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Year : 2017  |  Volume : 4  |  Issue : 1  |  Page : 23-26

Conjunctivitis progressing into endophthalmitis in an eye with an old scleral buckle and its managements

1 Department of Ophthalmology, Hospital Raja Permaisuri Bainun, 30990 Ipoh; Department of Ophthalmology, Hospital Universiti Sains , 16150 Kubang Kerian, Malaysia
2 Department of Ophthalmology, Hospital Universiti Sains , 16150 Kubang Kerian, Malaysia
3 Department of Ophthalmology, Hospital Raja Permaisuri Bainun, 30990 Ipoh, Malaysia

Date of Web Publication20-Apr-2017

Correspondence Address:
Logandran Vijaya Kumar
Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/erj.erj_17_16

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Conjunctivitis is a common eye infection but can be sight-threatening in patients with previous sclera buckles. A 73-year-old man who had right eye scleral buckle surgery two decades ago presented with right eye acute conjunctivitis, for which a topical antibiotic was prescribed. The right eye vision was 6/18, the conjunctiva was not chemosed, the anterior chamber remained quiet, and the fundus was unremarkable. A week later, he returned complaining of right eye painful and blurring of vision. The right eye vision had deteriorated to hand movements. Examination showed right lid swelling, chemosed conjunctiva, exposed scleral buckle, anterior chamber cells, and dense vitritis. These clinical features were suggestive of right eye endophthalmitis. Emergency intravitreal injections, early scleral buckle removal, and vitrectomy with silicone oil tamponade were performed. The patient was also treated with intravenous and topical antibiotics. The final right eye vision was preserved to 6/18. Simple conjunctivitis can progress into endophthalmitis in a patient with a scleral buckle. Prompt surgical management gives the best outcome.

Keywords: Conjunctivitis, endophthalmitis, infected exposed buckle, intravitreal antibiotics, silicone oil, vitrectomy

How to cite this article:
Kumar LV, Tai L M, Yusof WM, Hitam WH. Conjunctivitis progressing into endophthalmitis in an eye with an old scleral buckle and its managements. Egypt Retina J 2017;4:23-6

How to cite this URL:
Kumar LV, Tai L M, Yusof WM, Hitam WH. Conjunctivitis progressing into endophthalmitis in an eye with an old scleral buckle and its managements. Egypt Retina J [serial online] 2017 [cited 2023 Jan 30];4:23-6. Available from: https://www.egyptretinaj.com/text.asp?2017/4/1/23/204838

  Introduction Top

Scleral buckling surgery was one of the earliest procedures used to treat retinal detachment. A silicone rubber element, sutured on the sclera, indents the wall of the eye under the retinal tear, allowing reapposition of the detached neurosensory retina to the retinal pigmented epithelium and indirectly restoring the physiologic forces which maintain retinal attachment. In most instances, the buckles are left on the eyeball permanently. Scleral buckling surgery has declined in favor over recent years, being replaced by vitrectomy and tamponade for the repair of retinal detachments. However, patients with scleral buckles may still present to the clinician with common eye conditions or late complications related to the procedure. We present a case of conjunctivitis in an old scleral buckle, which progressed to endophthalmitis.

  Case Report Top

A 73-year-old highly myopic man with underlying hypertension complained of right eye watery discharge and redness for 3 days before presentation. His vision remained good. He had a history of bilateral recurrent retinal detachments, with pneumatic retinopexy and cryopexy performed in each eye, followed by scleral buckling in both eyes about 20 years ago. He also had uneventful cataract operations with intraocular lens implantation bilaterally about 10 years ago. He had no recent use of topical eye drops. On examination, he had a best corrected visual acuity of 6/18 in the right eye and 6/24 in the left eye. There was conjunctival injection in the right eye, but no pseudomembrane or lid swelling. Other anterior and posterior segment findings of the right eye were normal. The left eye findings were unremarkable. The patient was diagnosed with right eye conjunctivitis and started on topical ciprofloxacin.

