Endogenous endophthalmitis is a rare but vision-threatening intraocular infection in neonates with an estimated incidence of 4.42 per 100,000 live births.1 The disease results from hematogenous dissemination of microorganisms across the blood–ocular barrier, most commonly Group B streptococci, Gram-negative bacilli, Pseudomonas aeruginosa and Candida species.2 Neonatal endogenous endophthalmitis is strongly associated with prematurity, prolonged neonatal intensive care unit (NICU) stay, invasive procedures and systemic sepsis.3 Gram-negative organisms, particularly Pseudomonas aeruginosa are highly virulent and often cause rapid ocular destruction with poor visual outcomes.4 Case Report A 28-day-old preterm male neonate (31 weeks of gestation; birth weight of 1.8 kg) admitted to the NICU for respiratory distress subsequently developed fever. Routine retinopathy of prematurity (ROP) screening demonstrated dense vitritis with marked media haze in the affected eye Fig. 1.Figure 1: 28-day-old male preterm neonate had been on ventilatory support since birth because of respiratory distress. On routine ROP examination, media haze with vitritis was noted in the right eye. ROP = retinopathy of prematurityB-scan ultrasonography demonstrated heterogeneous echogenic vitreous echoes without calcification Fig. 2, favoring an infectious etiology over retinoblastoma.5 MRI of the brain and orbits revealed vitreous heterogeneity, diffusion restriction and peripheral choroido-scleral enhancement without an intraocular mass Fig. 3, consistent with endophthalmitis.6 Retinoblastoma was considered as a differential diagnosis but was excluded based on imaging characteristics. Systemic investigations showed leukocytosis and elevated inflammatory markers with Pseudomonas aeruginosa isolated from both blood and vitreous cultures, confirming endogenous pseudomonal endophthalmitis.Figure 2: On ultrasound, there is heterogenous echogenicity noted in the posterior chamber of the right eyeball with no internal vascularity on color Doppler (a and b)Figure 3: MRI brain and orbits revealed the right globe appears mildly enlarged and deformed with evidence of ill-defined T1 isointense, T2 heterogeneously iso to slightly hyperintense and Fluid attenuated inversion recovery (FLAIR) hyperintense contents within the vitreous chamber (a-c). It shows diffusion restriction with high Diffusion weighted imaging (DWI) and reduced Apparent diffusion coefficient (ADC) values (e and f). On post-contrast study, there is evidence of choroido-scleral thickening with peripheral enhancement around the globe (d and h). There is no evidence of any intraocular enhancing mass or any foci of blooming on Susceptibility weighted imaging (SWI) (g)Discussion Recent Indian pediatric data report vitritis (89.6%), hypopyon (47.9%) and leukocoria (27.1%) as the most frequent presenting signs with Gram-negative organisms isolated in approximately 35% of cases.2 Delayed diagnosis significantly worsens anatomical and visual outcomes.7,8 The infant was treated with systemic and intravitreal antibiotics. At 8-week follow-up, anterior segment and fundus photographs showed complete resolution of inflammation with restoration of normal retinal morphology Fig. 4.Figure 4: Post-treatment images at the 8-week follow-up: (a) Anterior segment photograph demonstrating clear media with complete resolution of intraocular inflammation; (b) Fundus photograph showing restored retinal clarity and normal retinal morphology, confirming a favorable outcomeConclusion This case highlights the importance of early imaging, microbiological confirmation and prompt targeted therapy in neonates with sepsis and leukocoria. Authors’ contributions Concept, design – Dr Sanket; Definition of intellectual content – Dr Ratnapriya; Literature search – Dr Sanket; Clinical studies – Dr Ratnapriya; Manuscript preparation – Dr Ratnapriya; Manuscript editing – Dr Ratnapriya; Manuscript review – Dr Sanket. Both authors have approved the final version of the manuscript and agree to be accountable for all aspects of the work. Declaration of patient consent The authors certify that they have obtained all appropriate consent forms from the legal guardians (parents) of the patient. In the form, the guardians (parents) have given consent for the patient’s images and other clinical information to be reported in the journal. The guardians (parents) understand that the patient’s name and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.
Davra et al. (Wed,) studied this question.