Treatment of Staphylcoccus Aureus Subretinal Abscess and Endogenous Endophthalmitis With Good Visual Outcome

Abstract

Purpose:: Bacterial subretinal abscess is a rare and often visually devastating entity for which an optimal treatment stategy has not yet clearly been elucidated. A few cases with acceptable visual outcomes have been reported with aggressive surgical intervention combined with antibiotics. Here we present two cases of subretinal abscess and endogenous endophthalmitis from Staph aureus with excellent visual outcomes.

Methods:: Retrospective analysis of all cases of Staph aureus from one surgeon in the Retina Service at Massachusetts Eye and Ear Infirmary from 1996 to 2006. Patients underwent complete ophthalmic and systemic evaluation.

Results:: Two cases of subretinal abscess and endogenous endophthalmitis from Staph aureus were identified. Case 1 was a 51-year-old man with a history of poorly controlled diabetes who presented with decreased vision, conjunctival injection and pain OS. Initial examination revealed a visual acuity of 20/40, 3+ anterior chamber cells, 1+ vitreous cells and a creamy-white subretinal lesion in the temporal retina. The diagnosis was endogenous endophthalmitis with a subretinal abscess. Blood cultures and vitreous tap demonstrated Staph aureus. Despite intravitreal and intravenous antibiotics the vision decreased to 20/400, the ocular inflammation worsened and the subretinal abscess enlarged. The patient underwent pars plana vitrectomy (with spontaneous drainage of the subretinal abscess), endolaser around the abscess site, lensectomy, and injection of intravitreal antibiotics. The patient also continued IV antibiotics. Final visual acuity with secondary AC IOL was 20/16. Case 2 was a 40-year-old man with a history of IV drug use who presented with a subcutaneous abscess and decreased vision OD. Initial examination showed a visual acuity of 20/400 OD, a 1.5 mm hypopyon and a limited view of the posterior pole due to significant vitritis. B-scan ultrasonography revealed a 3 mm subretinal abscess in the nasal periphery. Blood cultures were positive for MRSA. Tap of the vitreous and anterior chamber was negative. Intravitreal antibiotics were injected. The subcutaneous abscess was drained and the patient started IV antibiotics. Over the course of several weeks the hypopyon resolved, the vitritis cleared and the patient’s final visual acuity was 20/32.

Conclusions:: Subretinal abscess and endogenous endophthalmitis from Staph aureus may respond to intravitreal and intravenous antibiotics but may require surgical management. Careful monitoring for worsening infection and prompt surgical intervention is necessary to ensure good visual outcome.

Keywords: Staphylococcus • retinitis • endophthalmitis