On follow-up, a week later, he complained of worsening eye redness, associated with painful lid swelling and blurring of vision. The right eye vision decreased to hand movement. There was obvious right eye periorbital and lid swelling, with an injected and chemosed conjunctiva [Figure 1]. There was also exposure of the scleral buckle medially with erosion of the conjunctiva [Figure 2]. The cornea was clear and the anterior chamber was filled with cells, grading 2+ (SUN Working Group Grading). Dense vitritis in the posterior segment obscured our fundus view. B-scan ultrasonography of the right eye showed vitreous opacities over a flat retina [Figure 3].
Figure 1: Color photograph of the patient's right eye showing swollen lids and injected conjunctiva.

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Figure 2: Color photograph of the patient's right eye showing conjunctival erosion exposing the scleral buckle (point to the silicon tire) at the upper medial canthus.

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Figure 3: B-scan of the patient's right eye showed vitreous opacity.

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The patient was treated for presumed right eye endophthalmitis secondary to an infected scleral buckle. Emergency right eye intravitreal tapping with intravitreal antibiotics injections (ceftazidime 2 mg/0.1 ml and vancomycin 1 mg/0.1 ml) was performed. The vitreous tap appeared clear. The patient was also started on intravenous ciprofloxacin 400 mg twice a day, topical vancomycin, ceftazidime, dexamethasone hourly and topical homatropine thrice a day. The following day, scleral buckle removal and vitrectomy with silicone oil tamponade were performed as the patient did not show significant clinical improvement. A second dose of intravitreal antibiotics (ceftazidime and vancomycin) was also given during the procedure. Copious amounts of purulent discharge over the exposed silicone tire, and the anchoring scleral sutures were noted during the surgery. There was also dense vitritis and periphlebitis. However, the retina remained flat.

The removed silicone tire was sent for culture and sensitivity. It grew methicillin-resistant coagulase-negative Staphylococci, which was susceptible to most antibiotic groups, including ciprofloxacin. Vitreous tap and biopsy were negative for any organisms. Topical and intravenous antibiotics were continued while in the ward, and the patient was discharged well after completing his course of ciprofloxacin for a week. On discharge, his vision improved to 6/48 with no signs of inflammation. Topical medications were tapered over the next few weeks. On follow-up at 3 weeks postsurgery, the vision in his right eye had improved to 6/24, pinhole 6/18. His recovery was uneventful, except for a slight rise in intraocular pressure noted during his 6-week postoperative visit, which was controlled with topical timolol. He subsequently underwent uneventful removal of oil 5 months later and topical timolol was discontinued. His best-corrected visual acuity at 1-month post removal of oil was 6/15. The left eye remained normal.

  Discussion Top

Infected scleral buckle is a rare postoperative complication, with reported incidence rates ranging from 0.5% to 5.6%.[1] The median interval between scleral buckling surgery and the onset of symptoms of infection varies, from as early as 1-month postoperation to years after surgery.[2],[3] The risk factors for infection include perioperative treatment, duration of surgery, and explant material.[4] An exposed buckle is also at risk of infection.

Conjunctivitis in a sclera buckle patient is drier than isolated conjunctivitis in a patient with no ocular comorbidities. If not adequately treated, the festering infection may progress to exogenous endophthalmitis, as in our patient. Our proposed mechanism for the development of endophthalmitis, in this case, is that infection spreads into the vitreal cavity through the contaminated buckle implant or suture material used to anchor the buckle. Suture erosion can be transscleral or transconjunctiva.[5] The risk of transscleral spread may be greater in a highly myopic eye, in which there is pathological thinning of the sclera. Although it is still marginally possible that a red eye is an early sign of buckle infection, rather than the cause, the likelihood of endogenous endophthalmitis in our patient was low as he had no systemic comorbidities or foci of infection.

Most cases of scleral buckle infection are due to coagulase-negative Staphylococci, especially Staphylococcus epidermidis.[2] However, not all scleral buckle infections are symptomatic and not all symptomatic infections will give a positive culture as demonstrated by Wirostko et al. in their study of explanted scleral buckles.[6] In that study, 44% of patients with clinical infection had a positive culture, but interestingly, so did 27% of patients without clinical signs of infection. Certain organisms, such as coagulase-negative Staphylococci and Mycobacterium, were more likely to be associated with clinical infection.[6],[7] Meanwhile, in a study of scleral buckle infections, 19% of cases were related to methicillin-resistant Staphylococcus aureus.[8]

