Silicone Punctal Plugs as a Significant Risk Factor for Iatrogenic Endophthalmitis: A Case Report

PURPOSE: Case report. METHODS: We report a rare case of exogenous endophthalmitis following intravitreal anti-VEGF injection in a 75-year-old woman with silicone punctal plugs for refractory dry eye. The patient presented 24 hours after injection with acute vision loss and ocular pain. Despite initial broad-spectrum topical therapy, her condition deteriorated, and ultrasonography confirmed evolving endophthalmitis. 23 G pars plana vitrectomy with intravitreal antibiotics was performed, revealing extensive purulent material. RESULTS: Microbiological cultures from aqueous humour, vitreous aspirate, and explanted punctal plugs all grew Streptococcus oralis, an oral commensal. Postoperatively, inflammation resolved but vision remained limited to hand motion. CONCLUSION: This case highlights the potential role of punctal plugs as reservoirs for bacterial colonization and a novel risk factor for intraocular infection after intravitreal therapy. Awareness of this association may prompt clinicians to assess the presence of punctal plugs prior to ocular procedures and consider individualized management to reduce the risk of endophthalmitis.