a y6a ff3 fs7 fc0 sc0 ls1 ws1e">or recurrence. She has received cataract surgery addi-
tionally due to cataract secondary to intraocular inflam-
mation in both eyes. Her final visual acuity was 20/20 in
both eyes.
Figure 2. Fundus photographs at first examination. (A)
Photographs of the right eye revealed vitreous cloudiness;
(B) In the left eye, vitreous cloudiness was less severe; how-
ever, hard exudates and multiple discrete lesions were ob-
served.
Figure 3. Serial fundus photographs after intravitreal anti-
biotics injection. Upper pictures are of the right eye on days
2, 5, and 8 after intravitreal antibiotic injection (A, B, C).
Lower pictures are of the left eye on days 2, 5, and 8 after
the injection (D, E, F). Fundus images demonstrated grad-
ual vitreous clearing.
3. Discussion
According to prior reports, most endogenous endophthal-
mitis develops from pneumonia, hepatobiliary disease,
myocarditis, or meningitis [3]. However, facial cellulitis
as a focus of endogenous endophthalmitis is rare. Facial
cellulitis usually appears more rapidly than other deep
infections, so treatment is performed earlier. For this rea-
son, endogenous endophthalmitis associated with facial
cellulitis is relatively rare. However, facial cellulitis can
be a direct or indirect causative infection. The indirect
pathway involves distant spread through the blood stream
Copyright © 2012 SciRes. OJOph
Endogenous Endophthalmitis Associated with Facial Cellulitis After a Tongue Bite 87
via the internal jugular vein. Microorganisms are then
able to spread through the heart to the internal carotid
artery and ophthalmic artery. Furthermore, they can fol-
low a retrograde pathway toward the cavernous sinus of
the skull, establishing thrombophlebitis in the facial ves-
sels [4]. These anatomical characteristics explain how
facial cellulitis can be a primary infection site of endo-
genous endophthalmitis.
We also considered that a severe ur emic condition due
to ESRD could contribute to the development of endo-
genous endophthalmitis because severe uremia generates
an immunosuppressive state. Although hemodialysis (HD)
can provide a direct infection route for normal skin flora.
[8]. HD may have had a positive effect on the treatment
of endogenous endophthalmitis in this case because the
severe uremia that contributed to an immunosuppressive
state was well treated by HD. Many ophthalmologists
think that systemic antibiotics in endophthalmitis have
low efficacy because of the blood-ocular barrier [9]. A
major difference between this case and previous reports
was successful treatment with intravitreal antibiotic in-
jection and continuous intravenous antibiotic administra-
tion. The patient’s ESRD could have potentially contrib-
uted to improvement of her disease. In ESRD, low serum
protein reduces colloid osmotic pressure, and renal-in-
duced hypertension increases hydrostatic pressure [8].
Therefore, a higher pressure gradient may be induced
between the blood to the retina. Although we did not eva-
luate her previou s fundoscopy, we expect that the patient
had hypertensive retinopathy due to uncontrolled hyper-
tension and a very low estimated GFR, 2 mL/min/1.73
m2. According to a recent report, a low estimated GFR is
associated with a much higher incidence of fundus pa-
thology, similar to that in hypertensive retinopathy [10].
In addition to hypertensive retinopathy, inflammation of
the retina and retinal vasculature in endophthalmitis dis-
turbs the inner and outer blood-retinal barrier [9]. These
changes may increase retinal vascular permeability,
which may aid systemic antibiotics in more effectively
reaching the retina. In endogenous endophthalmitis,
Greenwald et al. proposed that the breakdown of the
blood-ocular barrier by ocular infection allows adequate
penetration of systemic antibiotics into the vitreous cav-
ity [9,11]. Intravenous imipenem also achieved excellent
penetration of the vitreous in a prior report [12]. It is pos-
sible that all of these factors might produce a synergistic
effect.
However, as shown in many studies, intravenous anti-
biotics cannot be the main treatment of endogenous en-
dophthalmitis. In this exceptional case, we were able to
treat endogenous endophthalmitis with intravenous and
intravitreal antibiotics due to the patient’s special condi-
tion, which includ ed ESRD. Intravitreal injection of anti-
biotics remains important because the intravitreal route
provides immediate and high drug concentrations [12].
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