Immunosuppressants/povidone-iodine

Abstract

Toxic endophthalmitis and paradoxical worsening in the form of anterior fibrinous reaction: case report A 52-year-old man developed toxic endophthalmitis during treatment with povidone-iodine as an antiseptic solution. Additionally, he had paradoxical worsening in the form of anterior fibrinous reaction during treatment with prednisolone, prednisolone acetate and dexamethasone [not all routes dosages and indications stated]. The diabetic man was diagnosed with central retinal vein occlusion and secondary macular oedema with neovascular glaucoma in his left eye. He was initiated treatment with ranibizumab and underwent an anterior chamber paracentesis. After the procedure, he was started treatment with ofloxacin and aqueous suppressants. In the following week, he was scheduled for definitive treatment with pan-retinal photocoagulation. However, due to severe eye pain, he was revisited to the emergency department on the next day. His intraocular pressure (IOP) was 60mm Hg with a 1mm hyphema and diffuse corneal oedema. It was established that, due to underlying iris neovascularisation, his IOP elevated. Hence, another anterior chamber paracentesis was performed by using topical anaesthetic followed by a 5% povidone-iodine antiseptic solution into the conjunctival sac. His IOP was decreased immediately after the procedure. He was reinitiated povidone-iodine and anti-glaucoma drops, and his IOP had normalised. However, a small area of scanty leakage of fluid was noticed from the entry site of the needle, but the anterior chamber remained deep. Subsequently, he discharged home with a topical antibiotic, maximal anti-glaucoma medications, and asked for follow-up after 2 days. Therefore, he was reassessed after 2 days and found a reduced vision, which associated with conjunctival injection, and 2mm hypopyon overlying a layer of hyphema, a mild fibrinous reaction in the anterior chamber was noted. A hazy cornea without keratic precipitates on the corneal endothelium was also noted. Therefore a retina and a B-scan revealed mild-to-moderate vitritis. Eventually, he was diagnosed with acute post-procedural infectious endophthalmitis. Immediately, the man treated with an injection of intravitreal antibiotics. Additionally, he received empirical treatment with vancomycin and ceftazidime. He also received cefuroxime and gentamicin alternatively along with atropine and ciprofloxacin. Oral prednisolone 30mg once daily, dexamethasone and 1% drops of prednisolone acetate hourly were initiated. A few hours later, he had paradoxical worsening in the form of anterior fibrinous reaction, obscuring the iris and lens. In the subsequent days, he remained asymptomatic. However, his vision decreased further to light perception. After that, a Slit-lamp examination was performed, which revealed worsening corneal oedema and a densely organized fibrinous membrane in the anterior chamber. Threafter, a plana vitrectomy with anterior chamber washout, endo-laser pan-retinal photocoagulation was performed. He administered ceftazidime and vancomycin. His vision was improved post-operatively. His topical and oral prednisolone were tapered and fibrinous remnants in the anterior chamber gradually improved. All vitreous and aqueous samples resulted negative. His anterior chamber and cornea were completely cleared without any sequelae after day 10 of the surgery.