CASE REPORT/SMALL CASE SERIES

Corynebacterium macginleyi-associated Blebitis:

A Case Report
Vincent Qin, MD, MBA, MPH, FEBO,* Terry Laurent, MSc,†
and Aurélie Ledoux, MD*

CASE DESCRIPTION
Purpose: The purpose of this study was to report a rare case of The patient is a 60-year-old female who presented with a red and
posttrabeculectomy bleb-related infection associated with Cor- painful right eye since a week and complained of secretions and a
ynebaterium macginleyi, a rare conjunctival pathogen. sticky eye; she noticed in addition a white conjunctival swelling supe-
Methods: Case description including clinical imaging and micro- riorly. Past medical history included advanced bilateral chronic open
biology data, and literature review of Corynebacterium macginleyi- angle glaucoma, bilateral trabeculectomy 10 years before presentation
related infections. as well as bilateral cataract extraction 7 years before presentation. No
postoperative manipulation of the bleb was indicated. She did not use
Results: A 60-year-old glaucomatous female patient presented with any other medication and had no other systemic comorbidities.
a bleb-related infection 6 years after trabeculectomy in her right Ophthalmological examination revealed a corrected visual
eye, suggestive of blebitis. No bleb-related endophthalmitis was acuity of 14/20 OD and 20/20 OS. Slit lamp biomicroscopy showed
reported. in the right eye showed superiorly a white swollen abscess at the
location of the bleb (Fig. 1). Conjunctival hyperhemia was noted.
Conclusions: C. macginleyi is a rare conjunctival pathogen that can The cornea was clear, and no involvement of the anterior chamber
cause conjunctivitis and, rarely, bleb-related infections. was noted. No bleb leakage could be seen, and the Seidel test was
negative. Anterior Segment optical coherence tomography demon-
Key Words: blebitis, Corynebacterium macginleyi, diphteroid, bleb-
strated the cystic pus-containing hollow and septate structure of the
related infection, endophthalmitis bleb (Fig. 2). Fundus examination showed no vitreous or retinal
(J Glaucoma 2018;27:e174–e176) involvement. The left eye had a normally functioning bleb superi-
orly and was unremarkable otherwise. On secondary questioning of
the patient, no trauma to the eye, no eye rubbing, no debris or any
other unusual activity was noted.

B leb-related infections are serious complications of glau-

coma filtration surgery. Their incidence in the literature1
after trabeculectomy lie in the range of 0.4% to 6.9% over a
Applanation intraocular pressure was measured at 7 mm Hg
OD and 16 mm Hg OS.
We concluded that the clinical picture matched that of a stage
follow-up period of 1.7 years to 8.5 years, and they cause 1 bleb-related infection without anterior chamber involvement, and
with no signs of bleb-related endophthalmitis. Conjunctival and
significant morbidity. Bleb-related infections are a spectrum of bleb swabs were taken for investigation. No anterior chamber tab
infectious pathogen-related conditions of the filtration bleb, was realized as there was no anterior chamber involvement. Since
and range from localized blebitis without intraocular there was no intraocular involvement, it was decided to put the
involvement, to infection with anterior chamber involvement, patient on reinforced topical antibiotics, alternating hourly topical
and to bleb-related endophthalmitis, the latter being a
potentially severe condition that can result in very poor visual
acuity. Patients can present initially on any range of the
spectrum. Risk factors mainly include postoperative bleb
leakage and manipulation, the inferior position of a bleb and
diabetes. The most common pathogens isolated in bleb-
related infections are Streptococci, followed by Staphylococci,
and then gram-negative organisms such as Moraxella
catarrhalis, Haemophilus influenzae, and Enterococcus faeca-
lis.2 Corynebacterial species have only rarely been reported as
a cause of bleb-related infections, and to date, Cor-
ynebacterium macginleyi has never been described in the lit-
erature as a causative pathogen in bleb-related infections.
C. macginleyi was first identified in 1995 by Riegel
et al3 during investigations on lipophilic corynebacteria and
has been almost uniquely isolated from ocular surfaces.

Received for publication March 18, 2018; accepted August 4, 2018.

From the Departments of *Ophthalmology; and †Microbiology, CHU
UCL Namur, site Sainte Elisabeth, Namur, Belgium.
Disclosure: The authors declare no conflict of interest.
Reprints: Vincent Qin, MD, MBA, MPH, FEBO, 15 Place Louise Godin, FIGURE 1. Clinical image of the bleb-related infection in the right
5000 Namur, Wallonia, Belgium (e-mail: Vincent.qin@live.be). eye of the patient before treatment showing an abscess-like
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. superiorly located filtration bleb, with pus. No corneal infiltration
DOI: 10.1097/IJG.0000000000001051 or anterior chamber involvement was noted.

