MRI findings in endophthalmitis and panophthalmitis

Description

Endophthalmitis is an inflammation of the eyeball without the involvement of the sclera and involvement of the sclera makes the diagnosis panophthalmitis. Endophthalmitis can occur exogenously, usually after ophthalmic surgery, post-traumatically or endogenously. Endogenous bacterial endophthalmitis is a severe and emergency condition that develops when bacteria cross the blood-ocular barrier and multiply inside the deep structures of the eye, such as the vitreous and aqueous chambers. Endophthalmitis is the most common complication after cataract surgery. Regardless of aetiology, endophthalmitis usually causes vision loss.¹ Severe posterior and anterior segments inflammation are frequently associated with scleral abscess, corneal opacity and perforation or rupture in panophthalmitis.

MRI with diffusion-weighted imaging (DWI) helps further assess complications, disease extent and response to therapy, especially when ophthalmoscopic visualisation is obscured by lens opacification.²

Here, we discuss an elderly male patient who came to our hospital with complaints of complete loss of vision, unable to open eyes, blood discharge from the right eye, purulent discharge from the left eye and severe pain in both eyes for the last 10 days. On examination, both eyes were swollen, extensive eyelid oedema and erythema, and proptosis of both eyes, the right eye appeared red, and the left eye revealed a darkened anterior chamber. He had a history of right eye cataract surgery before 7 months. After surgery, he developed pain and congestion in both eyes. He also had a history of uncontrolled diabetes and hypertension. As the patient was unable to open his eyes and was very apprehensive to the pain, the ophthalmologist could not fully examine the eyes. The patient underwent an MRI of both orbits under a mild sedation to evaluate his orbital symptoms and to assess for the optic nerve status. The MRI demonstrated that the right globe was deformed with irregular margins, and hypo to mixed-signal was observed within the vitreous (figure 1A, B and figure 2A), showing patchy restricted diffusion on DWI and blooming on susceptibility-weighted images representing pus collections (figure 1C, D and figure 2B). The right eye had a subretinal collection, exudative vitreoretinal detachment and deformed iris (figure 2C). Similar imaging features were also seen within the extraconal and intraconal compartments of the left orbit. The retro-orbital fat looked dirty on MRI sequences, and these signal abnormalities extended till the orbital apex (figure 2D). Bilateral optic nerves appeared thickened with altered signal intensities representing the optic neuritis. The MRI also precisely depicted soft tissue involvement in the preseptal and postseptal compartment of orbits extending along the zygomatic, maxillary regions bilaterally. The patient was advised for evisceration of the eyes, which he declined. Presently he is being managed on antibiotics; however, his overall condition is deteriorating.

Figure 1.

MRI of bilateral orbits in the axial plane; (A) Restricted diffusion is observed in right eye globe on DWI (white arrow) and subretinal space of left globe (black arrow), which corresponds to an area of low apparent diffusion coefficient (ADC) value, (B) Representing exudates/pus, (C)T2W image showing a deformed right globe with a vitreous collection (white arrow) and (D) Axial T1WI demonstrates bilateral retro-orbital fat stranding (white arrow) and exudative vitreoretinal detachments (black arrow).

Figure 2.

MRI of right panophthalmitis and left endophthalmitis: (A) T2W coronal plane image demonstrates differential signal intensities in bilateral globes extensive peribulbar fat stranding (white arrow) and extraocular muscle swelling,(black arrow) (B) Axial FLAIR image depicting hyperintense signal in the right globe (white arrow), vitreal exudates, with bilateral retinal detachment (black arrow), (C) Blooming artefacts are illustrated in bilateral orbits (white arrows) on SWI image representing blood degradation products and (D) T2W sagittal plane image showing a subretinal collection, irregular scleral thickening, retinal detachment, (white arrow) edematous periorbital soft tissues in the right orbit (black arrow). FLAIR, Fluid-attenuated inversion recovery; SWI, Susceptibility weighted imaging.

MRI findings of panophthalmitis and endophthalmitis are scarcely available in the literature. Here, we have discussed the spectrum of imaging findings of endophthalmitis and panophthalmitis. Other orbital non-infectious inflammatory diseases can show similar findings on MRI; however, DWI supports identify infectious exudates/pus and monitor response to therapy. Familiarity of the spectrum of imaging findings of panophthalmitis and endophthalmitis is essential for radiologists and helps in disease management.²

Patient’s perspective.

I was operated for the cataract and was recovering well. Few months later, I had started feeling severe pain in my both eyes with pus and reddish discharge. Then I went to the hospital for a check-up and by that time the pain became intolerable and I also lost my vision. After considering my situation doctor advised an MRI. MRI report showed some serious diagnosis and advised removal of the eye balls, but I refused for the same. Currently I am on medications and hoping for a good outcome.

Learning points.

• Endophthalmitis and panophthalmitis are surgical emergencies with poor outcomes.

• In patients with orbital infection, MRI is advised to evaluate disease extension, optic nerve and cavernous sinus involvement. MRI provides better in depth soft tissue resolution of the globe and retro-orbital area.

Ethics statements

Patient consent for publication

Consent obtained from parent(s)/guardian(s).