Shape is Endophthalmitis , it is prevalent in Nepal (more or less it is seen more commonly in Kaski District ). This diseases is associated with exposure to Moth.

2. Age: 9 yrs
Sex: Male
Address: Nepal

3. LE redness since 2 days
LE Loss of vision since 2 day

4. Redness- sudden in onset, progressive
Hx of trauma to left eye by wooden stick while
playing kite 2 days prior to redness of eye
Associated features:
Ocular pain, Sudden on onset
 Mild
 dull ache
 Non radiating
 Not aggravated by ocular movements
 No relieving factor

5. No hx of nausea and vomiting, No history of colour halos
Visual loss:
-sudden, profound
-No hx of headache
-No hx focal neurological weakness
-no hx of viral flu prior to illness
-no hx of vaccination

6. - No foreign body sensation, burning sensation, itching
- No H/O rash around eye

7.  No H/O of fever
 No H/O of cough
 No H/O malaise
 No H/O back pain
 No H/O recurrent oral/genital ulcers
 No H/O TB
 No H/O joint pain
 No H/O rash elsewhere in the body

8. No H/O similar illness in the past
No H/O surgery of any kind

9. Occupation: student
Non-vegetarian diet
No history of similar illness to any family member
 No history of white moth in surrounding and no hx of
direct contact of any sort

10. Was treated in nearby hospital as LE SHAPU and was on:
Gtt. Prednisolone acetate 1% 1hrly in LE
Gtt. Atropine 1% TID in LE
Tab Prednisolone 30 mg PO OD(pc) for 1 day

12.  Conscious, irritative and well
oriented to time, place and
person
 weight: 30kg
 Vitals:
 Temperature: 98 deg. F
(axillary)
 Pulse : 72bpm regular,
normal volume, rate,
rhythm
 Respiratory rate: 16bpm
 Blood pressure:
110/60mmHg
No
suggestive
signs

13. Respiratory
• B/L normal vesicular
breath sound
• No added sounds
Abdomen
• Soft, non-tender
• No organomegaly
Cardiovascular
• S1 S2 M0
CNS
• Grossly normal
• No signs of hearing/
memory impairment
Skin and
integumentary
• No rashes
Skeletal system
Normal

15. 15
Right side Examination Left side
Normal Head position Normal
Symmetrical Facial Symmetrical
Symmetrical, No
periorbital ecchymosis,
tenderness, emphysema
Orbit
Symmetrical, No
periorbital ecchymosis,
tenderness, emphysema
No redness, No
regurgitation, Normally
placed puncta
Lacrimal System
No redness, No
regurgitation, Normally
placed puncta

16. Right eye Examination Left Eye
Visual acuity
6/6 UCVA
PL+
PR accurate
PH NI
Retinoscopy
Working distance
= 50 cm+2D

18. Right eye Examination Left Eye
Pupillary Examination
Round and regular Shape Round and regular
Reactive Reactivity Sluggish
Present Direct light reflex Couldn't be assessed
Present Consensual light reflex Couldn’t be assessed
Couldn’t be assessed RAPD Couldn’t be assessed
Eye lids and adnexa
No ectropion/entropion Position No ectropion/entropion
Absent Swelling Absent
Normal
No trichiasis
Lashes
Normal
No trichiasis
Conjunctiva
absent Congestion CCC + diffuse
absent Chemosis absent
absent Discharge Mild
18

19. Right Eye Examination Left Eye
Clear Cornea
No hair like structures.
Corneal stromal
edema, fine diffuse kps,
epithelial staining with
fluorescein dye, Normal
corneal sensation
VH IV AC
>50 cells/hpf ; Flare 4+
Hypopyon- 1mm,
shifting, White colored
Fibrinous membrane
over anterior lens
capsule

20. Right eye Examination Left eye
Normal Iris Normal
Clear Lens Not visible
Clear AVF Not visible

21.  Digitally RE=LE

22. Right eye Examination Left Eye
Clear Vitreous Vitreous opacities +4
Disc- round, pink, regular
margin,
cup-disc ratio- 0.3:1,
NRR- healthy,
Vessels- normal,
peripapillary area- healthy,
macula- healthy,
foveal reflex + and
periphery- healthy
FUNDUS
fundal glow couldn't be
appreciated
No other structures visible

