereus was isolated, which was sensitive to conventional antibiotics except penicillin. Two eyes required therapeutic keratoplasty, combined with a scleral patch graft in 1 eye, 1 eye was eviscerated after 48 hours of onset of symptoms, and 2 eyes experienced phthisical changes within 10 days of onset.

Conclusions: We found that APE owing to B cereus has an onset within 12 to 24 hours of intraocular surgery and simulates TASS in the first few hours. The clinical course is marked by rapidly worsening necrotizing infection, leading to very poor outcomes despite early institution of appropriate therapy. One must closely observe every case of TASS that presents with intense pain and extremely high IOP and rule out APE owing to B cereus with microbiologic testing.

Financial disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.