Case Report

TIM JAGA IGD

Anamnesis

86 years old female came to Emergency Unit of Cicendo Eye Hospital on 13th January 2022 with chief
complaint : swollen & red left eye one day before hospital admission
History of Current Illness

3 days before 2 days before 1 day before

hospital admission hospital admission hospital admission

Left eye difficult to Go to an eye Doctor: Fever

open, foreign body 1. Pink eye drop
sensation 2. Lyteers

Without improvement
 History of Previous Illness

1995 and 1996 September 2020 November 2021 No history of:

1. Glaucoma on patient
2. Galucoma on family
3. Using eyedrops for a long
Cataract operation • Avastin injection on time
both eyes 4. Repeated red eyes
• The treatment was Hstory of hip surgery due to 5. Use of glasses
stopped because of fracture on right leg 6. Asthma
pandemic 7. Diabetes Mellitus
8. Drug allergy
Physical Examination
• General condition : CM, moderately ill
• Vital sign : Within normal limit

BP: 128/89
HR: 104x/min
RR 20x/min
S: 36.3
Opthalmological Examination
-3 -3
0 0

-3 -3
0 0

-4 -4
0 0
OD OS
1/60 Visual acuity NLP
10 mmHg IOP 32 mmHg
Normal Palpebrae Blepharospasme (+)
Normal Conjunctiva Conjunctiva chemosis (+)
Normal Cornea FT (+), PEE (+), Edema (+), KP (+)

Normal Anterior chamber VH grade I flare and cells hard to assess

+/ Reverse RAPD (+) Pupil Mid dilated pupils, RC /, RAPD sdn
Normal Iris Normal
PC IOL (+) lens with PCO grade I Lens PC IOL (+)
Drusen (+), Geographic atrophy Fundusopy Cloudy
Laboratoy Exam
Complete Haematology • Limphocyte : 23
• Haemoglobin : 13.7 • Monocyte : 10
• Leucocyte : 15.520 Chemical
• Erythrocyte : 4,52 • Random blood glucose : 159
• Thrombocyte : 206.000 Immunology
• Hamatocrite : 39.3 • CRP quantitative : 80
Leucocyte Differential Count Chemistry
• Basophil :0 • Ureum : 55
• Eosinophil :0 • Kreatinin : 1.34
• Rod neutrophils :1
• Segment neurtrophil : 66
 USG Examination
Ultrasound of the left
eye showed retinal
detachment with
vitreous opacification
e.c. inflammatory
cells
USG OS 13/1/22
USG OS 13/1/22
Diagnosis
Panoftalmitis OS + Secondary Glaucoma OS + Ablatio Retina OS (USG) + Geographic Atrophy OD e.c post
AMD + Susp. Wet AMD ODS + Pseudophakia ODS + Post right hip surgery + Dental Caries
 Treatment
• - Consult to consultant on call
• - Consult to EED, Vitreoretina and Glaucoma consultant
• - Ceftriaxone 2x1 gr iv
• - Metronidazole 3x500mg iv
• - Levofloxacin gtt/ jam OS
• - Cyclon ed 3x OS
• - Artificial tears ed 6x OS
• - Methylprednisolone 1mg/kg BB/hr--> BW 43kg: 1x40mg /hr PO (GDS 159)
• - Omeprazole 2x20 mg
• - Beta blocker timolol maleate 0.5% 2XOS
• - Acetazolamide tab 3x250 mg
• - Kalium L -aspartate 1x300 mg
Follow Up EED
14/01/2022 15/01/2022 16/01/2022 17/01/2022
OS OS OS OS

Palpebrae Blepharospasme (+), Blepharospasme (+), Minimal Minimal blepharospasme

minimal edema (+), minimal edema (+), blepharospasme(+),
hyperemis (+) hyperemis (+) minimal NT (+)
Conjunctiva Chemosis (+), hyperemis Chemosis (+), hyperemis Hyperemis (+), minimal Effron ciliary injection
(+), secret (+) (+), secret (+) chemosis (+) grade III, inferior chemosis
(+)
Cornea Inferior: FT (+), PEE (+), Inferior: FT (+), PEE (+), Edema (+), FT hard to Infiltrate on temporal
edema (+), KP (+) edema (+), KP (+) assess sideport, edema (+), FT (-)
Anterior chamber Shallow, fs dfa Shallow Shallow, f/s dfa Shallow, f/s dfa
Pupil Round, pharmacology Round, pharmacology Round, pharmacology Round, pharmacology
dilated dilated dilated dilated
Iris Sinechia (-) Sinechia (-) Sinechia (-) Sinechia (-)
Lens PC IOL (+) PC IOL (+) PC IOL (+) PC IOL (+)
Follow Up GLAUCOMA
14/01/2022 15/01/2022 16/01/2022 17/01/2022
OS OS OS OS

Palpebrae Secret (-), crustae (+) Blepharospasm (+) Secret Blepharospasme (+), Blepharospasme, minimal
(+) secret (+) secret
Conjunctiva Hyperemis, inferior Chemosis (+) chemosis (+) Chemosis (+) minimal
chemosis (+) inferior
Cornea Edema (+) Edema (+) Edema (+) Edema (+)

