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 Table of Contents  
Year : 2020  |  Volume : 58  |  Issue : 3  |  Page : 189-191

Acute endophthalmitis caused by Enterococcus faecalis following intravitreal ranibizumab injection

1 Department of Retina-Vitreous Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
2 Department of Ocular Microbiology, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, Tamil Nadu, India

Date of Submission14-May-2020
Date of Decision29-May-2020
Date of Acceptance22-Jun-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. Ram Sudarshan Ravindran
Department of Retina-Vitreous Services, Aravind Eye Hospital, Madurai - 625 020, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_55_20

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A 58-year-old immunocompetent male developed acute endophthalmitis after intravitreal ranibizumab injection for choroidal neovascular membrane. The preinjection vision in the left eye (LE) was 6/24. One-day postinjection, he presented with pain, redness, and defective vision. The vision in the LE was hand movements at presentation. On examination, the presence of circumcorneal congestion, hypopyon (2 mm), and anterior-chamber reaction was noted. Core vitrectomy was done along with intravitreal injections of vancomycin and ceftazidime. Vitreous biopsy grew Enterococcus faecalis. The isolate was sensitive to vancomycin and moxifloxacin. There was an improvement in vision (6/36) at the final follow-up. We present the case of acute endophthalmitis caused by E. faecalis after intravitreal ranibizumab injection with better visual outcome.

Keywords: Endophthalmitis, Enterococcus faecalis, intravitreal injection, ranibizumab

How to cite this article:
Ravindran RS, Mishra C, Kannan NB, Lalitha P, Rameshkumar G. Acute endophthalmitis caused by Enterococcus faecalis following intravitreal ranibizumab injection. TNOA J Ophthalmic Sci Res 2020;58:189-91

How to cite this URL:
Ravindran RS, Mishra C, Kannan NB, Lalitha P, Rameshkumar G. Acute endophthalmitis caused by Enterococcus faecalis following intravitreal ranibizumab injection. TNOA J Ophthalmic Sci Res [serial online] 2020 [cited 2020 Oct 31];58:189-91. Available from: https://www.tnoajosr.com/text.asp?2020/58/3/189/294998

  Introduction Top

Endophthalmitis is a devastating complication of any invasive intraocular procedure.[1]Enterococcus faecalis, a Gram-positive bacterium, and part of the normal human gastrointestinal track, is the second most common cause of nosocomial infections.[2]E. faecalis accounted for 1% of all culture-proven acute postcataract surgery endophthalmitis cases in the Endophthalmitis Vitrectomy Study.[3] It has been reported in different clinical settings of endophthalmitis including acute-onset postcataract surgery, delayed-onset bleb-related cases, and trauma.[1] Visual prognosis in Enterococcus-related endophthalmitis is relatively poor.[1],[4] There has been only one published data regarding endophthalmitis caused by E. faecalis after intravitreal injection.[5] Here, we report a case of postintravitreal ranibizumab injection endophthalmitis caused by E. faecalis with clinical features, outcome, and management and report a good outcome.

  Case Report Top

A 58-year-old male presented to our outpatient department with complaints of redness and pain in the left eye (LE) for 1 day. The patient had received intravitreal injection of ranibizumab (Accentrix; Novartis Pharma, Stein AG, Switzerland) 0.5 mg in 0.05 cc in the LE for choroidal neovascular membrane (CNVM), a day before the onset of symptoms. Ocular history revealed that the patient had received one injection of intravitreal Accentrix 3 months before the present injection. The best-corrected visual acuity (BCVA) in the LE before injection was 6/24 and postinjection was perception of hand movement (HM). The intraocular pressure was 14 mmHg in the LE. Anterior-segment examination of the LE revealed the presence of circumcorneal congestion, hypopyon of 2 mm, and anterior-chamber reaction. Pupillary reaction was sluggish with the presence of fibrinous membrane and a thick coagulum over the anterior lens capsule. Detailed fundus examination of the LE was not possible due to hazy media. Ultrasound B scans of the LE revealed diffuse hyperreflective dot echoes in the vitreous cavity, suggestive of acute vitritis [Figure 1].
Figure 1: B-scan showing multiple small dot vitreous echoes suggestive of vitritis

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The patient underwent immediate core vitrectomy and intravitreal injections of vancomycin (1 mg/0.1 ml) and ceftazidime (2.25 mg/0.01 ml) in the LE. He received topical moxifloxacin (0.5%), fortified gentamycin (1.4%), and atropine eye drops in the LE. In addition, oral moxifloxacin tablets (400 mg) once daily for 5 days was given. Direct microscopic examination of the vitreous fluid revealed the Gram-positive cocci arranged in pairs in Gram stain [Figure 2]. The sample was inoculated on 5% sheep blood agar, chocolate agar, potato dextrose agar, thioglycollate broth, and brain–heart infusion broth. The culture grew small cream or white, smooth, entire γ-hemolytic colonies. The isolate was subjected to the identification by VITEK 2 compact system, and it showed a 99% identity with E. faecalis [Figure 3]. Antibiotic susceptibility test was performed by disk diffusion assay as per the CLSI guidelines.[6] The isolate was sensitive to vancomycin, moxifloxacin, levofloxacin, and chloramphenicol but resistant to cefazolin, cefotaxime, and cefuroxime. Postoperatively, the vitritis reduced and the anterior segment reactions decreased. In the postoperative visit at 3 months, the inflammation was well controlled and the BCVA was 6/36 in the LE.
Figure 2: Gram stain image of vitreous biopsy specimen revealing Gram-positive cocci arranged in pairs (×100)

