ACANTHAMOEBA AND PSEUDOMONAS CO-INFECTION FOLLOWING CATARACT SURGERY

To report the emergence of threatening infections and describe the many obstacles encountered in the management of postoperative panophthalmitis following cataract surgery in the midst of the economic and sanitary crisis in Lebanon.

Acute infectious endophthalmitis occurring post cataract extraction surgery is mainly caused by contamination with gram positive organisms, with rare cases of gram-negative bacteria isolated. We report a case of an endophthalmitis secondary to a co-infection with Acanthamoeba and Pseudomonas aeruginosa post cataract surgery in a peripheral hospital in Lebanon.

76-year-old male patient presented to our department 2 weeks post cataract surgery in left eye performed in a peripheral hospital; a diagnosis of acute postoperative endophthalmitis was made. Patient was already taking topical moxifloxacin and has received 4 intravitreal injections of vancomycin and ceftazidime. Corneal scrape and samples from incision discharge were taken for laboratory examination and culture. An attempt to remove a tap from the anterior chamber and from the vitreous was unsuccessful due to the high viscosity of the discharge present in both chambers. Patient was started on empirical broad spectrum topical treatment of moxifloxacin, tobramycin ointment, and fortified vancomycin eye drops. Cultures were positive for the growth of Pseudomonas Aeruginosa and Acanthamoeba cysts. PO itraconazole, topical ciprofloxacin, topical propamidine isethionate 0.1% were added to the regimen, and intravitreal ceftazidime and vancomycin were administered. Follow up was done on a frequent basis, but no signs of improvement were noted. After 3 weeks of full medical treatment, patient symptoms worsened and imaging showed retinal detachment with effusion, extensive scleral, vitreal, corneal and orbital swelling and edema, and enucleation was inevitable. 

We describe the case of an aggressive postoperative panophthalmitis due to two culprit organisms: Pseudomonas and Acanthamoeba. This co-infection has, to our knowledge, never been reported in the literature. Multiple difficulties and obstacles were faced to provide the optimal medical management for this patient due to high cost of medical interventions and drug unavailability in the Lebanese pharmaceutical market. The economic crisis in Lebanon and consequent decline in medical sanitary and sterilization standards in some peripheral medical centers should not be taken lightly in order to prevent further emergence of threatening and resilient infections as the one fore mentioned.