Endophthalmitis is a rare but potentially serious intraocular infection that can lead to permanent loss of vision. The following case report is from a true case that was filed for litigation.
The following case report is derived from an actual case.
A three year old boy was brought by his mother to an ophthalmologist. The mother reported that her child has crossed eyes since birth but had never seen an eye doctor prior to her visit. Examination by the ophthalmologist showed in-crossing of the eyes (esotropia) to a power level of 60 diopters. The child was treated with patching of the good eye.
Several months later the child underwent routine esotropia surgery. Bimedial rectus recessions under general anesthesia were performed. 6 mm of recession was performed for each eye using 6-0 Vicryl suture. 6-0 plan gut suture was used to close the conjunctiva. Tobradex antibiotic was used at the end of surgery and during the post-operative period. There was no indication or evidence of scleral perforation. The surgery was reportedly uneventful and took about 30 minutes. On the first post-operative day the child appearance to have straight eye (orthophoric) and was treated with eyedrops.
On the sixth post-operative day the child presented in the emergency room where orbital cellulitis is was suspected. A CT scan did not show evidence of orbital infection but clinical examination showed inflammation in the front portion of the left eye (anterior chamber). The child was referred to a retina specialist who suspected endophthalmitis. Scheduled surgery was postponed for three hours because the mother fed the baby a bottle of food despite instructions to the contrary.
Surgery showed fibrin covering the lens inside the eye. A vitrectomy and iridectomy was [performed. Inspection of the muscle sutures showed no evidence of a deep suture. There was no evidence of leakage of fluid or vitreous around the suture. There was no evidence of an infected suture. Cultures obtained from the anterior chamber and vitreous turned out to be negative for bacteria.
Two months later the child underwent examination under anesthesia with possible vitrectomy to remove inflammatory debris from the eye and prevent amblyopia. However, examination showed a pressure of zero a cyclitic membrane and vascularized retina precluded performance of the vitrectomy. The lens was clear and the vitreous was also clear. The eye was deemed unrepairable by three ophthalmologists.
Endophthalmitis is a potentially devastating condition that can lead to permanent loss of vision. The damages in this case are significant because of loss of vision in one year for a lifetime. However, one of the key issues is that of causation. In this case there was no clear evidence of negligence at the time of surgery. Certainly, perforation of the eye with suture can lead to ingress of bacteria with infection, but there was no indication of perforation admitted in the operative report or by inspection by a second ophthalmologist.
Although most observers would assume a connection between surgery and the presence of endophthalmitis, the time interval between both events makes them unlikely to be related. Most cases of endophthalmitis due to surgery occur with 48 hours after the procedure. In this case, the onset of endophthalmitis was only apparent six days after surgery. Therefore, surgery as a causal factor for endophthalmitis becomes even less likely.
Experts also need to consider the type of endophthalmitis. In this case, the endophthalmitis may be labeled as a “sterile” endophthalmitis because bacteria were never cultured from inside the eye. This factor is another reason why the case was not pursued by the plaintiff’s attorney.
Salmon SM, Friberg TR, Luxenberg MN. Endophthalmitis after Strabismus Surgery. American Journal of Ophthalmology. 1982 January; 93(1):39-41