23. USG B-scan LE

24. LE endophthalmitis consistent with SHAPU
(Seasonal Hyperacute Panuveitis)

25.  Points in favour-
- U/L
- Child
- Autumn season
- Rapidly reduced severe vision loss
- Sudden onset ocular redness followed by mild
ocular pain
- Fibrinoid AC reaction
- Hypopyon- shifting
- Low to medium internal reflectivity in USG A-scan
- Echogenic shadow in anterior and mid vitreous
USG B-scan
 Points against-
No hx of direct contact with Moth or any
insects/surrounding

26. Post traumatic Endophthalmitis
Endogenous Endophthalmitis
Acute nongranulomatous hypopyon anterior and intermediate
uveitis
- HLA B 27 related
- Behcet’s disease

27.  Points in favour-
 Hx of trauma by wooden material
- Severely reduced VA
- Circumciliary congestion
- Hypopyon
- Plenty AC reaction with fibrin
- Low to medium internal reflectivity in USG A-scan
- Echogenic shadow in anterior and mid vitreous USG B-scan
- Points not in favour-
- No detectable perforation site
- Normal plain radiograph

28.  Points in favour-
- Severely reduced VA
- Circumciliary congestion
- Hypopyon- shifting
- Plenty AC reaction with fibrin
- Low to medium internal reflectivity in USG A-scan
- Echogenic shadow in anterior and mid vitreous USG B-scan
 Points not in favour-
- No H/O systemic illness like fever, cough, malaise,
- No any systemic infectious foci
- Not being treated for any infectious condition recently,
- Mild ocular pain,
- blood/urine c/s

29.  Points in favour-
- Reduced VA
- Circumciliary congestion
- Plenty AC reaction with fibrinous membrane over anterior lens capsule
 Points not in favour-
- No H/O low back pain, past TB, recurrent oral/genital ulcers or joint pain
- Shifting hypopyon

30.  Points in favour-
- Reduced VA
- Circumciliary congestion
- Plenty AC reaction with fibrinous
membrane over anterior lens capsule
- Shifting hypopyon
 Points not in favour-
- No H/O low back pain, past TB
- No H/O any skin lesions
- No H/O recurrent oral/genital ulcers
- No H/O joint pain
- Laterality

31.  CBC
Hb 13.4mg/dl,
TC 12000 N83, L13, M1,E1
ESR 35mm/1st hr
 RBS – 98mg/dl
 Urine R/M/E :Normal
 Serology( HIV, HBsAg and HCV)- negative
 Blood C/S
 Urine C/S
 Nasal swab C/S
 Conjunctival swab C/S

32.  LE Pars Plana Vitrectomy + Lensectomy + Vitreous tap+ Intravitreal
Vancomycin(1mg/0.1ml)+ Ceftazidime(2.25mg/0.1ml) and S/C
Vancomycin +Ceftazidime + Dexamethasone(0.4mg/0.1ml) under GA
on next day.
 Vitreous tap - turbid
- Gram stain: pus cells 5-20/OIF
- Giemsa stain: pus cells 5-15 /OIF
- KOH: fungus not seen
 Vitreous C/S sent

33. Intraoperative finding:
Retina whitened edematous with tortuous and inflammed
blood vessels and peripheral sheathing, disc barely visible

34. Removed eye pad after 4hours and started on:
- Gtt. Fortified Vancomycin 5% 1 drop 1hrly LE
- Gtt. Fortified Ceftazidime 5% 1 drop 1hrly LE
- Gtt. Atropine 1% 1 drop TDS LE
- Gtt. Prednisolone Acetate 1% 1 drop 1 hrly LE
- Oc. Ciprofloxacin 0.3% LA HS LE

35.  VA- child was uncooperative for vision
 Child symptomatically much better, pain reduced
 Decreased congestion
 AC- >25 cells/hpf
 No fibrin
 Hypopyon- Trace
 Uncooperative for PS examination
 Fundus: Dull glow
 Rx:
- CST
 F/U in 1day

