Concurrent endophthalmitis and orbital cellulitis in a child with congenital glaucoma and a glaucoma drainage device

Abstract

SummaryA 3-year-old monocular boy with a history of congenital glaucoma and aqueous shunt implantation presented with periorbital swelling, erythema, and purulent discharge in his seeing right eye. Examination revealed an extensive hypopyon. Computed tomography (CT) showed right-sided proptosis, and a displaced aqueous shunt device deep in the orbit. Significant purulent fluid was encountered when the device was removed; vitreous and orbital cultures revealed Streptococcus pneumoniae. The patient received intravitreal, topical, intravenous, and oral antibiotics as well as intraocular tissue plasminogen activator and topical steroid. Orbital and intraocular inflammation decreased significantly but he developed a cataract, further complicated by a retinal detachment. Case ReportA 3-year-old monocular boy with a history of congenital glaucoma presented to the ophthalmology clinic at the Royal Alexandra Hospital in May 2011 with purulent discharge from his seeing right eye associated with periorbital swelling and erythema. The patient had a routine examination by his pediatric ophthalmologist 2 days prior. At the time, red reflex and retinoscopy streak in his right eye was noted to be clear, but the examination was lengthy and difficult and attempts at a slit-lamp examination were unsuccessful. He presented to the emergency room the next day complaining of severe pain behind the right eye with no obvious eyelid swelling. Examination was limited since he was unwilling to open the eye, and he was referred to the ophthalmology clinic the next day. The parents denied a history of the patient rubbing his eye.The family was of Turkish descent, and the patient's paternal and maternal grandfathers were distant relatives. The patient's older sister had also been diagnosed with congenital glaucoma and had received extensive treatment. Genetic testing found the patient to be autosomal recessive for the Cyp1B1 gene, which has been mapped to the 2p21 region and linked with primary congenital glaucoma. 1

Orbital Cellulitis Following Uncomplicated Glaucoma Drainage Device Surgery: Case Report and Review of Literature

“…Most patients presented within two days of symptom onset. [1][2][3][4][5][6][7][8] On presentation, all patients had eyelid erythema and edema, and most patients had chemosis, proptosis or globe displacement, and limited extraocular motility.…”

“…The most common GDD associated with post-implantation OC was the Ahmed valve (n = 7), [2][3][4][5][6][7] although Molteno, [1] Krupin-Denver, [2] and Baerveldt [8,9] implants have also been associated with post-implantation OC. In seven cases, symptoms of OC started in the immediate postoperative period (≤ 3 months after the surgery).…”

“…[1,2,[5][6][7][8] In the other four cases, OC developed after the postoperative month 3. [2][3][4]9] In three of the four cases of delayed-onset OC, [2,4,9] the tube was exposed, presumably serving as a conduit for bacteria to travel from the ocular surface into the orbit. In one case of delayed-onset OC, the tube was not specifically exposed; however, the patient had concurrent endophthalmitis.…”

“…In one case of delayed-onset OC, the tube was not specifically exposed; however, the patient had concurrent endophthalmitis. [3] The authors theorized that organisms may have gained entry into the eye from the ocular surface and OC from drainage via the tube. [3] Table 2 summarizes the management of OC.…”

“…[3] The authors theorized that organisms may have gained entry into the eye from the ocular surface and OC from drainage via the tube. [3] Table 2 summarizes the management of OC. CT is the imaging modality of choice for OC and was the most common modality used.…”