Abstract
A 43-year-old male suffered from a corneolimbal laceration with an iron nail in the right eye while hammering on metal. The patient complained of eye pain and immediate visual loss after ocular injury. His visual acuity at presentation was hand motion in the right eye and 20/20 in the left. On examination, the anterior segment demonstrated an 8 mm length of full-thickness corneolimbal laceration, fibrin over the anterior chamber, traumatic aniridia and traumatic cataract. No fundal details were visible. Penetrating injury of the eyeball with traumatic endophthalmitis was diagnosed, and an emergent operation was arranged immediately to perform primary suture of the corneolimbal laceration, pars plana lensectomy and vitrectomy. Conditions identified during the surgery were diffuse arterial and venous vasculitis, superotemporal retinal detachment with retinal tears, vitreous haemorrhage and subretinal haemorrhage. At the end of surgery, prophylactic photocoagulation (over retinal breaks and 36 ° peripheral retina) and silicone oil endotamponade were performed, and the patient was treated with intravitreal vancomycin [1 mg (0.1 ml)–1], amikacin [0.25 mg (0.1 ml)–1] and dexamethasone [0.4 mg (0.1 ml)–1]. Postoperative treatment included oral ciprofloxacin (500 mg, twice per day), and topical vancomycin (25 mg ml–1, hourly), amikacin (25 mg ml–1, hourly) and 1 % prednisolone acetate (four times per day).
Gram staining of a vitreous sample demonstrated Gram-positive cocci, Gram-negative bacilli and numerous neutrophils. The vitreous fluid sample was cultured in thioglycolate broth, and on chocolate blood agar, eosin methylene blue agar and tryptic soy agar with 5 % sheep blood. Bacterial growth detected after 72 h revealed mixed organisms, which were then identified as Enterobacter gergoviae and Enterococcus raffinosus on day five. The Enterobacter gergoviae isolate was strongly urease-positive; however, it was negative for adonitol, inositol and sorbitol utilization. The isolate was confirmed as Enterobacter gergoviae by the API 20E system (bioMérieux). Identification of the enterococcal species may be complicated by misidentification by the API 20 Strep system. Therefore, Enterococcus raffinosus was confirmed by conventional tests, including growth on bile aesculin agar and with 6.5 % NaCl. The Enterococcus raffinosus isolate showed positive pyrrolidonyl arylamidase, mannitol, sorbose, arabinose and raffinose reactions; it was negative for arginine dihydrolase. The standard Kirby–Bauer disc diffusion technique was utilized for antibiotic susceptibility testing of the Enterobacter gergoviae and Enterococcus raffinosus isolates. The Enterobacter gergoviae isolate was sensitive to piperacillin, piperacillin–tazobactam, amikacin, gentamicin, aztreonam, cefuroxime, ceftazidime, ceftriaxone, ciprofloxacin and ertapenem; however, it was resistant to cefazolin and amoxicillin–clavulanic acid. The Enterococcus raffinosus isolate was sensitive to penicillin, ampicillin, vancomycin and teicoplanin. On day 10, the inflammation of the anterior and posterior segments decreased significantly; in addition, the visual acuity improved to counting fingers. Six weeks later, retinal detachment with foveal involvement was identified at the temporal retina. Meanwhile, proliferative vitreoretinopathy with three retinal holes was identified. Pars plana vitrectomy with retinectomy, encircling scleral buckle, laser photocoagulation and silicone oil endotamponade were performed. Three months later, visual acuity with aphakic correction was 20/200 without complication in the right eye. Fundus examination showed fine epiretinal membrane over the posterior pole, and revealed resolution of the retinal vasculitis.