Congenital nasolacrimal duct obstruction (NLDO) is one of the common problems seen in the pediatric population. It occurs in 5% to 6% of infants.1 Congenital cataract is considered a major cause of preventable blindness in the pediatric age group. In this report, we describe the management of right eye conjunctivitis secondary to methicillin-resistant Staphylococcus aureus (MRSA) in an infant born with bilateral congenital cataracts and congenital NLDO in his right eye. MRSA is the notorious organism that attacks the eye and can lead to vision-threatening complications.
A 4-week-old male infant presented with bilateral congenital cataracts and congenital NLDO in his right eye (Figures 1–2). He was born at term via cesarean section and remained hospitalized for physiological jaundice for 1 week. Digital lacrimal massage and topical antibiotic were started in the right eye for NLDO. The B-scan of both eyes was within normal limits. Consent was provided by the patient's parents. The treatment plan was early probing in the right eye and lensectomy in the left eye under general anesthesia, followed by right eye lensectomy as a second procedure in addition to topical tobramycin.
Cataract and conjunctivitis in the right eye.
Congenital cataract in the left eye.
On the day of the left eye surgery, the right eye was sticky and conjunctival congestion in the inferior fornix was noted. The left eye surgery was postponed and a conjunctival swab was taken from the right eye for culture and sensitivity tests. The microbiology report showed growth of MRSA, resistant to quinolones and sensitive to vancomycin, lenzolid, gentamicin, and fucidic acid. Topical fortified vancomycin drops (25 mg/mL) were prescribed every 4 hours in the right eye and the infant was referred to a neo-natologist for systemic examination. His complete blood cell count was within normal limits and the C-reactive protein was negative.
After 7 days of topical treatment in the right eye, conjunctival swabs of both eyes were repeated. The culture showed moderate growth of MRSA in the right eye but the left eye had no growth. We planned to screen the parents for MRSA. This case was also referred to pediatric infectious disease specialists, who started intravenous lenzolid. The plan was to give the antibiotic intravenously for 3 days and then orally for 5 days. The nasal swabs of both parents were positive for MRSA. Skin scrubs, muporocin 2% nasal ointment, and neomycin nasal ointment were prescribed to the parents and they were advised to repeat the swab in 7 days.
While the infant was receiving topical vancomycin and oral lenzolid treatment, conjunctival swabs were repeated and there was no growth in culture reported. Because two consecutive negative swabs are required to clear a patient before surgery, the conjunctival swab for culture and sensitivity was repeated 3 days after the completion of the systemic antibiotic treatment and there was no growth seen. There was also spontaneous resolution of congenital NLDO in the right eye. The parents' nasal swabs were repeated after local treatment, and they had no growth in culture.
The infant was scheduled for cataract surgery and general anesthesia fitness was acquired. After meticulous draping, lensectomy of the left eye was performed by one author (SNS). After 5 days, lensectomy of the right eye was performed by the same surgeon. Postoperative examination of both eyes was within normal limits and aphakic glasses were prescribed. One month after surgery, the infant was fixating well with aphakic glasses.
The study and data collection conformed to all local laws and were compliant with the tenets of the Declaration of Helsinki.
MRSA is the latest and toughest to treat among the pathogens that infect patients following cataract surgery.2 This pathogen may be found in hospital settings or in patients otherwise having no known risk factors. Ocular MRSA colonization was reported with long-term use of antibiotics and/or steroids and recent hospitalization.2 Our patient and his parents had to stay in the hospital due to treatment for jaundice, which may have contributed to acquiring this infection.
Routine screening for MRSA infection prior to cataract surgery has been inconsistent, as noted in a study performed in the United Kingdom.3 However, emphasis has been on the universal precautions that must be followed to reduce postoperative ocular infections.4 We performed povidone-iodine cleaning of the ocular surface as a protocol before cataract surgery. One may consider lengthening the time of the application to the eyelids and eyelashes and conjunctiva in cases of patients known to be colonized or at high risk for MRSA to increase the efficacy of povidone-iodine.5 Lensectomy was performed after negative culture results were obtained in more than two laboratory reports. Postoperative vancomycin drops were effective in the follow-up period in the patient.6
Most studies have described an increased incidence of MRSA in older age groups where the risk increases due to factors related to decreased immunity, dry eye, meibomian gland dysfunction, and frequent topical medication instilled in the eyes.2 When dealing with infants, the aforementioned factors affecting the elderly population are of less concern. Pediatric ophthalmologists intend to plan early cataract surgery to prevent amblyopia in cases of congenital cataract. A blocked nasolacrimal duct may lead to persistent discharge and delay the procedure. Case reports on ocular MRSA in the pediatric age group are scarce. Experiences like those of the current patient will lead us to share how such a situation can be handled successfully. Conjunctival swab culture and sensitivity tests play a significant role in managing a case with congenital NLDO with a history of recent hospitalization, especially in cases where intraocular surgery is contemplated.
- Paul TO, Shepherd R. Congenital nasolacrimal duct obstruction: natural history and the timing of optimal intervention. J Pediatr Ophthalmol Strabismus. 1994;31:362–367.
- Mah FS, Davidson R, Holland EJ, et al. Current knowledge about and recommendations for ocular methicillin-resistant Staphylococcus aureus. J Cataract Refract Surg. 2014;40:1894–1908. doi:10.1016/j.jcrs.2014.09.023 [CrossRef]
- Rathod D, Luqmani N, Webber SK, Hosein IK. Survey of meticillin-resistant Staphylococcus aureus policies in UK eye departments. J Hosp Infect. 2009;72:314–318. doi:10.1016/j.jhin.2009.04.015 [CrossRef]
- Joshi L, West SK, Herbert L and . Survey of policy for MRSA screening in English cataract surgical units and changes to practice after updated National guidelines. BMC Ophthalmology. 2013;13:80. doi:10.1186/1471-2415-13-80 [CrossRef]
- Chronister DR, Kowalski RP, Mah FS, Thompson PP. An independent in vitro comparison of povidone iodine and SteriLid. J Ocular Pharmacology Therapeutics. 2010;26:277–280. doi:10.1089/jop.2010.0018 [CrossRef]
- Major JC Jr, Engelbert M, Flynn HW Jr, Miller D, William E, Smiddy WE, Davis JL. Staphylococcus aureus endophthalmitis: antibiotic susceptibilities, methicillin resistance, and clinical outcomes. Am J Ophthalmol. 2010;149:278–283. doi:10.1016/j.ajo.2009.08.023 [CrossRef]