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Year : 2016  |  Volume : 9  |  Issue : 5  |  Page : 344-346
Fulminant course with dismal outcomes in cases of Bacillus cereus endophthalmitis

Department of Ophthalmology, St John's Medical College, Bengaluru, Karnataka, India

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Date of Web Publication12-Sep-2016


Bacillus cereus (B. cereus) endophthalmitis is a serious and rare ocular infection. Infection with B. cereus needs to be suspected in penetrating injuries sustained with retention of intraocular foreign bodies (IOFBs) and in agricultural settings. Additionally, it can be a cause of endogenous endophthalmitis in intravenous (IV) drug abusers and in dialysis patients. It is characterized by acute onset and a rapid fulminant course, often leading to enucleation or evisceration of the involved eye. Intravitreal and IV vancomycin has good coverage against B. cereus. Though associated with poor outcomes, high index of suspicion with early initiation of treatment might improve prognosis. Case reports of two patients with fulminating B. cereus endophthalmitis treated in our hospital in the last 1 year are reported.

Keywords: Bacillus cereus (B. cereus), endophthalmitis, fulminant course

How to cite this article:
Shroff S, Nithyanandam S, Joseph M, Raghunandan N. Fulminant course with dismal outcomes in cases of Bacillus cereus endophthalmitis. Ann Trop Med Public Health 2016;9:344-6

How to cite this URL:
Shroff S, Nithyanandam S, Joseph M, Raghunandan N. Fulminant course with dismal outcomes in cases of Bacillus cereus endophthalmitis. Ann Trop Med Public Health [serial online] 2016 [cited 2020 Apr 2];9:344-6. Available from:

   Introduction Top

Endophthalmitis is a devastating infection of the eye; however, early recognition and treatment leads to favorable outcomes. Endophthalmitis caused by Bacillus cereus (B. cereus), although uncommon, is often associated with a fulminant course and dismal outcomes despite early treatment. [1],[2]

Bacillus species are aerobic, gram-positive, spore-forming bacteria widely found in soil, water, and air. They are important pathogens in posttraumatic endophthalmitis and in endogenous endophthalmitis in patients with indwelling catheter and intravenous (IV) drug abuse. [3],[4] The clinical manifestation and the course are unlike endophthalmitis caused by other organisms. It produces an enterotoxin that causes a marked inflammatory response resulting in extensive retinal necrosis. It is characterized by acute onset and a fulminant course, leading to panophthalmitis that often necessitates enucleation or evisceration of the involved eye. In this report, we present case details of two patients with fulminant B. cereus endophthalmitis treated in our hospital recently.

   Case Reports Top

Case 1

A 56-year-old male presented with painful diminution of vision in the right eye (RE) of a 1-day duration. He is a known diabetic and hypertensive with end-stage renal failure requiring renal replacement therapy by peritoneal dialysis. Due to peritonitis, he was started on hemodialysis through a neck arterial-vein access 1 month prior.

On examination, the RE visual acuity was 20/500 m. There was conjunctival congestion with chemosis, corneal edema, and diffuse hyphema obscuring iris details. The pupils were 4 mm in size and sluggishly reacted to light. The media was hazy, obscuring fundus details. Intraocular pressure (IOP) was 36 mmHg. Extraocular movements were normal.

Left eye (LE) examination showed a visual acuity of 20/80, with normal anterior segment and brisk pupillary reaction. Fundus evaluation revealed proliferative diabetic retinopathy with grade 3 hypertensive retinopathy. IOP was 14 mmHg. Extraocular movements were normal.

The patient was started on IOP-lowering medicines, considering a diagnosis of neovascular glaucoma. Within 6 h of initiation of treatment, the patient developed proptosis with corneal ring infiltrate and hypopyon [Figure 1]. Corneal scraping and a conjunctival swab were taken and sent for Gram stain, potassium hydroxide (KOH), aerobic, anaerobic, and fungal culture. Under sterile aseptic precaution, intravitreal vancomycin (1 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL) were given immediately. The patient was additionally started on IV ceftriaxone and metrogyl. The patient developed proptosis with restriction of ocular movements 24 h later. The patient underwent evisceration for panophthalmitis. Cultures from the cornea, conjunctiva, and the eviscerated specimen all showed a luxuriant growth of Gram-positive rods consistent with B. cereus, sensitive to clindamycin and vancomycin. Histopathology of ocular contents revealed extensive tissue necrosis with hemorrhage. The patient was continued on IV medication for a week and was discharged.
Figure 1: Right eye showing proptosis, corneal ring infiltrate, and hypopyon of case 1

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Case 2

A 20-year-old male quarry worker presented with painful diminution of vision associated with foreign body (FB) sensation in both eyes, following a blast injury. On examination, the patient had severe photophobia with burns and FBs embedded in the eyelids bilaterally. Visual acuity was 20/400 and 20/320 in the RE and LE respectively. There were multiple corneal FBs with diffuse haze of the central corneas in both eyes with intact globe integrity [Figure 2]. The anterior chamber was normal, with normal iris. The pupils were 5 mm with sluggish response to light and near reflex. The fundus details were obscured. On computed tomography, there was no evidence of intraocular FB (IOFB). Thorough wash was given and corneal FBs, as many as possible, were removed. It was difficult to remove the corneal FBs, as they were fine sand and sulfur particles. The patient was started on topical moxifloxacin and IV ceftriaxone in the dose of 1 gm twice daily. On digital tonometry, IOPs were normal.
Figure 2: Right eye anterior segment showing third degree lid burns with singeing of lashes, inferior subconjunctival hemorrhage, and multiple corneal foreign bodies of case 2

