Inside-out: Infectious Endophthalmitis with Secondary Corneal Perforation

A 98-year-old man with exudative age-related macular degeneration receiving intravitreal aflibercept injections was referred for worsening left eye endophthalmitis. Prior vitreous culture grew Streoptococcus pneumonia. He received two rounds of intravitreal vancomycin and ceftazidime. Examination revealed corneal necrosis with intraocular lens extrusion (Fig A, arrow). Ultrasound revealed multiple, loculated collections with heterogenous echogenicity (Fig B). Computed tomography demonstrated thickened posterior sclera without retro-orbital extension (Fig C). Following evisceration, histopathologic analysis demonstrated severe neutrophilic infiltration of the posterior cornea (Fig D). Although infectious keratitis may infrequently develop into secondary endophthalmitis, primary endophthalmitis leading to secondary corneal perforation is very rare (Magnified version of Fig A-D is available online at www.aaojournal.org).