METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS INFECTIOUS SCLERITIS AFTER VITRECTOMY FOR ENDOPHTHALMITIS Stephen J. Kim, MD, Bryan J. Schwent, MD, Sunil K. Srivastava, MD
Purpose: To report a case of methicillin-resistant Staphylococcus aureus infectious scleritis after vitrectomy for endophthalmitis. Methods: Retrospective chart review of one patient referred to a tertiary academic center for management of methicillin-resistant S. aureus infectious scleritis. Antecedent history, clinical course, response to treatment, and final visual acuity were documented. Results: Methicillin-resistant S. aureus infectious scleritis required combination systemic, periocular, intraocular, and topical antibiotics for complete resolution. Visual recovery was limited. Conclusion: Methicillin-resistant S. aureus infectious scleritis can complicate vitrectomy for endophthalmitis and requires long-term and multiple-route administration of antibiotics for resolution. Greater awareness of this serious complication along with preventive measures may reduce future occurrences. RETINAL CASES & BRIEF REPORTS 3:407– 408, 2009
From the Department of Ophthalmology, Emory University, Atlanta, Georgia.
Case Report An 83-year-old man underwent uncomplicated clear cornea phacoemulsification cataract surgery in his left eye. Three days later, he developed pain, increased intraocular inflammation, vitreous opacities, and hand motion vision. He underwent emergent 20-gauge vitrectomy for endophthalmitis with injection of intraocular antibiotics (1 mg vancomycin, 2 mg ceftazidime). Vitreous cultures grew MRSA. Pain and inflammation improved, but 2 weeks later, he returned with a hypopyon and a raised, injected, purulent scleral mass located inferior–temporally. He underwent repeat 20-gauge vitrectomy, drainage of his scleral abscess, and injection of intraocular and subconjunctival vancomycin. He was placed on topical vancomycin (25 mg/mL) postoperatively, and his hypopyon and scleral abscess resolved, but after 2 weeks, his scleral abscess returned and he was referred to Emory. On presentation, his visual acuity was 20/20 in the right eye and 20/200 in the left eye. Slit-lamp examination of the left eye demonstrated a paracentral epithelial defect in an area of neovascularization (Figure 1A). There was moderate anterior and posterior inflammation and a scleral abscess was present inferior–temporally (Figure 1B). On dilated examination, a yellowish infiltrate extended into the midvitreous from the location of the scleral abscess. Ultrasound confirmed an echodensity extending through the sclera at this location consistent with infectious scleritis. The abscess was recultured and regrew the previous MRSA isolate sensitive to vancomycin and rifampin. The patient was admitted and after infectious disease consultation began intrave-
O
ver the last decade, increasing rates of methicillinresistant Staphylococcus aureus (MRSA) ocular infections have been reported.1,2 This reality presents both greater challenges and concerns for ophthalmologists given MRSA’s known resistance to commonly used antibiotics and its association with higher morbidity.2,3 Endophthalmitis remains one of the most feared complications after cataract surgery and rates of MRSA-related cases will undoubtedly increase. We describe the clinical course, response to treatment, and visual outcome of a case of MRSA infectious scleritis complicating vitrectomy for endophthalmitis after cataract surgery. Supported, in part, by the Heed Foundation (S.J.K.), the Ronald G. Michels Foundation (S.J.K.), and an institutional grant from Research to Prevent Blindness. The authors have no proprietary interests in this article. Reprints requests: Stephen J. Kim, MD, 2311 Pierce Avenue, Nashville, TN 37203; e-mail: [email protected]
407
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2009
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Fig. 1. Slip-lamp photograph of the left eye with paracentral epithelial defect in an area of neovascularization (A). Sliplamp photograph of the same eye demonstrating an inferiortemporal scleral abscess with a focal purulent center and surrounding edema (B).
nous vancomycin (1 mg every 12 hours), oral rifampin (600 mg per day), and hourly topical vancomycin (25 mg/mL). Two days later, his abscess was redrained and both intraocular and subconjunctival vancomycin were injected. The patient received 14 days of intravenous vancomycin and oral rifampin and was then transitioned to oral bactrim DS twice a day for 4 weeks. Despite complete resolution of his epithelial defect and scleral infection, his course was complicated by chronic macular edema and his best-corrected visual acuity, 6 months later, remained 20/160.
