Surprise Package: Rare Case Of Ralstonia Endophthalmitis Presenting As Fungal Endophthalmitis

To highlight a rare instance of Ralstonia mannitolilytica endophthalmitis that mimics fungal endophthalmitis.

This is a case report of a 56 year-old, female patient that presented to our hospital with indolent endophthalmitis one month after uneventful cataract surgery. She was complaining of decreased vision, pain and photophobia one month after cataract surgery. She was diagnosed with endophthalmitis and posted for vitrectomy.

A 56 year-old female presented to our tertiary care centre with the complaints of blurring of vision, pain and photphobia in right eye. She  had undergone right eye phacoemulsification with posterior chamber IOL implantation one month ago and was non-compliant with her post-operative medications. On examination, her vision was found to be perception of light (PL) with inaccurate PR. The IOP was measured to be 13 mm HG in right eye. There were cells and flare in the anterior chamber with obscuration of fundal glow. B-scan of te right eye revealed moderate vitreous echoes suggestive of vitreous exudates. A decision for promt pars plana vitrectomy with culture and sensitivity of vitreous sample was decided upon. 

Intraoperative picture was suggestive of fungal endophthalmitis with whitish lesions on the surface of the retina. However, the vitreous sample was negative for fungal elements. Instead, a rare organism i.e. Ralstonia mannitolilytica was isolated. It was found to be sensitive to Co-trimoxazole. The patient was started on oral Co-trimoxaziole along with topical medications. his led to a resolution in anterior chamber flare and exudates over the IOL slowly disappeared. The patient's vision improved to 3/60 within a week of starting oral anti-microbial therapy.

Indolent endophthalmitis can be caused by rare organisms as in our case. Although, it is easier to assume fungal etiology and treat accordingly, a culture and sensitivity test of the vitreous sample collected should be stressed upon and carried out with utmost care to yield good results.