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After 24 h, the patient developed worsening of lid edema with mucopurulent discharge in the RE. B-scan revealed multiple intravitreal echoes. The patient was started on topical fortified vancomycin (0.30%) and ceftriaxone (5%) with intravitreal vancomycin (1 mg/0.1 mL) and amikacin (0.4 mg/0.1 mL) was given. Conjunctival swab was sent for microbiological analysis. By day 3, the lids became more tense, associated with ring ulcer of the cornea and purulent discharge. There was hypopyon in the anterior chamber. Restriction of ocular movements was noted and a diagnosis of panophthalmitis was made. Evisceration was done and the specimen was sent for microbiology and histopathology. Microbiologic analysis revealed Gram-positive rods consistent with B. cereus sensitive to clindamycin and vancomycin.

   Discussion Top

Bacillus species commonly cause endophthalmitis following penetrating ocular trauma. It was isolated in 15-46% of reported cases of posttraumatic endophthalmitis [5],[6] and is strongly associated with the presence of IOFB and when the injury occurred in an agricultural setting. The most common species isolated in multiple studies of posttraumatic endophthalmitis is B. cereus. [3]

Diagnosis of posttraumatic endophthalmitis immediately, following open globe injury can be difficult because of trauma-induced inflammation and disruption of ocular structures. B. cereus less commonly causes endophthalmitis-associated with IV drug abuse, dialysis, and blood transfusion. [4] Acute postoperative endophthalmitis owing to Bacillus species is relatively rare, with a cumulative probability of 0.08%. [7]

Endophthalmitis caused by the Bacillus species is characterized by rapid onset of symptoms associated with the presence of corneal ring abscess, fever, and leukocytosis [1] , and often has poor outcomes. [2] In the study conducted at Bascom Palmer Eye Institute, 7/22 patients underwent enucleation or evisceration or developed phthisis bulbi and 10/22 patients lost all light perception. [2] The intraocular virulence of B. cereus is caused by its secretion of exotoxins (tripartite hemolysin BL, phosphatidylcholine-preferring phospholipase C, and collagenase), the exuberant inflammatory response triggered by the potent immunogenic bacterial cell-wall components, and the rapid intraocular migration of the organisms. Its destructive pathogenicity was demonstrated histologically by the massive destruction of the corpus vitreous and extensive retinal necrosis.

Intravitreal vancomycin (1 mg/0.1 mL) and IV vancomycin provide good coverage against the Bacillus species. For severe cases, intravitreal amikacin (0.4 mg/0.1 mL) may be added. Low dose gentamicin can be used in certain cases with adequate dilution. Systemic fluoroquinolones can be added as a second line of treatment. [8]

   Conclusion Top

In conclusion, although B. cereus endophthalmitis is associated with poor prognosis, a high index of suspicion with early initiation of therapy may help in improving outcomes.

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Conflicts of interest

There are no conflicts of interest.

   References Top

David DB, Kirkby GR, Noble BA. Bacillus cereus endophthalmitis. Br J Ophthalmol 1994;78:577-80.  Back to cited text no. 1
Miller JJ, Scott IU, Flynn HW Jr, Smiddy WE, Murray TG, Berrocal A, et al. Endophthalmitis caused by bacillus species. Am J Ophthalmol 2008;145:883-8.  Back to cited text no. 2
Cebulla CM, Flynn HW Jr. Endophthalmitis after open globe injuries. Am J Ophthalmol 2009;147:567-8.  Back to cited text no. 3
Cowan CL Jr, Madden WM, Hatem GF, Merritt JC. Endogenous Bacillus cereus panophthalmitis. Ann Ophthalmol 1987;19:65-8.  Back to cited text no. 4
Alfaro DV, Roth D, Liggett PE. Posttraumatic endophthalmitis. Causative organisms, treatment, and prevention. Retina 1994;14:206-11.  Back to cited text no. 5
Verbraeken H, Rysselaere M. Post-traumatic endophthalmitis. Eur J Ophthalmol 1994;4:1-5.  Back to cited text no. 6
Rishi E, Rishi P, Sengupta S, Jambulingam M, Madhavan HN, Gopal L, et al. Acute postoperative bacillus cereus endophthalmitis mimicking toxic anterior segment syndrome. Ophthalmology 2013;120:181-5.  Back to cited text no. 7
Bhagat N, Nagori S, Zarbin M. Post-traumatic infectious endophthalmitis. Surv Ophthalmol 2011;56:214-51.  Back to cited text no. 8

Correspondence Address:
Sujani Shroff
Department of Ophthalmology, St John's Medical College, Bengaluru - 560 034, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.190190

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