Discussion Emergent vitrectomy is recommended in cases of endophthalmitis with light perception vision or worse,4 but many vitreoretinal surgeons perform vitrectomies in patients with better than light perception vision (like in this case) or soon after presentation. In our case of MRSA endophthalmitis, the presence and then removal of the infusion cannula may have facilitated direct seeding of scleral tissue either through vitreous incarceration or perhaps by direct bacteria inoculation from the metal cannula itself. Supporting this assertion is the location of the scleral abscess at the site of the infusion cannula and the lack of infection at the other sclerotomy sites, where more complete removal of vitreous and constant wound irrigation may have prevented bacterial seeding. Although infectious scleritis after vitrectomy is rare, its considerable morbidity underscores the importance of prevention.5,6 In this particular case, intraocular antibiotics, even hours before vitrectomy, may have sufficiently decreased the bacterial count. In addition, meticulous shaving of vitreous gel around the infusion cannula, copious irrigation of the sclerotomy site after cannula removal with complete sutured closure, and subconjunctival injection of vancomycin over the infusion sclerotomy site may have prevented this serious complication.
Finally, this case report emphasizes the increasing prevalence of MRSA and the need for long-term and combination systemic, periocular, intraocular, and topical antibiotic treatment of MRSA infectious scleritis. To our knowledge, this is the first report of infectious scleritis after vitrectomy for endophthalmitis. Such cases may require long-term antibiotics through multiple routes for complete resolution. Greater awareness of this serious complication and the increasing prevalence of MRSA, along with appropriate preventive measures, may reduce future occurrences. Key words: methicillin-resistant Staphylococcus aureus, MRSA, infectious scleritis, endopthalmitis, scleral abscess.
References 1.
Freidlin J, Acharya N, Lietman TM, et al. Spectrum of eye disease caused by methicillin-resistant Staphylococcus aureus. Am J Ophthalmol 2007;144:313–315. 2. Soloman R, Donnenfeld ED, Perry HD, et al. Methicillinresistant Staphylococcus aureus infectious keratitis following refractive surgery. Am J Ophthalmol 2007;143:629 – 634. 3. Rutar T, Zwick OM, Cockerham KP, et al. Bilateral blindness from orbital cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus. Am J Ophthalmol 2005;140:740 –742. 4. Feiz V, Redline DE. Infectious scleritis after pars plana vitrectomy because of methicillin-resistant Staphylococcus aureus resistant to fourth-generation fluoroquinolones. Cornea 2007;26:238 –240. 5. Margo CE, Pavan PR. Mycobacterium chelonae conjunctivitis and scleritis following vitrectomy. Arch Ophthalmol 2000; 118:1125–1128. 6. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995; 113:1479 –1496.
Purpose: To report a case of methicillin-resistant Staphylococcus aureus infectious scleritis after vitrectomy for endophthalmitis. Methods: Retrospective chart review of one patient referred to a tertiary academic center for management of methicillin-resistant S. aureus infectious scleritis. Antecedent history, clinical course, response to treatment, and final visual acuity were documented. Results: Methicillin-resistant S. aureus infectious scleritis required combination systemic, periocular, intraocular, and topical antibiotics for complete resolution. Visual recovery was limited. Conclusion: Methicillin-resistant S. aureus infectious scleritis can complicate vitrectomy for endophthalmitis and requires long-term and multiple-route administration of antibiotics for resolution. Greater awareness of this serious complication along with preventive measures may reduce future occurrences. RETINAL CASES & BRIEF REPORTS 3:407– 408, 2009
From the Department of Ophthalmology, Emory University, Atlanta, Georgia.
