Case Reports

Endophthalmitis: A rare complication ofarteriovenous fistula infection

Madhav DESAI,1 Ram RAPOOR,1 Swarna Latha GUDITHI,1 Ravi KUMAR,2

Neela PRASAD,1 Kaligotla Venkata DAKSHINAMURTY1

1Department of Nephrology, Nizam’s Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India;2Hyderabad Opthalmology Institute, Hyderabad, Andhra Pradesh, India

AbstractVascular access infection is a frequent problem in patients undergoing maintenance hemodialysis.

Infection of arteriovenous fistula (AVF) is less common than dialysis catheter-associated infection.

Previous case reports described endophthalmitis secondary to hemodialysis catheter-related infec-

tion, but not secondary to native AVF infection. We report a rare patient of endophthalmitis as a

metastatic infection of AVF cannulation site abscess. A 19-year-old girl on maintenance hemodialysis

for the past 2 years has presented with a history of fever, chills, and rigor of 3-days duration and

painful dimness of vision in the left eye of 1-night duration. It was followed by redness of the eye,

photophobia, and ocular discharge. On examination, the patient was febrile with an abscess near

cannulation site of AVF. There was no perception of light in the left eye, conjunctiva was congested,

cornea was clear, hypopyon present, and pupil was mid-dilated, not reacting to light. Lens was clear.

Vitreitis and exudative retinal detachment was present. Methicillin sensitive Staphylococcus aureus

was isolated from blood, pus from AVF abscess and vitreous fluid. Diagnosis of endophthalmitis was

confirmed by B-scan ultrasound. She was treated with both intravenous and intraocular antibiotics

and drainage of pus from AVF abscess and therapeutic vitrectomy. Though arteriovenous abscess

responded to sensitive antibiotics and drainage, vision has not improved much. Strict aseptic pre-

cautions during regular AVF cannulation are required. Lapses may lead to loss of vision apart from

described complications like access closure, endocarditis, and osteomyelitis.

Key words: Arteriovenous fistula infection, endophthalmitis, hemodialysis

INTRODUCTION

An ideal permanent access delivers a flow adequate for

the dialysis prescription, lasts for a long time and has a

low complication rate. The autologous arteriovenous

fistula (AVF) comes closest to satisfying these criteria.1

Infection is the most common reason for access failure

when cuffed silicone catheters are used for long-term

access, and is the second most common cause of graftfailure when poly tetra fluoro ethylene (PTFE) grafts are

used. Infection rates of an AVF continue to be acceptable

(o1%).2 The infections are potentially lethal due to

impaired immunological status of long-term dialysis

patients. Infection may be at the arteriovenous anasto-

mosis, which requires immediate resection of infected

tissue and securing a new AVF. Infection at cannulation

sites requires cessation of cannulation at that site. Access-

related bacteremia leading onto metastatic complicationshas been described with intravenous catheters.3 We

report a rare patient case of acute endophthalmitis as a

metastatic infection of AVF cannulation site abscess.

CASE REPORT

A 19-year-old girl has been on maintenance hemodialysis

since February 2005. She was diagnosed with focal seg-

Correspondence to: Prof. K.V. Dakshinamurty, Departmentof Nephrology, Nizam’s Institute of Medical Sciences,Punjagutta, Hyderabad – 500082, Andhra Pradesh, India.E-mail: kvdm1954@gmail.com

Hemodialysis International 2008; 12:227–229

r 2008 The Authors. Journal compilation r 2008 International Society for Hemodialysis 227

mental glomerulosclerosis in 1999. An AVF was securedin October 2004. She has been on regular thrice-weekly

bicarbonate hemodialysis and erythropoietin. Her Kt/V

in December 2006 was 1.4.

She has presented with history of fever, chills, and rigor

of 3-days duration and painful dimness of vision in left

eye of 1-night duration. It was followed by redness of eye,

photophobia, and ocular discharge. On examination,

patient was febrile with an abscess near cannulation siteof AVF (Figure 1). There was no perception of light in the

left eye, conjunctiva was congested, cornea was clear,

hypopyon present, and pupil was mid-dilated, not react-

ing to light. Lens was clear. Vitreitis and exudative retinal

detachment was present. A B-scan ultrasound had

features like choroidal thickening, ultrasound echoes in

the anterior and posterior vitreous and retinal detach-

ment, thus confirming the endophthalmitis (Figure 2).Her cardiac examination was normal as were the chest

