Endogenous panophthalmitis in a patient with COVID-19 during hospitalization in an intensive care unit: A case report.

Purpose: To report a case of endogenous panophthalmitis in a patient with COVID-19 during treatment in an Intensive Care Unit. Observation: A 64-year-old woman with COVID-19 and Salmonella septicemia presented with decreased visual acuity, ocular pain, and proptosis in her right eye after treatment with favipiravir, intravenous dexamethasone, and ceftriaxone. An ocular examination of her right eye revealed periorbital tenderness, exophthalmos, and corneal haze. The ultrasonography showed a subretinal abscess. Her right eye lost light perception vision and underwent enucleation. Microbiologic evaluation of the enucleated right eye was negative for organisms. Conclusions and importance: Patents with COVID-19 may develop severe ocular involvement after COVID-19 due to a generalized reduction in immunity. Comorbidities and intensive care unit treatments can predispose COVID-19 patients to endogenous panophthalmitis.

Introduction

In March 2020, Thailand was the first country outside China to report patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). By January 2022, 2 308 615 people had been infected with the novel coronavirus (COVID-19), and 21 898 had died from COVID-19 or its consequences. The disease has been studied intensively. COVID-19 affects the respiratory system primarily and may have severe pulmonary and extra-pulmonary complications.

Ocular involvement has been reported in patients with COVID-19 infection during the condition and its recovery phase.2, 3, 4 Treatment of COVID-19 during hospitalization may increase the susceptibility of COVID-19 patients to several ocular consequences and complications. Endogenous panophthalmitis is a rare sight‐threatening condition usually associated with patients with comorbidities such as diabetes mellitus, intravenous drug use, or a systemic immunocompromised state. , Patients hospitalized with COVID-19 are vulnerable to endophthalmitis and panophthalmitis due to general predisposing risk factors of being in the intensive care unit and the use of immunocompromising therapeutics such as corticosteroids. We report a case of endogenous panophthalmitis in a patient with COVID-19 during hospitalization in an intensive care unit in Thailand.

Case report

A 64‐year‐old, unvaccinated woman with COVID-19 (presumed to be the delta-serotype consistent with becoming infected during the second pandemic wave) was admitted to the intensive care unit with severe acute pneumonia and septicemia. Her underlying diseases were diabetes mellitus, essential hypertension, and a recent pons infarction. She had been treated with favipiravir, intravenous dexamethasone, oxygen cannula, and intravenous ceftriaxone as antibiotic prophylaxis. Once the hemoculture revealed Salmonella subgroup D, ceftriaxone was replaced by intravenous meropenem. COVID-19 was confirmed to be undetected 3 weeks after admission by real-time polymerase chain reaction (RT-PCT).

On the 29th day after admission, she developed fever, decreased vision, ocular pain, and proptosis in her right eye. An ocular examination revealed visual acuity (light perception in the right eye and 20/30 in the left eye); periorbital tenderness and swelling; mild exophthalmos; limited extraocular movement; marked chemosis; and a generalized corneal haze. Due to corneal opacity, the anterior chamber, pupil, lens and posterior segment of the right eye could not be evaluated. Her left eye was unremarkable. The ocular manifestations are illustrated in Fig. 1 A and B.

Fig. 1

A and 1B. Clinical presentation of Covid-19 patient with panophthalmitis in the right eye on the 29th day after admission to the intensive care unit for Covid-19 treatment.

A computed tomography (CT) scan of the orbit revealed exophthalmos, relatively thickened and enhanced right anterior periorbital soft tissue, minimal fat haziness of the right intra-extraconal fat, and suspected pre- and postseptal cellulitis. Fig. 2 A, B, 2C, and 2D present the orbit CT scan. Ultrasonography of the right eye showed normal globe contour, heterogeneous vitreous debris (a), subretinal and choroidal abscess (b), and total retinal detachment (c) (Fig. 3 A and B). A diagnosis of endogenous endophthalmitis was made. Topical antiglaucoma medications and moxifloxacin were administered, and intravenous ciprofloxacin was initiated.

Fig. 2

A, 2B, 2C, and 2D: A computed tomography scan of the orbit revealed exophthalmos, thickened enhanced right anterior periorbital soft tissue, minimal fat haziness of right intra-extraconal fat, relatively thickened enhanced right anterior periorbital soft tissue, and suspected pre- and postseptal cellulitis.

Fig. 3

A and 3B. Ultrasonography of the right eye showed normal globe contour, heterogenous vitreous debris (a), subretinal and choroidal abscess (b), and total retinal detachment (c).