The patient was fortunate that the infecting organism was sensitive to ciprofloxacin. Approximately only 75% of Gram-positive isolates in scleral buckle infection are sensitive to ciprofloxacin.[9] This is in contrast to vancomycin which has markedly better efficacy on Gram-positive organisms.[7],[9] This may explain why the latter is an essential part of the intravitreal medication cocktail used in the management of presumed endophthalmitis. The removal of the infected buckle should not be delayed as it is usually impossible to treat the infection with topical or systemic antibiotics alone, due to bacterial secretion of a biofilm that surrounds the sclera buckle, preventing adequate penetration of antibiotics.[10] This is illustrated in our case, in which although the organism was sensitive to topical ciprofloxacin, the patient still developed endophthalmitis, which was only successfully treated by removal of the infected buckle. A case report by Rostron et al. described a 65-year-old woman with recurrent right eye conjunctivitis for 2 years, which only resolved after an extruding sclera buckle was noted and removed.[11]

Once endophthalmitis has been suspected, prompt empirical management even with intravitreal regimens is imperative even before the results of culture are available. Vancomycin, a larger molecule, leaves the eye predominantly through the anterior chamber by passive diffusion across the vitreous into the aqueous (anterior route).[12] Meanwhile, ceftazidime, a much smaller molecule, exits the eye through the anterior route and also through uveal blood flow, facilitated by active transport by the retinal pigment layer pump (posterior route).[12],[13] In an inflamed eye, drugs eliminated through the anterior route have faster clearance, while the clearance via the posterior route is compromised.[14] In vitrectomized eyes, clearance through the posterior route is enhanced. Thus, both these drugs are safe choice in their original dosing for intravitreal regimes, with or without vitrectomy.

Although the endophthalmitis vitrectomy study recommends surgical intervention only if vision deteriorates to light perception, early vitrectomy with silicone oil tamponade is increasingly gaining acceptance.[15],[16] We chose to use silicone oil tamponade in our patient as it has antimicrobial activity against endophthalmitis-causing agents and is associated with a lower rate of retinal detachment and improved visual acuity.[17-19] However, Hegazy et al.[20] demonstrated in rabbit's eyes that when the vitreous cavity is occupied by silicone oil, the concentration of antibiotics is higher than in nonvitrectomized eyes, due to a longer elimination time, as the drugs trapped in the retrosilicone-preretinal space, resulting in retinal toxicity. Their study recommended a decrease of 75% from the original dose to avoid toxicity. We did not reduce the dosing; instead, intravitreal antibiotics were given after changing the infusion fluid to air. The vitreous cavity was still filled with balanced salt solution up to the level of the ports at this time, and full air-fluid exchange was performed 1–2 min after the antibiotics injections, after which the silicon oil was injected. In this way, the retinal toxicity was reduced and the original antibiotics dosing could be maintained.

In spite of the fact that the incidence of infected scleral buckle is rare, endophthalmitis could progress rapidly and the prognosis depends on the duration of endophthalmitis, time to treatment, virulence of bacteria, etiology of entry, and existing ocular diseases.

Conjunctivitis in patients with scleral buckles should be managed more aggressively, including sending a conjunctival swab for culture and sensitivity. If endophthalmitis occurs, we advocate explantation of the buckle implant and early vitrectomy with silicone oil tamponade.