Anterior chamber Shallow Shallow Shallow VH grade I, f/s dfa

Pupil Round, pharmacology Round, pharmacology Round, pharmacology Round, pharmacology
dilated dilated dilated dilated
Iris Sinechia (-) Sinechia (-) Sinechia (-) Sinechia (-)
Lens PC IOL PC IOL PC IOL PC IOL
Follow Up RETINA
14/01/2022 15/01/2022 16/01/2022 17/01/2022
OS OS OS OS

Palpebrae Normal Minimal blepharospasm Blepharospasm, secret, Blepharospasm, secret, NT

(+), minimal NT (+) NT (+), hyperemic (+), hyperemic
Conjunctiva Inferior chemosis (+), Hyperemic (+), minimal Chemosis, hyperemic Chemosis (+), hyperemic
ciliary injection (+) chemosis (+)
Cornea Edema (+) Edema (+), FT hard to Edema Edema
assess
Anterior chamber Shallow Shallow, f/s sdn Shallow Slightly shallow
Pupil Round, mid dilatation (+) Round, pharmacology Round, pharmacology Round, mid dilated
dilated dilated
Iris Sinechia (+) Sinechia (-) Sinechia (-) Sinechia (-)
Lens PC IOL (+) PC IOL PC IOL PC IOL
Funduscopy Cloudy Cloudy Cloudy Cloudy
USG OS 17/1/22
USG OS 17/1/22
PANOPTHALMITIS
 Definition
Panophthalmitis is an inflammation of all three coats of the eye (and adjacent cavities);  it often starts a an
endophthalmitis that then involves the sclera an spreads to orbital structures.

Yanoff, Myron (2015). Ocular Pathology || Nongranulomatous Inflammation. , (), 53–66.e2. doi:10.1016/b978-1-4557-2874-9.00003-x 
 Source of Inflammation
• Exogenous:
Sources originate outside the eye and body[e.g., local ocular physical injury (surgical trauma, penetrating and
perforating nonsurgical trauma, and radiant energy); chemical injuries (acid and alkali); and allergic reactions to
external antigens (conjunctivitis secondary to pollen)].

• Endogenous:
Sources originate in the eye [e.g., inflammation secondary to cellular immunity (phacoanaphylactic endophthalmitis);
spread from contiguous structures (the sinuses); hematogenous spread (virus, bacteria, fungus, and foreign particle);
and conditions of unknown cause  (sarcoidosis)].

Yanoff, Myron (2015). Ocular Pathology || Nongranulomatous Inflammation. , (), 53–66.e2. doi:10.1016/b978-1-4557-2874-9.00003-x 
 Clinical Features
• Severe ocular congestion, chemosis, and haziness of the cornea, aqueous, and vitreous are characteristic a purulent
exudate, frequently visible as a hypopyon, may be present in the anterior chamber.
• Pain is prominent in both conditions but especially in panophthalmitis.
• Extension into orbital tissue often results in congestion and edema of the lids and even exophthalmos.
• The cause may be infectious or noninfectious.

Yanoff, Myron (2015). Ocular Pathology || Nongranulomatous Inflammation. , (), 53–66.e2. doi:10.1016/b978-1-4557-2874-9.00003-x 
 Classifications
• Exogenous
 Infectious keratitis and corneal ulcers may cause a reflex sterile suppurative iridocyclitis and hypopyon
 Nonsurgical penetrating or perforating trauma may lead to the presence of a contaminated or sterile intraocular
foreign body, producing a suppurative inflammation.
 Postoperative suppurative inflammation in the first day or two after surgery is usually purulent, fulminating,
and caused by bacteria.
1. Delayed (e.g., a month or two after intraocular surgery) endophthalmitis suggests a fungal infection.
2. A bacterial infection is also a possible cause of delayed endophthalmitis, especially with less virulent
bacteria such as Staphylococcus epidermidis and Propionibacterium acnes

Yanoff, Myron (2015). Ocular Pathology || Nongranulomatous Inflammation. , (), 53–66.e2. doi:10.1016/b978-1-4557-2874-9.00003-x 
 • Endogenous
 Metastatic septic emboli, especially in children or debilitated persons, may occur in subacute bacterial
endocarditis, meningococcemia, or other infections associated with a bacteremia, viremia, or fungemia.
 Necrosis of an intraocular neoplasm, particularly retinoblastoma, may rarely result in a suppurative
endophthalmitis or even panophthalmitis.

Yanoff, Myron (2015). Ocular Pathology || Nongranulomatous Inflammation. , (), 53–66.e2. doi:10.1016/b978-1-4557-2874-9.00003-x 
Risk Factor
● Endogenous ● Exogenous

1. Chronic metabolites 1. Bacterial colonized in eyelid

2. Immunosuppression margin and conjunctiva
3. Malignancy 2. Helathcare presonnel
4. IV drug abuse 3. Surgical instrument and solutions
5. Long term intracorporeal foreign 4. Intraoperative complication
body 5. Systemic issues (older age abpve
6. Invasive surgery 80, DM)
Treatment
• The main treatment for endogenous bacterial panophthalmitis included intravitreal and periocular injections of
antibiotic/dexamethasone combinations.
• The periocular treatment included subconjunctival and sub-Tenon’s injections
Thank You
Laboratoy Exam