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Successful Treatment of a Case of
Unilateral Endogenous Klebsiella pneumoniae Endophthalmitis
Omer Takes, 1 Gamze Kocaoglu, 1 Ziya Ayhan 2 and A Osman Saatci 3
1. Resident; 2. Fellow; 3. Professor, Department of Ophthalmology, Dokuz Eylul University, Izmir, Turkey
Abstract A 52-year-old woman with diabetes was examined for acute visual loss and ocular pain in oculus dexter (OD). Two weeks earlier, a
nephrostomy catheter was inserted for the treatment of nephrolithiasis and 10 days after this procedure she suffered an acute myocardial
infarction. During hospitalisation, she developed a high fever and Klebsiella pneumoniae was detected in the blood cultures. On eye
examination, mild corneal oedema, minimal hypopyon, vitritis and subretinal abscess of 3DD size at the uppertemporal retina were noted
in the right eye. Single intravitreal injection of vancomycin, ceftazidime and clindamycin was given in addition to systemic antibiotic
treatment for 14 days. Intraocular inflammation resolved rapidly within days and she regained a visual acuity of 8/10 with a residual
chorioretinal scar 2 months later. Endogenous endophthalmitis can be treated successfuly if the diagnosis can be established early
enough and treated accordingly.
Keywords Endogenous endophthalmitis, intravitreal injection, Klebsiella pneumoniae, retina, uveitis
Disclosure: Omer Takes, Gamze Kocaoglu, Ziya Ayhan and A Osman Saatci have no conflicts of interest to declare. No funding was received in the publication of this article.
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation
and reproduction provided the original author(s) and source are given appropriate credit.
Compliance with Ethics Guidelines: Informed consent was received from the patient involved in the case study.
Received: 11 June 2015 Accepted: 3 July 2015 Citation: European Ophthalmic Review, 2015;9(1):23–4
Correspondence: A Osman Saatci, Mustafa Kemal Pasa Bulvari, No. 73, A blok, Daire: 9, Narlidere, 35320, Izmir, Turkey. E: firstname.lastname@example.org
Endogenous endophthalmitis is a rare inflammatory condition of the
intraocular cavity that is caused by the haematogenous spread of
bacterial and/or fungal agents from the distant infectious loci mostly
located in liver, lung, endocardium, meninges and urinary tract. 1,2 It is
commonly associated with an underlying immunosuppressive status
including diabetes mellitus, cardiac disease, renal insufficiency and
malignancy. Gram-negative bacteriae are relatively more frequent than
Gram-positive bacteriae, particularly in Asia. 3
We report a successfully treated case of 52-year-old woman with
diabetes who developed Klebsiella pneumoniae septicaemia secondary
to nephrostomy and subsequent unilateral endogenous endophthalmitis.
A 52-year-old woman with 20 years history of poorly controlled
diabetes experienced acute visual loss and ocular pain in her right
eye. Two weeks earlier a nephrostomy catheter was inserted for the
treatment of nephrolithiasis. Ten days after this procedure she suffered
an acute myocardial infarction and was hospitalised. Three days
after the hospitalisation she developed the above-mentioned ocular
symptoms in her right eye in association with high fever. She also had
herpes labialis for 2 days. On eye examination, best-corrected visual
acuity was 1/10 in oculus dexter (OD) and 20/20 in oculus sinister
(OS). Slit-lamp examination showed mild corneal oedema, +++ cells,
minimal hypopyon and mild to moderate vitritis in OD. The anterior
segment was unremarkable in OS. Intraocular pressure was within
normal limit oculus uterque (OU). Fundoscopy revealed a subretinal
Tou ch MEd ica l MEdia
abscess of almost 3DD at the uppertemporal retina in OD and a few
cotton-wool spots at the posterior pole in OS (see Figure 1). Blood
cultures already demonstrated K. pneumoniae. Our diagnosis was
unilateral K. pneumoniae endophthalmitis (KPEE). She was treated
with a single intravitreal injection of vancomycin + ceftazidime and
clindamycin in association with the systemic antibiotics (gentamicin +
daptomycin and acyclovir) for 14 days. Vitreous culture turned out to
be negative. Topical cyclopentolate and prednisolone acetate drops
were also administered.
Intraocular inflammation resolved rapidly within days and she regained
visual acuity of 8/10 with a residual choroiretinal scar 2 months later
(see Figure 2).
Discussion Among inpatients with haematogenous infection, the overall incidence
of presumed endogenous endophthalmitis was 0.04 % among patients
with bacteraemia. 4 In a recent review of 342 cases of endogenous
bacterial endophthalmitis reported between 1986 and 2012
predisposing conditions were present in 60 % of cases. 2 The median
final visual acuity was 20/100 with 44 % of eyes achieving visual acuity
worse than 20/200. Among all cases, 24 % required evisceration or
enucleation and the mortality was 4 %. The most common causative
Gram-negative bacteria were K. pneumonia, Pseudomonas aeruginosa
and Neisseria meningitidis and the most common causative Gram-
positive bacteria were Staphylococcus aureus, group B Streptococcus,
Streptococcus pneumoniae and Nocardia species, respectively.