Endogenous endophthalmitis following prolong use of methotrexate

Abstract

A 46 yr old male presented to us with a 2 day history of pain, redness and discharge in left eye. The patient was on oral Methotrexate (12.5 mg) weekly with folic acid supplement for the last 1 year for recurrent Uveitis (LE). There was a history of three previous episodes of acute anterior uveitis in left eye 2 years back for which he was prescribed oral steroids. The uveitis attack use to flare up on tapering the steroids. In the hope to reduce the recurrences and to prevent long-term complications, the patient was shifted to oral methotrexate (12.5 mg) weekly with folic acid supplementation. On the basis of clinical examination and B- scan a presumptive diagnosis of endogenous endophthalmitis was made. Vitreous tap revealed a straw colored sample and the culture subsequently grew methicillin sensitive Staphylococcus epidermidis. Intravitreal injection of (Piperacillin+Tazobactum) 225 microgram in 0.1 ml was administered. In addition, intravenous (piperacillin+tazobactum) 4.5 gram BD was given for 3 days. Post intra vitreal injection the symtoms and signs resolved remarkably. Methotrexate has not been previously implicated with endogenous endophthalmitis. Besides, Endogenous endophthalmitis is an ongoing diagnostic and therapeutic dilemma for ophthalmologists as it is relatively rare and often presents like uveitis. It requires a high index of suspicion for prompt diagnosis and treatment. The treatment of EE is still controversial due to a lack of clinical trials. Future large group studies need to be done for validation of the above therapeutic regime.