Beyond The Lens: Navigating Chronic Endophthalmitis

Chronic endophthalmitis is a persistent intraocular infection resulting from bacterial or fungal invasion, often following ocular surgery or trauma. Unlike acute endophthalmitis, it develops gradually and is characterized by persistent inflammation. Diagnosis involves clinical examination, microbiological cultures, and imaging. Treatment typically requires antimicrobial therapy and surgical intervention to remove infectious material. In this case report, we describe a particularly challenging diagnosis of chronic endophthalmitis.

Ophthalmology department, Unidade Local de Saúde Vila Nova de Gaia/Espinho

A 75-year-old male with history of hypertension and benign prostatic hyperplasia underwent uncomplicated phacoemulsification in the right eye (RE) after previously having phaco-vitrectomy in the left eye (LE) due to macular epiretinal membrane.

Postoperatively, brimonidine with timolol was prescribed to ocular hypertension control. Three weeks later, he presented to urgency room with RE decreased visual acuity (VA) (20/80). Biomicroscopy revealed corneal edema, granulomatous keratic precipitates, anterior chamber cells and well-positioned intraocular lens (IOL). Granulomatous anterior uveitis was diagnosed and treated with uveitis protocol eye drops. Subsequent evaluations showed clinical improvement, with mild persistent ocular hypertension managed with eye drops.

However, after a month, VA decreased again to 20/80 with 2+ vitreous haze. Negative serological and analytical studies enable oral corticosteroid therapy. Only partial improvement was noted after a month on oral prednisone, prompting vitrectomy.

At the two-month evaluation, VA worsened to 20/200 and a whitish infiltrate posterior to the IOL was observed. Chronic endophthalmitis was suspected, leading to surgery for microbiological sampling and intracapsular vancomycin injection. Vitreous and aqueous humour were positive to Candida parapsilosis. Immediate postoperative management included fluconazole and intravitreal voriconazole injections, resulting in progressive improvement of clinical condition.

In conclusion, this case underscores the complexities in diagnosing and managing chronic endophthalmitis. Despite initial treatment, recurrent inflammation necessitated aggressive intervention, leading to the identification of Candida parapsilosis and targeted therapy. This highlights the need for a multidisciplinary approach to achieve optimal outcomes in such cases.