Intrastromal Injection Of Levofloxacin 1.5% Intravitreal Injection Of Vancomycin, Ceftazidime, And Amikacin With Pars Plana Vitrectomy For Bacterial Infectious Keratitis With Subsequent Endophthalmitis

The purpose of of this paper was to present a combination of proven effective treatment protocols alongside exploration of other treatment options that may be beneficial for similar cases. Intrastromal injection as an adjunctive treatment option proved to be effective for the treatment of infectious keratitis with subsequent endophthalmitis for this particular case. Limited data and only few case reports have discussed the use of intrastromal injection of Levofloxacin 1.5 percent. The results of combined treatment demonstrated marked improvement and control of infection and may warrant further research as a considered treatment option. 

This is a case of a 34 year old Filipino male seen at a tertiary hospital in the Philippines who complained of right eye redness, pain, and blurring of vision. Patient was diagnosed as a case of Infectious Keratitis with Subsequent Endophthalmitis. Visual acuity was hand movement with good light projection. Slit lamp examination showed a hazy cornea with a whitish stromal opacity along the corneal suture from previous operation, with whitish fibrous membranes in the anterior chamber. 

Initial treatment with topical Levofloxacin 1.5 percent every hour was initiated with Intravitreal injections of 0.1ml Vancomycin and 0.1ml Ceftazidime with Vitreous tap done on the same day. Eventually, a Pars Plana Vitrectomy with Intravitreal Injection of 0.1ml Vancomycin, 0.1ml Amikacin, and 0.1ml Voriconazole was done. Due to only minimal improvement, the patient was started on Oral Moxifloxacin 400mg once a day for one week and referred to a Cornea and External Disease specialist for co-management. Intrastromal injection of 0.4ml of Levofloxacin 1.5% was advised and Prednisolone Acetate eye drops was initiated. A total of four instrastromal injections were given, which provided marked improvement. 

Immediate and significant improvement following the first dose of intrastromal injection was noted. The corneal haze improved and the 2mm x 4mm whitish stromal opacity remained stable with significant decrease in size of the fibrous membrane seen inferiorly. A total of four intrastromal injections was given. Considerable improvement was seen with the opacity appearing flatter and more well defined. Topical Levofloxacin and Prednisolone Acetate were slowly tapered as the opacity stabilized and visual acuity of the patient improved to 20/160 sans correction. There was complete resolution of eye pain and redness. Further improvement was noted after each subsequent follow up.

It is necessary to provide prompt treatment for cases of Infectious Keratitis and Endophthalmitis. Delays could lead to further complications and poorer visual prognosis. Treatment protocol for endophthalmitis was done for the case of the patient, however, due to response on succeeding consults, additional treatment was warranted. Intrastromal injection as an adjunctive treatment option was done and proved to be effective for treatment of the patient's case. The results of combined treatment demonstrated marked improvement and control of infection and may warrant further research as a considered treatment option for patients that present with similar findings and assessments.