36.  Blood C/S
 Urine C/S No growth
 Nasal swab C/S
 Conjunctival swab C/S
Vitreous
 Gm stain NAD
 Giemsa NAD
 KOH No fungus
 Culture: Streptococcus pneuomniae isolated

37.  VA-
 Conjunctival congestion and pain subsiding
 Decreased corneal edema
 AC- >25 cells/hpf,
 No fibrin and No hypopyon
 IOP-Digitally RE=LE
 Faint fundal glow was seen
 Rx-
 Oral prednisolone 1mg/kg/day(30mg) PO OD (PC) was started
 Gtt moxifloxacin 0.5% 1 drop LE 1 hrly
- CST
 F/u after 1 day

38. Streptococcus Pneumoniae positive endophthalmitis
consistent with SHAPU

39.  VA-
 Conjunctival congestion and decreased pain
 Decreased corneal edema
 AC> 25 cells/hpf
 No fibrin
 No hypopyon
 IOP- RE=LE
 Fundal glow +
 Rx-
- CST
 F/u after 3 day

40.  VA
 Conjunctival congestion and decreased pain
 Decreased corneal edema
 AC-12- 15 cells/hpf
 No fibrin
 No hypopyon
 IOP- Digitally RE=LE
 Thin veil like VO in front of posterior pole, glow present , details
not seen

41.  Rx-
- Started Gtt moxifloxacin 0.5% 1 drop 2 hrly LE
- Gtt. Prednisolone Acetate 1% 1 drop 2 hrly LE
- Gtt atropine 1 % 1 drop HS LE
- Tab Prednisolone 30 mg for 2 days then 20mg PO OD for 1 week
 F/u after 1 week

42.  VA; RE 6/6 LE CF at 50 cm with +14 D 6/36
 Conjunctival congestion and decreased pain
 AC-12- 15 cells/hpf,
 No fibrin
 No hypopyon
 IOP- 18 mmHg
 VO 2+

43.  Rx-
- Started Gtt moxifloxacin 0.5% 1 drop QID LE continue
- Gtt Prednisolone acetate 1 % 1 drop 6times/day for 1 week
- Gtt Prednisolone acetate 1 % 1 drop 4 times/day for 1 week
- Gtt Prednisolone acetate 1 % 1 drop 3 times/day for 1 week
- Gtt Prednisolone acetate 1 % 1 drop 2times/day continue
- Tab Prednisolone 15mg PO OD(PC) for 1 week
- Tab Prednisolone 10mg PO OD(PC) for 1 week
- Tab Prednisolone 7.5mg PO OD(PC) for 1 week,
- Tab Prednisolone 5 mg PO OD(PC) to continue
 F/u after 1 month

44.  VA; LE CF 4m with +11 D sphere and -1 cylinder at 180 ; 6/9
 Conjunctival and corneal: clear
 AC-7-8cells/hpf,
 No fibrin
 No hypopyon
 IOP- 16 mmHg air puff
 Disc- round, regular margin
 Minimal VO more inferiorly

45.  Rx-
- Started Gtt moxifloxacin 0.5%1 drop 3 times LE for 2 week
- Gtt Prednisolone acetate 1% 1 drop 3 times LE for 2 weeks,
- Gtt Prednisolone acetate 1 % 1 drop 2times LE for 1 month
- Tab Prednisolone 7.5mg PO OD ( PC ) for 1 week
- Tab Prednisolone 5mg PO OD(PC) 5 mg 1 month
 F/u after 1 month

46.  VA; RE 6/6, LE 1/60 with +12 D ; 6/9
 Conjunctival and corneal: No fresh Kps
 AC-1-3cells/hpf,
 No fibrin
 No hypopyon
 IOP- 16 mmHg by GAT
 Minimal VO inferiorly

48.  Rx-
- Gtt Prednisolone acetate 1 % 1 drop 2 times for 1 month
- Gtt Prednisolone acetate 1 % 1 drop OD LE to continue
- Tab Prednisolone 5mg PO OD 1 month
- Tab Prednisolone 2.5mg PO OD (PC) continue
 F/u after 1 month