A Rare Case Of Enterococcus Faecalis Keratitis In A Neurotrophic Cornea, Successfully Treated With Topical Antibiotics And Amniotic Membrane

The aim of this study is to report a rare case of Enterococcus faecalis keratitis and highlight the challenges in its treatment. 

Department of Ophthalmology, Queen's hospital

Barking, Havering and Redbridge University Hospital Trust

A 60-year-old male presented with pain, redness and reduced vision for 2 days in his only good eye. Past medical and social history revealed diabetes, obesity and high alcohol intake. His vision was 0.95 and 1.1 LogMAR in the affected and fellow amblyopic eye, respectively. Examination showed right eye lower lid tarsal ectropion, advanced meibomian gland dysfunction, deeply injected conjunctiva. There was a large inferior keratitis with 4.5 mm by 3.7 mm epithelial defect, surrounding corneal oedema and 1.8 mm hypopyon. Corneal scrapes revealed Enterococcus faecalis, resistant to Levofloxacin (which was started initially) and sensitive to Vancomycin and Ciprofloxacin.

The patient was non-compliant with topical Vancomycin due to severe burning sensation; hence, treatment was changed to topical Ciprofloxacin with later addition of preservative-free topical corticosteroids and lubricants, to address his ocular surface disease, resulting in gradual improvement. He was found to have moderate neurotrophia resulting in persistent epithelial defect. Since his right eye was his only good eye, a special type of frozen dried amniotic membrane with a pinhole effect was inserted to promote healing without covering his visual axis. This accelerated corneal epithelialization and two months from presentation, significant improvement was noted with complete corneal re-epithelialisation and BCVA of 0.2 LogMar.

This rare infection poses a clinical challenge due to high virulence and multi antibiotic resistance. It tends to occur in presence of systemic and ocular risk factors, as in our case: diabetes, obesity, high alcohol intake, ectropion, blepharitis, and neurotrophic cornea. It is sensitive to Vancomycin which is not licensed for keratitis treatment, difficult to obtain and known to cause epithelial toxicity. The use of amniotic membrane may have a remarkable role in epithelial healing, particularly in patients with neurotrophia whose only seeing eye is affected by Enterococcus faecalis.