Acute fulminant endophthalmitis complicating traditional lens couching

A study about acute fulminant endophthalmitis complicating traditional lens couching.

A 76-year-old woman presented to the department of ophthalmology in February, 2014, with painful unilateral exophthalmos, 5 days after undergoing couching of the right cataractous lens by a traditional healer. The following day her eye had become red and painful with reduced vision. On examination visual acuity in the right eye was light perception, the intraocular pressure was high (45 mm Hg; normal 10–20 mm Hg), and there was proptosis and ophthalmoplegia. Biomicroscopic examination showed eyelid oedema, conjunctival injection, total chemosis, abundant purulent secretions, and a greenish hypopyon occupying the anterior chamber, typical of pseudomonas infection (figure). CT showed preseptal and retroseptal cellulitis, exophthalmos grade II, and a dislocated cataractous lens in the lower vitreous. We took vitreous and aqueous humour samples and gave one injection of intravitreal antibiotics (vancomycin 1 mg/0·1 mL and ceftazidime 2·25 mg/0·1 mL). We started systemic antibiotics (intravenous ceftriaxone 1 g twice daily and levofloxacin 500 mg twice daily) and a systemic hypotonic (oral acetazolamide 250 mg twice daily). 48 h later we gave a second dose of intravitreal antibiotics and started methylprednisolone 40 mg twice daily for 5 days to reduce the inflammation. Vitreous cultures grew Pseudomonas aeruginosa. By the seventh day the patient's pain, eyelid oedema, and proptosis had resolved (figure), but she had a persistent vitreous opacity. We did pars plana vitrectomy and iris-claw intraocular lens on the posterior side of the iris to compensate for the refractive disorder caused by absence of the crystalline lens. At last follow-up in May, 2014, her best corrected visual acuity was 6/60 in the right eye and intraocular pressure had returned to normal (16 mm Hg).

Lens couching is the oldest technique of cataract surgery. It was first practised by the Assyrians of Hammurabi in the 17th century BC, and then by the Hindu surgeon Sushruta around 600 BC. It consists of traumatising the zonula through the sclera using a pen so the lens falls into the vitreous and releases the visual axis, allowing the patient to see the light. The visual outcome of this technique, unfortunately still prevalent in some parts of the world, is often poor. Its complications are retinal detachment, secondary glaucoma, hyphaema, uveitis, optic atrophy, and endophthalmitis.

Contributors

All authors cared for the patient and wrote the report. Consent to publication was obtained.