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Editor,—Exogenous endophthalmitis is a common complication of intraocular foreign bodies (IOFBs).1 It commonly occurs in association with a non-metallic foreign body and often results in profound visual loss.2 Early diagnosis and treatment with intravitreal antibiotics are essential in its treatment.3 We describe an unusual case of exogenous endophthalmitis caused by a heroin filled needle, the patient rapidly losing vision despite active intervention.
A 24 year old remand prisoner presented to the casualty department with a vague 2 day history of visual loss in his right eye. He had been stabbed in the eye 2 days previously with a hypodermic needle, which had recently been used for heroin injections.
The patient had a visual acuity of hand movement vision in the affected eye, which was inflamed and had a fibrinoid uveitis. A 3 mm hypopyon was present but a puncture wound was not visible. No fundus view was present. A high reflectivity shadow was seen in the vitreous on B scan ultrasonography (Fig 1A) and an intraocular hypodermic needle was confirmed on plain xray (Fig 1B).
The patient underwent a vitreous biopsy and intravitreal ceftazidine 2 mg/0.1 ml, vancomycin 2 mg/ml, and amphotericin B 0.005 mg/ml. The following day, a three port pars plana vitrectomy was performed. Postoperatively, the retina was observed to be detached with two giant retinal tears, one temporally and one nasally. Widespread periphlebitis and retinal necrosis was noted (Fig 2). The broken hypodermic needle was recovered and removed through a corneal incision. Retinal detachment repair was undertaken with heavy liquids, silicone oil, and endolaser photocoagulation. Postoperatively, he was treated with intravenous ciprofloxacin 750 mg twice daily, chloramphenicol eyedrops ½ hourly, atropine eyedrops 1% twice daily, Pred Forte eyedrops (Allergan) ½ hourly, and 40 mg prednisolone orally.
The endophthalmitis settled slowly postoperatively, the retina remained flat but vision was reduced to perception of light. The vitreous biopsy grew Streptococcus oralis which was sensitive to chloramphenicol.
Penetrating eye injuries predominantly occur in young males, and are a common cause of monocular visual loss.4 5 Endophthalmitis occurs in around 15% of patients with intraocular foreign bodies, the commonest organisms being Staphylococcus epidermidis (23.4%) and mixed organisms (17.3%). The visual prognosis is particularly poor with concurrent infection, 82.3% of patients having no perception of light.
The timing of surgery remains contentious. Many authors recommend vitrectomy within 14 days of presentation, particularly if there is retinal detachment. The advantage of intervening before proliferative vitreoretinopathy has develops usually outweighs the universal risk of intraoperative haemorrhage in a recently traumatised globe. In our case endophthalmitis and sight loss developed as a result ofStreptococcus oralis contaminated hypodermic needle, which is an uncommon intraocular pathogen.
A unique factor of this case was the marked retinal necrosis, which was presumed to be due to heroin toxicity. The delay in presentation and co-toxicity of heroin significantly worsened the prognosis for this patient.