Post cataract Pseudomonas stutzeri endophthalmitis: Report of a case and review of literature.

We report a rare case of Pseudomonas stutzeri endophthalmitis in an immunocompetent individual along with the review of the literature. A 39-year-old healthy lady presented with sudden painful loss of vision in her right eye. She was diagnosed with postcataract surgery acute endophthalmitis and underwent vitrectomy, intraocular lens explantation and intravitreal antibiotics. P. stutzeri was isolated from vitreous. Though the infection was controlled, the anatomy of the eye could not be salvaged and the right eye became phthisical. P. stutzeri is a rare cause of endophthalmitis with usually poor outcomes.

Pseudomonas species are known to cause devastating ocular infections including endophthalmitis and bacterial keratitis.[12] Among its various species, Pseudomonas aeruginosa has been mainly implicated as the cause of endophthalmitis. Pseudomonas stutzeri as an etiological microorganism for delayed onset of endophthalmitis has been sparingly described in the literature.[3] To the best of our knowledge, present report was the first to describe acute endophthalmitis by P. stutzeri in a patient who underwent extra capsular cataract extraction with intraocular lens implantation.

Case Report

A 39-year-old lady presented with sudden painful decrease in vision in the right eye for two days. She had undergone extracapsular cataract extraction with intraocular implantation 12 days back elsewhere. The best corrected visual acuity (BCVA) in the right eye was perception of light with accurate projection of rays. Anterior segment examination showed circumciliary congestion, corneal haze, 3+ anterior chamber cells, and exudative plaque covering the pupil intraocular pressure with applanation tonometer was 10 mm of Hg. Left eye was normal. Fundus of left eye was not visible due to pupillary exudates. Ultrasound B scans showed plenty of dot echoes. A provisional diagnosis of acute postcataract surgery endophthalmitis was made. A complete systemic examination that included routine blood investigations, and urine and blood culture along with a physician evaluation was done. No active systemic foci of infection were detected. The patient underwent standard three port 23-gauge pars plana vitrectomy, intraocular lens explantation, and intravitreal antibiotics (vancomycin 1 mg/0.1 ml and amikacin 0.4 mg/0.1 ml). Undiluted vitreous aspirate and intraocular lens were sent for microbiological tests. In view of recurrent exudates at pupil and no view of fundus again in postoperative period, the right eye received two more intravitreal injection of vancomycin and amikacin. No organism was identified on Gram's stain, 10% KOH mount and calcofluor-white stain. Vitreous culture revealed P. stutzeri causative organism. Antibiotic sensitivity testing was performed by the Kirby-Bauer disc diffusion method. The organism was sensitive to gentamicin, ciprofloxacin, amikacin and resistant to cefotaxime, ceftazidime, and vancomycin. Based on the sensitivity report, the patient further received two more intravitreal injections of amikacin and ciprofloxacin (0.1 mg/0.1 ml). However, at the end of follow-up of nine months, the eye became phthisical.

Discussion

P. stutzeri is an aerobic, gram negative bacteria first described by Burri and Stutzer in 1895. It is usually found in the soil, manure, pond water, and sewage. It is ubiquitous in hospital environment and is a rare opportunistic human pathogen. Though it has been isolated from surgical wounds, blood, sputum, and urine, isolation from the eye is extremely rare.[4] Most patients in whom the organism has been isolated have been elderly and in poor health.[45] Review of the literature shows that only a few isolated cases of ocular infections by P. stutzeri have been reported [Table 1]. In 1977, Brinzer[6] reported the first ever case of corneal ulcer due to P. stutzeri in a scarred cornea secondary to previous herpetic infection. In 2001, Lebowitz et al.[1] reported a single case of late onset panophthalmitis with orbital abscess due to P. stutzeri. One case of delayed onset endophthalmitis following cataract surgery has been reported in 1998 by Jiraskova et al.[3] The patient was elderly and in poor health. The organism was sensitive to tetracycline, gentamicin, amoxicilin, and ofloxacin, and resistant to oxacillin, chloramphenicol, vancomycin and cefalotin. P. stutzeri was identified as the cause of conjunctivitis in an eye with preexisting corneal opacity in a 66-year-old female by Malhotra et al.[7] In the current case, we report an acute onset postcataract surgery endophthalmitis due to P. stutzeri in a relatively young and immunocompetent patient. Report suggested that the organism was susceptible to gentamicin, ciprofloxacin, and amikacin whereas resistant to cefotaxime, ceftazidime, and vancomycin. The current case for the first time reports P. stutzeri as the cause of acute endophthalmitis following cataract surgery. Authors also intend to highlight the significance of early detection of causative microorganism and antibiotic sensitivity test in prompt management of endophthalmitis.

Table 1

Review of literature of P. stutzeri ocular infection

Authors	Year	Eye disease	Age/gender	Systemic history	Initial BCVA	Clinical presentation	Treatment	Final outcome
Brinser et al.	1977	Corneal ulcer	78 years; male	None	HMCF	Corneal abscess and hypopyon	Topical gentamicin and colistin. Intravenous gentamicin	Deceased
Jiraskova et al.	1988	Post cataract surgery endophthalmitis	88 years; female	None	20/1000	Corneal edema, hypophon, fibrin, and exudates	Vitrectomy, topical gentamicin	20/200
Lebowitz et al.	2001	Bleb related panophthalmitis with orbital abscess	69 years; male	None	No PL	Severe proptosis, corneal edema, fibrin, and hypopyon	Intravitreal vancomycin, ceftazidime. Enucleation	No PL
Kalra et al.	2015	Bacterial keratitis	25 years; female	Trigeminal nerve schwanoma	HMCF	Corneal edema, Multiple infiltrate and epithelial defect	Topical ciprofloxacin, fortified cefazoline and amikacin	20/40
Malhotra et al.	2008	Conjunctivitis	66 years; female	None	Not available	Discharge and dry eye	Topical ciprofloxacin	Resolution of conjunctivitis
Present report	2019	Post cataract surgery endophthalmitis	39 years; female	Hypertension	HMCF	Corneal edema, hypopyon, fibrin and exudates	Vitrectomy, IOL removal, Intravitreal Vancomycin, amikacin and ciprofloxacin	Phthisis

BCVA=Best corrected visual acuity; HMCF=Hand movement close to face; PL=Perception of light; IOL=Intraocular lens

Conclusion

Though rare, P. stutzeri should be considered in the list of microorganisms responsible for acute postcataract surgery endophthalmitis.

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Conflicts of interest

There are no conflicts of interest.