Case Report An 83-year-old man underwent uncomplicated clear cornea phacoemulsification cataract surgery in his left eye. Three days later, he developed pain, increased intraocular inflammation, vitreous opacities, and hand motion vision. He underwent emergent 20-gauge vitrectomy for endophthalmitis with injection of intraocular antibiotics (1 mg vancomycin, 2 mg ceftazidime). Vitreous cultures grew MRSA. Pain and inflammation improved, but 2 weeks later, he returned with a hypopyon and a raised, injected, purulent scleral mass located inferior–temporally. He underwent repeat 20-gauge vitrectomy, drainage of his scleral abscess, and injection of intraocular and subconjunctival vancomycin. He was placed on topical vancomycin (25 mg/mL) postoperatively, and his hypopyon and scleral abscess resolved, but after 2 weeks, his scleral abscess returned and he was referred to Emory. On presentation, his visual acuity was 20/20 in the right eye and 20/200 in the left eye. Slit-lamp examination of the left eye demonstrated a paracentral epithelial defect in an area of neovascularization (Figure 1A). There was moderate anterior and posterior inflammation and a scleral abscess was present inferior–temporally (Figure 1B). On dilated examination, a yellowish infiltrate extended into the midvitreous from the location of the scleral abscess. Ultrasound confirmed an echodensity extending through the sclera at this location consistent with infectious scleritis. The abscess was recultured and regrew the previous MRSA isolate sensitive to vancomycin and rifampin. The patient was admitted and after infectious disease consultation began intrave-
O
ver the last decade, increasing rates of methicillinresistant Staphylococcus aureus (MRSA) ocular infections have been reported.1,2 This reality presents both greater challenges and concerns for ophthalmologists given MRSA’s known resistance to commonly used antibiotics and its association with higher morbidity.2,3 Endophthalmitis remains one of the most feared complications after cataract surgery and rates of MRSA-related cases will undoubtedly increase. We describe the clinical course, response to treatment, and visual outcome of a case of MRSA infectious scleritis complicating vitrectomy for endophthalmitis after cataract surgery. Supported, in part, by the Heed Foundation (S.J.K.), the Ronald G. Michels Foundation (S.J.K.), and an institutional grant from Research to Prevent Blindness. The authors have no proprietary interests in this article. Reprints requests: Stephen J. Kim, MD, 2311 Pierce Avenue, Nashville, TN 37203; e-mail: [email protected]
407
RETINAL CASES & BRIEF REPORTSℜ
408
●
2009
●
VOLUME 3
●
NUMBER 4
Fig. 1. Slip-lamp photograph of the left eye with paracentral epithelial defect in an area of neovascularization (A). Sliplamp photograph of the same eye demonstrating an inferiortemporal scleral abscess with a focal purulent center and surrounding edema (B).
nous vancomycin (1 mg every 12 hours), oral rifampin (600 mg per day), and hourly topical vancomycin (25 mg/mL). Two days later, his abscess was redrained and both intraocular and subconjunctival vancomycin were injected. The patient received 14 days of intravenous vancomycin and oral rifampin and was then transitioned to oral bactrim DS twice a day for 4 weeks. Despite complete resolution of his epithelial defect and scleral infection, his course was complicated by chronic macular edema and his best-corrected visual acuity, 6 months later, remained 20/160.
Discussion Emergent vitrectomy is recommended in cases of endophthalmitis with light perception vision or worse,4 but many vitreoretinal surgeons perform vitrectomies in patients with better than light perception vision (like in this case) or soon after presentation. In our case of MRSA endophthalmitis, the presence and then removal of the infusion cannula may have facilitated direct seeding of scleral tissue either through vitreous incarceration or perhaps by direct bacteria inoculation from the metal cannula itself. Supporting this assertion is the location of the scleral abscess at the site of the infusion cannula and the lack of infection at the other sclerotomy sites, where more complete removal of vitreous and constant wound irrigation may have prevented bacterial seeding. Although infectious scleritis after vitrectomy is rare, its considerable morbidity underscores the importance of prevention.5,6 In this particular case, intraocular antibiotics, even hours before vitrectomy, may have sufficiently decreased the bacterial count. In addition, meticulous shaving of vitreous gel around the infusion cannula, copious irrigation of the sclerotomy site after cannula removal with complete sutured closure, and subconjunctival injection of vancomycin over the infusion sclerotomy site may have prevented this serious complication.
Finally, this case report emphasizes the increasing prevalence of MRSA and the need for long-term and combination systemic, periocular, intraocular, and topical antibiotic treatment of MRSA infectious scleritis. To our knowledge, this is the first report of infectious scleritis after vitrectomy for endophthalmitis. Such cases may require long-term antibiotics through multiple routes for complete resolution. Greater awareness of this serious complication and the increasing prevalence of MRSA, along with appropriate preventive measures, may reduce future occurrences. Key words: methicillin-resistant Staphylococcus aureus, MRSA, infectious scleritis, endopthalmitis, scleral abscess.
References 1.
Freidlin J, Acharya N, Lietman TM, et al. Spectrum of eye disease caused by methicillin-resistant Staphylococcus aureus. Am J Ophthalmol 2007;144:313–315. 2. Soloman R, Donnenfeld ED, Perry HD, et al. Methicillinresistant Staphylococcus aureus infectious keratitis following refractive surgery. Am J Ophthalmol 2007;143:629 – 634. 3. Rutar T, Zwick OM, Cockerham KP, et al. Bilateral blindness from orbital cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus. Am J Ophthalmol 2005;140:740 –742. 4. Feiz V, Redline DE. Infectious scleritis after pars plana vitrectomy because of methicillin-resistant Staphylococcus aureus resistant to fourth-generation fluoroquinolones. Cornea 2007;26:238 –240. 5. Margo CE, Pavan PR. Mycobacterium chelonae conjunctivitis and scleritis following vitrectomy. Arch Ophthalmol 2000; 118:1125–1128. 6. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995; 113:1479 –1496.
