Anterior Segment Stabilization and Tertiary Referral in Acute Bacterial Endophthalmitis at a Rural Secondary Hospital: A Longitudinal Case Study

Abstract

Background: Acute infectious endophthalmitis is a vision-threatening emergency, and access to vitreoretinal care may be limited in rural hospitals.

Objective: To describe the clinical trajectory during pre-referral stabilization and the proposed compartmental pharmacokinetic interpretation in a single patient.

Methods: A longitudinal case study followed a 51-year-old man at Regional General Hospital of Klungkung, Bali, Indonesia, from 21 March 2026 over 48 hours. Serial assessments included biomicroscopy, fluorescein planimetry, Gram and potassium hydroxide (KOH) microscopy of ocular exudate, and the Endophthalmitis Management Study inflammation score (EMS IS). Treatment included topical levofloxacin, prednisolone acetate and atropine, intravenous ceftriaxone, lubrication and analgesia.

Results: At presentation, right-eye visual acuity was light perception (assigned logMAR 3.00), hypopyon height was 3.2 mm, epithelial defect area was 68.0%, pain was 8.0/10 and EMS IS was 26.0. The exudate contained Gram-positive cocci and polymorphonuclear leukocytes; KOH microscopy was negative. At 48 hours, hypopyon height was 1.6 mm, epithelial defect area 44.0%, pain 2.0/10 and EMS IS 18.0. Visual acuity was recorded as 1/300 (assigned logMAR 2.48), while the red reflex remained absent. Tertiary referral was arranged for definitive evaluation and intervention.

Conclusion: Anterior segment findings improved during stabilization, but persistent media opacity required tertiary assessment. This single case does not establish treatment causality or patient-specific intraocular drug concentrations; post-referral outcomes were unavailable.