P. Acnes – February 2016

February 2016

Case Presentation

A 58-year-old man was presented to Illinois Retina Associates with blurred vision in his right eye.

Past ocular history was significant for LASIK in both eyes years ago and eight (8) weeks status post cataract extraction with intraocular lens placement in his right eye. He reported that his visual acuity gradually decreased since about a month after his surgery. He completed his postoperative drops as scheduled approximately one month ago. He is now pseudophakic in both eyes and has no complaints in his left eye. Cataract surgery was uncomplicated according to the patient.

Examination

Best-corrected visual acuity with was 20/80 OD and 20/25 OS. The anterior segment in his affected right eye revealed 1+ cell, diffuse endothelial pigment and posterior synechiae at 3 O’clock. There was whitish material behind the intraocular lens (Figure 1). The posterior segment exam was within normal limits.

Figure1
Figure 1

Differential Diagnosis

  • Delayed endophthalmitis
  • Rebound iritis
  • Occult retention of lens cortex or nucleus
  • Uveitis
  • Blebitis
  • Keratitis

Clinical Course and Follow-Up

The patient’s visual acuity remained decreased despite topical steroid treatment. YAG capsulotomy was attempted along with intravitreal injection of vancomycin. The patient’s vision improved slightly to 20/60. Due to the persistence of symptoms and inflammation after intravitreal vancomycin, the decision was made to perform intraoperative capsulotomy and biopsy. He underwent pars plana vitrectomy with posterior capsulotomy (Figure 2). The patient did very well postoperatively with 20/30 visual acuity.

Figure2
Figure 2

Discussion

Chronic postoperative endophthalmitis is a delayed infectious intraocular inflammatory process that is less common than acute infections status post cataract surgery. It usually manifests weeks or months after surgery. Organisms isolated tend to be less virulent bacteria and fungus. More than half of the cases reported are caused by Propionibacterium Acnes. Coagulase negative Staphylococcus and fungi such as Candida parapsilosis are other causative organisms. Routes of bacterial entry include intraoperative irrigation fluids and instruments. Placing the intraocular lens on external ocular surfaces has also been implicated.

The typical presentation involves a low-grade uveitis with decreased visual acuity. Pain or discomfort is sometimes present. The uveitis may include precipitates on the cornea or intraocular lens. An intracapsular plaque is often noted on examination in patients who have a propionibacterium species infection. Vitreal involvement is usually mild but can be more prominent with Staphylococcus infection. Fungal infections may sometimes manifest as “pearls on a string” or “fluff-balls” near the capsule.

When suspected, aqueous or vitreous samples should be obtained and analyzed for gram stain, culture as well as giemsa and fungal cultures (Figure 3).

Figure3
Figure 1

Treatment options include intraocular antibiotics with YAG laser capsulotomy, pars plana vitrectomy, with partial capsulectomy or total capsulectomy with IOL removal or exchange. Empiric treatment with intravitreal vancomycin is often employed.

Chronic fungal postoperative endopthalmitis has a poor prognosis. It is often treated with pars plana vitrectomy with the help of intravitreal amphoteric or voriconazole in addition to a systemic antifungal agent.

References

Findl, O. Neumayer, T. Hirnschall, N. et al. Natural Course of Elschnig Pearl Formation and Disappearance. IOVS, March 2012. Vol 51. No.3 1547-1553

R.R. Buggage, D.F. Shen, C-C Chan, D.G. Callanan Propionibacterium acnes endophthalmitis diagnosed by microdissection and PCR. Br J Ophthalmol 2003. September; 87(9): 1190-1191

Deramo, V.A. Ting, D. Treatment of Priopionibacterium acnes endophtalmitis Ophthalmol 2001, 12:225-229

Bingsheng Lou, Xiafeng Lin, Lixia Luo, Yao Yang, Yanting Chen, Yizhi Liu, Residual lens cortex material: Potential risk factor for endophthalmitis after phacoemulsification cataract surgery Journal of Cataract & Refractice Surgery, Volume 39, Issue 2, February 2013, Pages 250-257

Christopher T. Hood, Roni M. Shtein, Shahzad I Mian, Alan Sugar, Neodymium-Yttrium-Aluminum-Garnet Laser Lysis of Retained Cortex After Phasoemulsification Cataract Surgery American Journal of Ophthalmology, Volume 154, Issue 5, November 2012, Pages 808-813