radiograph and the echocardiography. Transoesophageal

echocardiogram was not done. A neurologist had not

suspected cerebral vein thrombophlebitis. A blood

culture was sent; so also the pus from the abscess at

AVF after incision and drainage. Vitreous was aspirated

after a sub-Tenon block, using 21-G needle on a tuber-

culin syringe. Vancomycin (15 mg/kg) and amikacin(1.8 mg/kg loading dose 13.75 mg/kg after hemodialy-

sis, once in 48 hr) were administered intravenously. In-

travitreal vancomycin (1.0 mg in 0.1 mL of normal saline)

and amikacin 400 mg in 0.1 mL of normal saline) were

also started. After 24 hr, the pus, the blood, and the vit-

reous cultures had grown methicillin sensitive Staphylo-

coccus aureus. A therapeutic vitrectomy was performed

with an aim of clearing the ocular media, reduction inharmful bacterial products and bacterial load. These mea-

sures improved her vision from no perception of light to

vision of counting fingers.

DISCUSSION

Individuals at risk for developing endogenous endo-

phthalmitis either have comorbidity that predisposes

them to infection like diabetes mellitus, chronic renal

failure, systemic lupus erythematosus, AIDS, leukemia,

gastrointestinal malignancies, neutropenia, lymphoma,alcoholic hepatitis, and bone marrow transplantation or

would have undergone invasive procedures, which may

result in bacteremia, such as hemodialysis, bladder cath-

eterization, gastrointestinal endoscopy, total parenteral

nutrition, chemotherapy, and dental procedures. Fungal

organisms account for more than 50% of all cases of en-

dogenous endophthalmitis. Gram-positive organisms are

most common among bacterial etiologies of endogenousendophthalmitis. The single most commonly involved or-

ganism is S. aureus, which often is implicated with skin

infections or chronic systemic disease, such as diabetes

mellitus or renal failure.4

Infectious complications due to an access-related

bacteremia include endocarditis, metastatic infection, dis-

citis, and myocardial abscess.5 Metastatic bacterial end-

ophthalmitis secondary to a dialysis catheter-relatedFigure 1 Arteriovenous fistula abscess.

Figure 2 B scan shows medium to high echo spikesthroughout the vitreous cavity, gain 72.4 db.

Desai et al.

Hemodialysis International 2008; 12:227–229228

septicemia has been described in the past.3,6,7 But therewere few reports of endophthalmitis due to AVF infection.

Marr et al.8 in a retrospective study of staphylococcal

bacteremia in hemodialysis patients in 5431.8 patient-

months have identified 58 (89%) episodes of bacteremia

considered to have originated in a vascular access device

of which 31 (53%) patients with device-related bacter-

emia were dialyzed through dual lumen, tunneled, cuffed

catheters; 8 (14%) were dialyzed through temporary cath-eters; 10 (17%) were dialyzed through AVFs; and 9 (16%)

were dialyzed through PTFE grafts. Not a single patient

of endophthalmitis has been described though infective

endocarditis, osteomyelitis, and septic arthritis were

reported. There was a report of simultaneous bacterial

endocarditis and endophthalmitis due to Pseudomonas

aeruginosa in a patient who had both the AVF and arte-

riovenous graft (AVG).9 The report was not explicit aboutthe source of infection—AVF or AVG.

At our Institute, ‘‘universal precautions’’ are strictly

implemented. Entry into the hemodialysis center, other

than for patients, was forbidden. The nurses were all

trained in aseptic handling of the vascular access.

Surgical mask, aseptic gloves, and dressing were donned

by the nurses before vascular access manipulation. The

skin before needle puncture was prepared with povi-done-iodine, followed by spirit. The needle puncture site

was enclosed prior by a drape.

Prevention can be done with obsessional requirement

of correct preparation of skin before needle puncture,

which should be no less rigorous than during a surgery.

Staff and patients alike should understand the importance

of such a care and should be ever vigilant for the signs of

infection. Other preventive measures include periopera-tive antibiotics, treatment of active infection at other sites

before implantation of a vascular prostheses and elimi-

nation of nasal carriage, particularly in patients in whom

recurrent staphylococcal infection was associated withwell-documented nasal staphylococcal carriage.

Manuscript received September 2007; revised January

2008.

REFERENCES

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AV fistula related endophthalmitis

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