A Very Unusual Burn Complication

Bilateral Endogenous Bacterial Endophthalmitis

Corey D Chan, MBBS; Lihan Zhang, MRCS; Ranjeet J Pandit, FRCOphth; Christopher J Lewis, FRCS(Plast)


ePlasty. 2023;23(e6) 

In This Article

Abstract and Introduction


Background: The authors report the rare, but potentially blinding, complication of bilateral endogenous bacterial endophthalmitis observed in a 35-year-old man during his admission to a regional burns center following a burn injury from an electronic cigarette device. This complication has been reported only twice in burn patients following extensive and life-threatening burn injuries. This patient underwent surgical debridement and split-thickness skin grafting of non-major burns as per standard of practice. In the postoperative period, the patient developed bilateral eye pain, redness, and photophobia, and was subsequently diagnosed with bilateral endogenous bacterial endophthalmitis secondary to a Staphylococcus aureus infection of the burn wound. After ophthalmology input and treatment with systemic and intravitreal antibiotics, he made a full recovery from both his burns and endophthalmitis.

Conclusions: This report describes a rare, sight-threatening complication that arose from an infected burn wound in an otherwise healthy patient. It highlights the importance of prompt diagnosis and treatment to preserve vision and the need for burn surgeons to have a high level of awareness of this entity, even in the context of minor burns.


In the United Kingdom, there is an increasing trend in burns caused by electronic cigarettes since their introduction in recent years.[1,2] Fires and explosions linked to such devices are thought to be caused by malfunctioning lithium-ion batteries or faulty devices,[3] and many users keep them in their pockets in close proximity to skin areas of the thighs, legs, and buttocks. As a result, these burns can be significant and often require inpatient care and surgical treatment at a specialist burn center. Infection of acute burn wounds is a common complication, and in larger burns this can often lead to sepsis and require admission to intensive care. Such infections are a significant cause of mortality in burn patients, with the breached area of skin being a key entrance for infection.[4]

Although burn wounds are initially sterile following thermal injury, they can become colonized with gram-positive, gram-negative, and fungal organisms, leading to systemic bacteremia and sepsis in some cases.[5] This bacterial colonization often occurs in the form of a biofilm, with Staphylococcus aureus and Pseudomonas aeruginosa being the most common cause of burn wound infections.[4] The risk factors for burn wound infections include male sex, older age, diabetes, and immunocompromised state, and patients with larger full-thickness burns and burns over the lower extremity are also at increased risk.[5] The prompt recognition and treatment of these infections with appropriate antibiotics, guided by microbiology culture and sensitivity, is an important aspect of burn management.

Endophthalmitis refers to intraocular inflammation secondary to infection, usually bacterial or fungal, within intraocular spaces. It is potentially devastating and carries a poor visual prognosis in most patients.[6] It is classified as exogenous or endogenous depending on the route of infection to the eye. Exogenous endophthalmitis occurs when microorganisms enter the eye from a breach of external ocular barriers (eg, following intraocular surgery, intraocular injections, or penetrating trauma). Contrastingly, endogenous endophthalmitis occurs when microorganisms enter the eye by crossing the blood-ocular barrier via hematogenous spread from a distant source of infection.[7] In these cases, there is no direct trauma to the eye, and as such, eye protection would not protect against this condition. Endogenous endophthalmitis is less common than the exogenous form and is responsible for about 2% to 8% of endophthalmitis cases.[7] Endogenous bacterial endophthalmitis (EBE) in burns patients is rare. There are currently only 2 case reports, and these have described patients with significant burns of more than 40% total body surface area (TBSA).[8,9] It is important to recognize this significant complication promptly so that the patient can receive specialist input, investigations, and early treatment to prevent visual loss.