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Figure 3: Small cream or white, smooth, entire γ-hemolytic colony was grown in 5% sheep blood agar at 37°C suggestive of Enterococcus faecalis

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  Discussion Top

Intravitreal anti-vascular endothelial growth factors are becoming a mainstay of treatment for various retinal pathologies, such as diabetic retinopathy, CNVM, polypoidal choroidal vasculopathy, and cystoid macular edema secondary to vascular occlusion.[7] Postinjection endophthalmitis is a serious adverse event associated with these injections and has been reported often in the literature.[5],[7],[8],[9],[10] McCannel in his study has shown the incidence of endophthalmitis postintravitreal injection to be 0.049% (52/105,536 injections).[7]

Different strategies have been adopted to decrease the incidence of intravitreal injection-associated endophthalmitis, such as using prefilled injection syringes, instead of single vial multiple puncture, prophylactic topical antibiotic eye drops, operation theater setting, or office setting. Two recent studies described decrease in the incidence of endophthalmitis with the use of prefilled injection syringes.[5],[8]

The most common organism isolated in the setting of postintravitreal injection endophthalmitis has been reported to be Gram-positive bacteria (over 95% culture positivity), such as Staphylococcus spp. (38%–60%) and Streptococcus spp. (25%–33%).[8]E. faecalis is the most predominant Enterococcus found in the gastrointestinal track of humans and is also a known causative pathogen of oral diseases, such as caries, endodontic infections, and periodontitis.[11]E. faecalis-related endophthalmitis is relatively rare, and it accounted for approximately 1% of endophthalmitis postcataract surgery in the Endophthalmitis Vitrectomy Study.[3] Since Enterococcus spp. is not a common organism in the ocular flora, it can be presumed that infection happened because of external contamination or from an endogenous origin in this case.

The visual prognosis is generally poor in E. faecalis endophthalmitis with one series reporting final BCVA as no perception of light in 50% of the cases.[11] Storey et al. in their study found three cases of postinjection endophthalmitis with E. faecalis of which two patients had a final visual outcome of HMs and light perception only, while the other patient had a final visual outcome of 6/60. This poor prognosis has been attributed to the extracellular toxins such as cytolysin and superoxide that are produced by E. faecalis. In a rabbit model, it was found that E. faecalis toxicity is not confined to ocular cavities as inflammatory cells were found in iris, cornea, ciliary body, and choroid.[12] In our patient, the visual acuity improved to 6/36, which was comparable before the onset of endophthalmitis.

Enterococci showed high degree of resistance to commonly used antibiotics. Rishi et al. reported that E. faecalis was resistant to gentamycin (50%), ceftazidime (72%), and vancomycin (3%).[4] The organism was sensitive to vancomycin in this case, which probably explains the relative better visual outcome in comparison to prior reports.

E. faecalis is a major virulent pathogen in ophthalmic settings and has shown to be associated with poor visual prognosis in previous published literature. Here, we present our case with a better visual outcome due to early surgical intervention and timely management of acute postintravitreal injection endophthalmitis.

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

Kuriyan AE, Sridhar J, Flynn HW Jr., Smiddy WE, Albini TA, Berrocal AM, et al. Endophthalmitis caused by Enterococcus faecalis: Clinical features, antibiotic sensitivities, and outcomes. Am J Ophthalmol 2014;158:1018-23.  Back to cited text no. 1
Arias CA, Murray BE. Emergence and management of drug-resistant enterococcal infections. Expert Rev Anti Infect Ther 2008;6:637-55.  Back to cited text no. 2
Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol 1995;113:1479-96.  Back to cited text no. 3
Rishi E, Rishi P, Nandi K, Shroff D, Therese KL. Endophthalmitis caused by Enterococcus faecalis: A case series. Retina 2009;29:214-7.  Back to cited text no. 4
Storey PP, Tauqeer Z, Yonekawa Y, Todorich B, Wolfe JD, Shah SP, et al. The impact of prefilled syringes on endophthalmitis following intravitreal injection of ranibizumab. Am J Ophthalmol 2019;199:200-8.  Back to cited text no. 5
Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing. 28th ed.. CLSI Supplement M100. Wayne, PA: Clinical and Laboratory Standards Institute; 2018.  Back to cited text no. 6
McCannel CA. Meta-analysis of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents: Causative organisms and possible prevention strategies. Retina 2011;31:654-61.  Back to cited text no. 7
Mishra C, Lalitha P, Rameshkumar G, Agrawal R, Balne PK, Iswarya M, et al. Incidence of endophthalmitis after intravitreal injections: Risk Factors, microbiology profile, and clinical outcomes. Ocul Immunol Inflamm 2018;26:559-68.  Back to cited text no. 8
Sigford DK, Reddy S, Mollineaux C, Schaal S. Global reported endophthalmitis risk following intravitreal injections of anti-VEGF: A literature review and analysis. Clin Ophthalmol 2015;9:773-81.  Back to cited text no. 9
Komiyama EY, Lepesqueur LS, Yassuda CG, Samaranayake LP, Parahitiyawa NB, Balducci I, et al. Enterococcus species in the oral cavity: Prevalence, virulence factors and antimicrobial susceptibility. PLoS One 2016;11:e0163001.  Back to cited text no. 10
Han DP, Wisniewski SR, Wilson LA, Barza M, Vine AK, Doft BH, et al. Spectrum and susceptibilities of microbiologic isolates in the Endophthalmitis Vitrectomy Study. Am J Ophthalmol 1996;122:1-7.  Back to cited text no. 11
Forster RK. Experimental postoperative endophthalmitis. Trans Am Ophthalmol Soc 1992;90:505-59.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3]


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