e174 | www.glaucomajournal.com J Glaucoma  Volume 27, Number 10, October 2018

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J Glaucoma  Volume 27, Number 10, October 2018 Corynebacterium macginleyi-associated Blebitis

and resolve favorably with classical topical antibiotherapy

regimens. C. macginleyi is mainly found in middle aged
patients without any sex preference, and infections in chil-
dren are reported.8 Many microbiological systems do not
identify C. macginleyi strains well, which might explain why
the species is seldom described in the literature.
Apart from conjunctivitis, there has only been 1 case of
corneal ulcer,9 1 case of suture-related keratitis,10 and 1 case
of postcataract endophthalmitis.11 It thus appears that
FIGURE 2. Anterior segment optical coherence tomography of C. macginleyi mainly affects the ocular surface and can easily
the bleb-related infection, before treatment, demonstrating the affect fragile or compromised conjunctivas. Since C. macgin-
cystic pus-containing hollow, and structure nature of its interior. leyi is a commensal resident of the conjunctival flora and is
known to cause conjunctivitis, it is unsurprising that it might
vancomycin with hourly topical gentamycin. After 48 hours, mon- also be an agent causing blebitis, as a glaucoma filtration bleb
odose dexamethasone was added 4 times per day. is made of conjunctival tissue. Thus, by reporting the first case
Gram staining of conjunctival material showed slightly curved, of C. macginleyi-associated blebitis, we can expect that the
gram-positive rods arranged as single cells, in pairs, in V shapes, in pathogen could also be encountered in the future in more
palisades and in clusters with a so-called Chinese letter appearance. severe conditions such as penetrating trauma, bleb-associated
The conjunctival smear material was cultured on different media at endophthalmitis, postcataract endophthalmitis, as well as in
37°C under aerobic CO2-enriched atmosphere, anaerobic and micro- broader filtration-related infections that involve glaucoma
aerophilic conditions at 37°C. Coryneform bacteria grew within
drainage devices, such as the Xen gel implant (Allergan).
48 hours of incubation on 5% sheep blood agar. Colonies were
identified as C. macginleyi using Matrix-Assisted Laser Desorption Besides, C. macginleyi has also been very rarely
Ionization-Time Of Flight (MALDI-TOF) mass spectrometry. Anti- reported in nonocular infectious sites, for example, in a
microbial susceptibilities were determined by the E-test method, car- bladder catheter,12 in intravenous catheters,13,14 in 2 cases of
ried out on Mueller-Hinton agar supplemented with 5% sheep blood. endocarditis,15,16 a case of surgical site infection,17 and 1
The minimal inhibitory concentrations (MIC) of this method have case of septicemia.18
been shown to correlate reasonably well with those of the broth The antimicrobial susceptibility of coryneform bacteria is
microdilution method, recommended by the Clinical Laboratory not predictable in every case, as it varies according to the
Standards Institute. As expected, this strain seemed to be susceptible taxon.19 Susceptibility testing should always be performed with
to a broad spectrum of antibiotics: Penicillin (MIC = 0.012 μg/mL),
clinically significant isolates. However, as discussed above, we
Cefotaxime (MIC = 0.023 μg/mL), Vancomycin (MIC = 0.38 μg/mL),
Ciprofloxacin (MIC = 0.003 μg/mL, MIC = 0.38 μg/mL), Tetracycline know that C. macginleyi is usually susceptible to a broad
(MIC = 0.25 μg/mL), Rifampicin (MIC = 0.047 μg/mL), and Genta- spectrum of antibiotics. More specifically, they are sensitive to
mycin. However, high-level Erythromycin and Clindamycin resistance most β-lactams, tetracyclines, fusidic acid, glycopeptides, and
was observed (MIC > 256 μg/mL). Thus, gentamycin and vancomycin rifampicin although recent fluoroquinolone and erythromycin
were maintained 2-hourly in alternation. After 5 days of topical resistance has been reported.20 As a result, we see that
therapy, clinical response was very favorable, with a decrease in C. macginleyi is susceptible to all the antibiotics classically used
abscess size, in inflammation, in pain and in discomfort. After 3 weeks in topical conjunctivitis treatments. This can also explain the
of treatment, the patient’s vision in her right eye increased back to 20/ reason why the clinical response to C. macginleyi-related con-
20 with disappearance of the abscess, normalization of the bleb and
junctivitis is usually favorable, and also why reports of the
decrease of inflammation. Pain and discomfort receded. The intra-
ocular pressure OD stayed at 10 mm Hg without topical anti- pathogen in the literature are few, as the conjunctivitis is usually
hypertensive medication, suggesting a still-functional bleb. mild and resolves after topical therapy.
Analyzing our case, no significant risk factor for the
development of blebitis was noted. There was no leakage,
DISCUSSION abnormal location or unusual manipulation or activity of
Classically, nondiphterial Corynebacteria are gram- the bleb in the right eye, as the patient had a normally
positive rod bacteria that have been perceived as non- functioning bleb since her trabeculectomy, with adequate
pathogenic, some of them even being part of the human control of the intraocular pressure. Because of the sensitivity
microbiome. However, in the last decades, some of them of C. macginleyi to most antibiotics and its low level of
have become to be known as pathogenic. C. macginleyi is a virulence, our infection case resolved without complication.
lipophilic dipheroidal Corynebacteria, which is seldom
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