Delayed Bacillus endophthalmitis due to delayed diagnosis of metallic intraocular foreign body: a case report

Abstract

Introduction
Missed intraocular foreign body may lead to devastating complications, including endophthalmitis. Post-traumatic endophthalmitis is most often due to Staphylococcus aureus or Bacillus cereus. Bacillus endophthalmitis is a fulminant infection that leads to substantial vision loss within 24-48 hours.
Report
A 22-year-old man presented with sudden painful loss of vision in the left eye. He reported being hit with a chunk of concrete while hammering 11 days previously. He had been evaluated previously by three different ophthalmologists who noted subconjunctival hemorrhage, corneal abrasion, vitreous hemorrhage, and a small choroidal rupture. On the day of presentation, he was found to have no light perception (NLP) in the left eye, high intraocular pressure unresponsive to topical and intravenous medications, and anterior chamber inflammation. Angle structures were not visible on gonioscopy given corneal edema; anterior chamber depth appeared similar to the fellow eye based on the Von Herick method. Ultrasound revealed choroidal detachment. A facial x-ray and computed tomography scan revealed a 4.5 mm metallic foreign body in the left vitreous cavity. The diagnosis of endophthalmitis secondary to metallic intraocular foreign body was established. Over the course of a few hours, his iris color also changed from blue to brown, thought to be secondary to either early siderosis or pseudo- rubeosis, and he developed a hyphema. The patient underwent vitreous sampling, intravitreal injection of vancomycin and ceftazidime, and washout of the anterior chamber. Removal of the intraocular foreign body was aborted given poor visualization. Vitreous culture was positive for Bacillus thuringiensis. Patient eventually underwent enucleation.
Conclusion
This is a case of delayed Bacillus endophthalmitis presenting 11 days following penetrating trauma due to missed intraocular foreign body. This case highlights the importance of investigating for an intraocular foreign body in patients presenting with suspicious mechanisms of injury and indirect signs of penetrating trauma.