An 8 years old male presented with rapidly detoriating vision in right eye with pain, redness and watering over a period of four days. He had history of trauma to right eye with fire cracker injury 3 days back on eve of festival “Diwali” in India. Right eye had visual acuity of perception of light (PL) only. On slit lamp examination, he had corneal perforation and hypopyon. Ultrasonography was suggestive of endophthalmitis. The exudates from vitreous and anterior chamber were sent for microbiological testing which showed the organism to be Bacillus cereus. He was treated with repair of corneal perforation with intracameral Vancomycin wash and intravtreal Vancomycin injection. Two days post operatively the hypopyon was cleared with decreased exudates in vitreous. Topical moxifloxacin was continued and second dose of intravitreal Vancomycin was given after 72 hours. After 7 days the symptoms improved with vision of 4/60.
“Diwali” is an Indian festival where people celebrate it with lights and different types of fire crackers. The injury due to firecracker is a common problem especially in children due to unawareness and certain minimum preventive measures not taken by them or their parents. Injury to eye is very grave condition, and prognosis depends on type of injury, severity of injury and time at presentation.
We are highlighting the fate of firecracker injury leading to serious infection in form endophthalmitis where we could save the vision to some extent in this patient due to prompt intervention and proper antibiotics.
An 8 years old male presented with rapidly detoriating vision in right eye with pain, redness and watering over a period of four days. He had history of trauma to right eye with fire cracker injury 3 days back on eve of festival “Diwali” in India. On examination, right eye had visual acuity of perception of light (PL) only with accurate projection of light rays in all quadrants. His left eye was normal with visual acuity of 6/6. On slit lamp examination,
the right eye had congestion and exudates in anterior chamber inferiorly, the hypopyon (Figure 1). On higher magnification with slit illumination, there was corneal perforation, yellowish membranous exudates in anterior chamber and hypopyon of height of 2.5 mm (Figure 2).
Ultrasonography (USG) was done to rule out the posterior segment involvement which showed there was mild to moderate amplitude spikes, suggestive of exudates in vitreous cavity (Figure 3) confirming the diagnosis of endophthalmitis. There was no retained intra ocular foreign body. Microbiological testing of anterior chamber and vitreous aspirate was done to know the organism and its sensitivity to antibiotics which showed the organism to be Bacillus cereus.
As there was corneal perforation, we repaired the corneal
perforation with 10-0 monofilament nylon suture with anterior
chamber wash. The exudates from vitreous and anterior chamber
were sent for microbiological testing after vitreous aspirate was
done with 23gauge needle. Intracameral Vancomycin washes
with intravitreal Vancomycin (1.15 mg in 0.01 ml) injection
and Ceftazidime (2.25 mg in 0.01 ml) was given thereafter. The
microbiological testing of the sample showed the organism to be
B. cereus. Two days post operatively the hypopyon was cleared
with decrease of exudates in vitreous on repeat USG. Topical
moxifloxacin 0.5%, 6 times was continued and second dose of
intravitreal Vancomycin and Ceftazidime was given after 72
After 7 days, the symptoms improved with vision of 4/60
and there were no exudates in vitreous. On next follow up after
2 weeks the vision was 5/60 with corneal suture intact. After 2
months there was cataract developed which was operated with
suture removal. One month post-operative best corrected vision
Endophthalmitis due to infection after open globe injuries
is not uncommon. The incidence of endophthalmitis varies from
3% to 48% in various studies after open globe injury depending
on a variety of factors which include setting of trauma, delay of
repair, retained intraocular foreign body, and involvement of
the crystalline lens . The type of pathogenic microorganism,
nature of the injury, the presence of a foreign body, and the
geographical region in which the trauma occurred are all
important factors influencing both treatment and prognosis .
There is not a confirmed treatment protocol recommended by
the Endophthalmitis-Vitrectomy Study Group  in traumatic
cases unlike postoperative endophthalmitis. The injury with fire
cracker usually results in more of burn injury but in this case there
was perforation due to impact of high speed particle from blast
of a fire cracker. Usually the high speed particle from firecracker
enters into the eye are sterile due to high temperature of it. But
in this case, due to the globe remained open for long period
without closure there was entry of organism, B. cereus and
superadded infection occurred. Bacillus spp. is most common
organism isolate after post trauma endophthalmitis  although
another study showed gram-positive cocci the most frequently
identified causative organism, followed by Bacillus species in
their study . Urgent intervention with intravitreal injection
of broad spectrum antibiotic in our patient lead to resolution
of endophthalmitis. As Bacillus spp. is poorly susceptible
to Ceftazidime,  we repeated the intravitreal injection
Vancomycin,  only in this patient after 72 hours which showed
positive response in form of resolution of infection.
Injury to eye can any time especially to children but there is
always an increased incidence of injury during an Indian festival
“Diwali” every year where people celebrate it with lights and
firecrackers. Due to proper care not taken by parents, children
always fall into firecracker injury to eye in form of burn injury
or perforation injury which should be noticed by government,
policy makers, media and social organization.