The patient lost light perception vision with an uncontrolled ocular infection and subsequently underwent enucleation of the right eye. Microbiologic evaluation of the enucleated right eye was negative for organisms. No additional abscesses were detected systemically. The patient was discharged once COVID-19 was reconfirmed to be negative by RT-PCR and her medical condition stabilized.

Discussion

Since January 2020, several ocular manifestations have been reported in patients with COVID-19. Ocular involvement may result from direct invasion of the COVID-19 virus and the immune-mediated effects it induces, which can be present at any stage of the disease. Furthermore, intensive management of COVID-19 during hospitalization predisposes patients to comorbidities and complications.

Conjunctivitis is one of the most common ocular manifestations in COVID-19 patients. To our knowledge, this is the first case report of panophthalmitis in a patient with COVID-19. Endogenous endophthalmitis accounts for approximately 2%–8% of cases of endophthalmitis , and can in rare circumstances lead to a more severe panophthalmitis. The causative organisms differ between Western and Asian countries. In Western countries, gram-positive organisms predominate, whereas gram-negative organisms are more common in Asian countries. , , Panophthalmitis can be exogenous (associated with ocular trauma, ocular surgery, or ocular infection) or endogenous (hematogenous spread of microorganisms from a primary location elsewhere in the body to the eye). Panophthalmitis is often found in immunocompromised patients or individuals with chronic debilitating illnesses. , Its clinical signs include extensive intraocular inflammation with intraorbital tissue involvement. Although vitreous culture may be supportive, endogenous panophthalmitis is a clinical diagnosis in the setting of positive serum cultures.

In general, intensive care and compromised immunity predispose patients to bacterial infection. Additionally, steroids can promote the development of bacterial and viral septicemia. The hypothesis of delayed organ infection in patients with COVID-19 is based on a generalized lowering of immunity by the disease itself, the use of immunosuppressants, and the multisystem inflammatory syndrome related to COVID-19. , In our case, the patient had COVID-19 infection treated with corticosteroids, Salmonella septicemia and diabetes mellitus as predisposing risk factors for endogenous endophthalmitis.

Endogenous panophthalmitis is commonly bacterial. Unfortunately, we did not perform vitreous RT–PCR for COVID-19, and we could not document a bacterial or viral causative organism from the enucleated eye. The absence of a detectable causative organism may have resulted from the patient's previous treatment with intravenous antibiotics and anti-COVID-19 medications. Identifying infection's focus in endogenous panophthalmitis is typically challenging, especially in cases with COVID-19. The evidence strongly suggested that our patient had endogenous panophthalmitis due to Salmonella septicemia. Salmonella is a rod-shaped (bacillus) gram-negative Enterobacteriaceae bacterium. Salmonella serotypes can be divided into typhoidal and nontyphoidal subgroups. Some serotypes cause illness, most of which can be resolved without antibiotics. Endogenous panophthalmitis caused by Salmonella is rare. , Early diagnosis and rapid systematic and local eye treatment are essential to reduce morbidity and mortality in panophthalmitis. Early systemic antibiotics in combination with intravitreal antibiotics are the mainstay of treatment in endogenous panophthalmitis. ,

The Endophthalmitis Vitrectomy Study recommended early vitrectomy as an alternative treatment for postoperative endophthalmitis in patients with poor visual acuity. Our patient received intravenous meropenem as a treatment for Salmonella septicemia. However, the meropenem was replaced by intravenous ciprofloxacin after the patient was diagnosed with endogenous panophthalmitis due to the superior ocular penetration of ciprofloxacin. We did not administer an intravitreal antibiotic injection or perform a vitrectomy, given that the patient's medical condition was so severe that she could not be moved out of the intensive care unit. Following intensive treatment, she lost light perception with evidence of total retinal detachment and subretinal abscess by ultrasonography. We did not consider vitrectomy but opted for enucleation despite an uncontrolled infection. However, most endogenous endophthalmitis/panophthalmitis cases have been reported to have a poor prognosis despite appropriate treatment. In many cases, evisceration or enucleation is required as empirical treatment, as with our patient.

Conclusions

Patents with COVID-19 may develop severe ocular involvement after COVID-19 due to a generalized reduction in immunity. Comorbidities, intensive care unit treatments, and immunosuppressants can predispose COVID-19 patients to endogenous endophthalmitis/panophthalmitis.

Patient consent

Written informed consent for publication was given by the patient.

Conflict-of-interest declaration

The authors declare there are no conflicts of interest related to this study.

Funding disclosure

This was an unfunded study.

Authorship

All authors attest that they meet the current ICMJE criteria for Authorship.