感染性心内膜炎に合併した内因性細菌性眼内炎の2例

Two cases of endogenous bacterial endophthalmitis caused by infective endocarditis

要約　目的：本邦において感染性心内膜炎に合併する内因性細菌性眼内炎は稀であるが，今回2例経験したので報告する。

症例：2例とも感染性心内膜炎と診断され，血液培養からB群溶連菌Streptococcus agalactiaeが検出された。

症例1：53歳，女性。初診時の視力は右光覚なし，左手動弁。右眼に前房蓄膿を認め，眼底透見不能。左眼に前房炎症があり，眼底は滲出性変化を強く認めた。両眼内因性細菌性眼内炎と診断した。まず心臓弁置換術が施行され，12日後に両眼硝子体手術および超音波水晶体乳化吸引術を施行した。術後，硝子体混濁は軽減したが，その後再燃した。右眼に1回，左眼に3回硝子体手術を行ったが，右眼は網膜全剝離となり光覚弁，左眼は一部のみ網膜復位し手動弁となった。

症例2：76歳，女性。初診時の視力は右光覚弁，左指数弁。右眼の前房中にフィブリンを認め，眼底透見不能。左眼の前房は清明で，眼底にしみ状出血を認めた。両眼内因性細菌性眼内炎と診断した。まず心臓弁置換術が施行され，9日後に右眼は眼球内容除去術，左眼は硝子体手術および超音波水晶体乳化吸引術を施行した。術後，左眼網膜の出血は消退し，眼内炎の再燃は認めなかった。左眼矯正視力は0.9に回復した。

結論：細菌性眼内炎は早急な治療を要するが，内因性の場合は全身の治療が優先され治療が遅れることがある。硝子体手術を施行しても，視力保持がきわめて困難であることがある。

Abstract　Purpose：Endogenous bacterial endophthalmitis associated with endocarditis is rare in Japan. However, we report two cases here.

Case：Both cases were diagnosed as those of infective endocarditis by ultrasonography, and a group B Streptococcus, S. agalactiae, was cultured in the blood samples.

Case 1：A 53-year-old woman. Our initial examination showed that she had no perception of light in the right eye and that of hand motion in the left eye. Hypopyon was detected in the anterior chamber of the right eye, but the fundus could not be observed. Inflammation was noted in the anterior chamber of the left eye, and the fundus showed severe exudative changes. A diagnosis of endogenous bacterial endophthalmitis was made for both eyes. Twelve days after heart surgery, vitrectomy combined with phacoemulsification cataract surgery was performed for both eyes. Postoperatively, the vitreous opacity was reduced, and the visual acuity improved to light perception in the right eye but did not change in the left eye. She underwent vitrectomy once in the right eye and three times in the left eye. Total retinal detachment developed in the right eye and with only partial retinal reattachment in the left.

Case 2：A 76-year-old woman. Initial examination revealed light perception in the right eye and ability to counting fingers by the left eye. Fibrin was observed in the anterior chamber of the right eye, and the fundus could not be observed. The anterior chamber of the left eye was clear, and a blot hemorrhage was observed in the retina. A diagnosis of endogenous bacterial endophthalmitis was made for both eyes. Nine days after heart surgery, the right eye underwent evisceration, and the left eye underwent vitrectomy and cataract phacoemulsification surgery. Postoperatively, the hemorrhage in the retina disappeared, and there was no recurrence of endophthalmitis. The decimal best-corrected visual acuity of the left eye recovered to 0.9.

Conclusion：Bacterial endophthalmitis requires immediate treatment, but in endogenous cases, treatment may be as the systemic treatment is prioritized. Preservation of vision may be extremely difficult even after vitrectomy.