A 59-year-old Caucasian man presented with a 10-day history of a progressive supero-nasal field defect in his right eye. He had been highly myopic prior to bilateral cataract surgery performed 4 years previously. Examination revealed an infero-temporal rhegmatogenous retinal detachment due to two small U-shaped retinal breaks. His past medical history included dilated and ischaemic cardiomyopathy and renal impairment. A non-drainage scleral buckling procedure was performed comprising cryotherapy and placement of a 4 mm radial scleral explant (Labtician Ophthalmics Inc, Canada) using 5.0 polyester sutures. The conjunctiva was closed with 8.0 vicryl sutures and subconjunctival cefuroxime (125 mg) was given. The retina was successfully re-attached on the first postoperative day. Three days later, he presented to his general practitioner with a painful right eye associated with diplopia and a mucopurulent discharge. Treatment was started with amoxicillin (500 mg three times daily orally) and chloramphenicol 1% eye ointment. A rapid deterioration in his symptoms occurred a few days later prompting re-presentation to our institution.
Visual acuity was 6/9 OD and 6/6 OS. The right eye was very painful and injected with copious mucopurulent discharge and point tenderness over the scleral explant (). Immediate management involved removal of the scleral explant and polyester suture with samples being sent for microbiology. Empirical antibiotic treatment was initiated comprising systemic ceftazidime (1 g three times daily intravenously) and ciprofloxacin (750 mg twice daily orally) with topical chloramphenicol 0.5% hourly.
Figure 1 A. Presentation with inferotemporal scleral abscess 8 days post-scleral buckling surgery. B. Appearance 5 months following removal of scleral explant and novel antibiotic treatment comprising systemic ceftazidine and ciprofloxacin. A residual anterior (more ...)
Microbiology results available 2 days later demonstrated isolation of Pseudomonas aueroginosa sensitive to gentamicin and ciprofloxacin with resistance to chloramphenicol. Antibiotic treatment was changed to systemic ceftriaxone (2 g once daily intravenously) and ciprofloxacin (750 mg twice daily orally) with topical ciprofloxacin 0.3% hourly. This treatment regime resulted in steady clinical improvement. He was discharged after 5 days in hospital on a treatment regime comprising systemic cefaclor (500 mg three times daily orally) and ciprofloxacin (750 mg twice daily orally) with topical ciprofloxacin 0.3% four times daily and dexamethasone 0.1% four times daily. His retina remained fully re-attached and both tears over the previous buckle site were closed.
During the following weeks, there was only modest further clinical improvement with a persistent non-healing necrotic ulcer. Therefore, he was re-admitted for a prolonged intensive course of antipseudomonal agents in order to eradicate the infection. The antibiotic treatment comprised systemic ceftazidime (2 g three times daily intravenously) and ciprofloxacin (750 mg twice daily orally) with topical ceftazidime 5% four times daily and ciprofloxacin 0.3% four times daily. This antibiotic treatment was continued for 3 weeks resulting in steady healing of the necrotic ulcer.