Bilateral Enterococcus Faecalis Corneal Ulcers With Right Eye Endophthalmitis And Consequent Bilateral Blindness As A Result Of Chronic Intentional Self-Injury – A Case Report

To present a case of Enterococcus faecalis corneal ulcers with endophthalmitis and consequent bilateral blindness as a result of unrecognised intentional self-injury

¹ Department of Ophthalmology, Zagreb University Hospital Center, Zagreb, Croatia

² School of Medicine, University of Zagreb, Zagreb, Croatia

³ Department of Pathology, School of Medicine, University of Zagreb, Zagreb, Croatia.

A 56-year-old woman was admitted to our Clinic with progressive corneal ulcer in the left eye. Her BCVA was 0,7 logMAR on the right eye and CF at 1m on the left eye. Clinical findings on the right eye showed conjunctival hyperemia with superficial punctuate keratopathy, and a corneal ulcer and severe conjunctival reaction of her left eye. Nodular and ulcerative eyelid skin lesions with central crusts were present. Similar skin lesions were also detected on earlobes, brows, left nostril, lips, and abdominal skin. Complete serological and immunological diagnostic panels excluded autoimmune diseases. Skin and mucosa biopsies were performed and the changes described as unspecific. Corneal scrapings and conjunctival swab were negative on Acanthamoeba. The only finding was Enterococcus faecalis  that caused the corneal ulcer for which she was treated.  After discharge, she was readmitted with the corneal ulcer on her right eye, followed by endophthalmitis. Skin changes showed more epidermal lesions and erythematous infiltrations. According to clinicians, changes in her skin were most likely from self-manipulation, but she decisively denied it. She was diagnosed with the anxiety-depressive disorder.  Penetrating keratoplasty  and cataract surgery were performed on both eyes but she developed repetitive corneal graft rejection. Despite all therapeutic and surgical protocols taken, she ended up blind with phthisis of both eyes. 

Corneal ulcer caused by Enterococcus faecalis infections is indeed a rare finding.  Although a rarity, intentional mechanical eye trauma should be considered in progressive and etiologically unclear eye pathology. The patient's uncooperative behavior, constant denial of self-harm and continuous worsening of her health condition should always raise a concern of underlying psychiatric problem. By setting proper diagnosis earlier and with psychiatric treatment, this case could have had different resolution.