Simple conjunctivitis in a patient with a scleral buckle can evolve into vision-threatening conditions. The integrity of the conjunctiva overlying a scleral buckle implant should be evaluated during routine follow-up for erosions, exposure, or infection. An exposed scleral buckle should always be removed as it forms a potential nidus of infection. Even when the conjunctiva in intact, a transconjunctival spread of the infection may sometimes be inevitable. A low threshold for surgical management gives the best outcome.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Tsui I. Scleral buckle removal: Indications and outcomes. Surv Ophthalmol 2012;57:253-63.  Back to cited text no. 1
Chhablani J, Nayak S, Jindal A, Motukupally SR, Mathai A, Jalali S, et al. Scleral buckle infections: Microbiological spectrum and antimicrobial susceptibility. J Ophthalmic Inflamm Infect 2013;3:67.  Back to cited text no. 2
Kazi MS, Sharma VR, Kumar S, Bhende P. Indications and outcomes of scleral buckle removal in a tertiary eye care center in South India. Oman J Ophthalmol 2015;8:171-4.  Back to cited text no. 3
[PUBMED]  [Full text]  
Doft BH, Lipkowitz J, Kowalski R, Taylor F. An experimental model to assess factors associated with scleral buckle infection. Retina 1983;3:212-7.  Back to cited text no. 4
Solomon K, Gussler JR, Gussler C, Van Meter WS. Incidence and management of complications of transsclerally sutured posterior chamber lenses. J Cataract Refract Surg 1993;19:488-93.  Back to cited text no. 5
Wirostko WJ, Covert DJ, Han DP, Connor TB Jr., Kim JE, Hammersley J, et al. Microbiological spectrum of organisms isolated from explanted scleral buckles. Ophthalmic Surg Lasers Imaging 2009;40:201-2.  Back to cited text no. 6
Mohan N, Kar S, Padhi TR, Basu S, Sharma S, Das TP. Changing profile of organisms causing scleral buckle infections: A clinico-microbiological case series. Retina 2014;34:247-53.  Back to cited text no. 7
Oshima Y, Ohji M, Inoue Y, Harada J, Motokura M, Saito Y, et al. Methicillin-resistant Staphylococcus aureus infections after scleral buckling procedures for retinal detachments associated with atopic dermatitis. Ophthalmology 1999;106:142-7.  Back to cited text no. 8
Pathengay A, Karosekar S, Raju B, Sharma S, Das T; Hyderabad Endophthalmitis Research Group. Microbiologic spectrum and susceptibility of isolates in scleral buckle infection in India. Am J Ophthalmol 2004;138:663-4.  Back to cited text no. 9
Asaria RH, Downie JA, McLauglin-Borlace L, Morlet N, Munro P, Charteris DG. Biofilm on scleral explants with and without clinical infection. Retina 1999;19:447-50.  Back to cited text no. 10
Rostron E, Abdelaziz L, Barbara R, Metcalfe T. Missed sclera buckle as a cause of recurrent conjunctivitis. BMJ Case Rep 2012;2012. pii: Bcr2012006931.  Back to cited text no. 11
Mitra AK, Anand BS, Duvvuri S. Drug delivery to the eye. In: Fischbarg J, editor. The biology of the eye. New York: Academic Press; 2006. p. 307-351.  Back to cited text no. 12
Shaarawy A, Meredith TA, Kincaid M, Dick J, Aguilar E, Ritchie DJ, et al. Intraocular injection of ceftazidime. Effects of inflammation and surgery. Retina 1995;15:433-8.  Back to cited text no. 13
Coco RM, L√≥pez MI, Pastor JC, Nozal MJ. Pharmacokinetics of intravitreal vancomycin in normal and infected rabbit eyes. J Ocul Pharmacol Ther 1998;14:555-63.  Back to cited text no. 14
Siqueira RC, Gil AD, Canamary F, Minari M, Jorge R. Pars plana vitrectomy and silicone oil tamponade for acute endophthalmitis treatment. Arq Bras Oftalmol 2009;72:28-32.  Back to cited text no. 15
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. 16
Ornek N, Apan T, Ogurel R, Ornek K. Comparison of the antimicrobial effect of heavy silicone oil and conventional silicone oil against endophthalmitis-causing agents. Indian J Ophthalmol 2014;62:388-91.  Back to cited text no. 17
Nagpal M, Jain P. Author Reply to Letter to the Editor on the Article: Nagpal M, Jain P, Nagpal K. Pars plana vitrectomy with or without silicone oil endotamponade in surgical management of endophthalmitis. Asia Pac J Ophthalmol (Phila) 2012;1:385.  Back to cited text no. 18
Bali E, Huyghe P, Caspers L, Libert J. Vitrectomy and silicone oil in the treatment of acute endophthalmitis. Preliminary results. Bull Soc Belge Ophtalmol 2003;288:9-14.  Back to cited text no. 19
Hegazy HM, Kivilcim M, Peyman GA, Unal MH, Liang C, Molinari LC, et al. Evaluation of toxicity of intravitreal ceftazidime, vancomycin, and ganciclovir in a silicone oil-filled eye. Retina 1999;19:553-7.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3]


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