May 01, 2000
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Capsulectomy, IOL exchange achieve 100% cure in P. acnes endophthalmitis patients

About 50% of patients were treated successfully initially with nonsurgical or limited surgical intervention.

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PHILADELPHIA — A review of four treatment strategies for postoperative Propionibacterium acnes endophthalmitis, a rare complication associated with cataract surgery and characterized by an indolent low-grade uveitis with latent onset, reveals that about 50% of patients can be successfully managed with nonsurgical or limited surgical intervention. However, all patients treated with a total capsulectomy and IOL removal or exchange — either as an initial treatment or for recurrent disease — were cured.

“Because postoperative P. acnes endophthalmitis is such an unusual condition, there have been no large, controlled studies looking at the most effective treatments,” said lead investigator Anthony J. Aldave, MD, a senior resident physician at Wills Eye Hospital here. “All the reports of treatments have been retrospective studies, as was ours.”

Dr. Aldave and his colleagues reviewed the clinical charts and microbiology files of all patients treated at Wills Eye Hospital between January 1991 and January 1998 with culture-proven P. acnes endophthalmitis after cataract extraction and posterior chamber IOL implantation. “This is a very difficult organism to culture, so many of the patients who probably had this infection were not included because their cultures were not positive,” Dr. Aldave said.

Of the 25 patients in the case series, two patients were initially treated with intraocular antibiotic (IOAB) injections alone, 10 patients had antibiotic injections along with a pars plana vitrectomy (PPV), nine patients underwent IOAB injections and PPV combined with a partial capsulectomy, and four patients had IOAB, PPV, total capsulectomy and IOL removal or exchange.

50% cure rates for most groups

Anthony J. Aldave, MD---Anthony J. Aldave, MD

With IOAB alone, “one of the two patients was cured. The other patient went on to develop recurrent disease,” Dr. Aldave told Ocular Surgery News. “The numbers are too limited to make any evaluation; however, other authors previously have reported limited success with this treatment alone.” On the other hand, five of the 10 patients treated with both IOAB and PPV were cured. Adding a partial capsulectomy indicated a similar success rate (five out of nine patients). But when an entire capsulectomy and lens removal or exchange was initially performed, all four patients were cured.

“Impressive” treatment

P. acnes---Cultures of P. acnes localized endophthalmitis have proven difficult to obtain.

This latter treatment “is impressive,” Dr. Aldave said. “Not only were the four patients that were initially treated cured, but all patients who previously failed other regimens also were cured by this secondary treatment. In total, 13 patients were treated with a total capsulectomy, either as primary, secondary or tertiary treatment. I think this is the most impressive number from the study.”

One question is, however, “whether you go with a less aggressive therapy initially — with about a 50% chance of curing the disease — or go for the cure-all right off the bat,” Dr. Aldave said. Compounding the dilemma is that final visual acuity was comparable for all four treatment groups. “So you really can’t say that one treatment is the definite way to go,” he said. “It really depends on the treatment philosophy of the physician and the preferences of an informed patient.”

Total capsulectomy for failed treatment

The investigators found no correlation between the severity and chronicity of presenting signs/symptoms and response to therapy. But patients who had already failed one of the three less aggressive treatments “really didn’t do well unless they had a total capsulectomy,” Dr. Aldave said. “So for recurrent disease, we recommend a total capsulectomy.”

Unlike most infections following cataract surgery, P. acnes endophthalmitis “is a very slow, progressing, smoldering process that many times is misdiagnosed for quite a period of time,” Dr. Aldave said. “Practitioners don’t think it’s infection, they think it’s merely inflammation.”

One newer technique for making an accurate diagnosis is to use polymerase chain reaction analysis on a vitreous specimen when performing a PPV, he said. “There are reports that this will detect very small amounts of the organism,” Dr. Aldave said. In any event, “larger studies are necessary to truly establish the most effective treatment strategies for P. acnes endophthalmitis, although this study and others are helpful in guiding physicians in their decision-making process.”

For Your Information:
  • Anthony J. Aldave, MD, can be reached at Wills Eye Hospital, Medical Education, 900 Walnut St., Philadelphia, PA 19107 U.S.A.; +(1) 215-629-7485; fax: +(1) 215-928-3435; e-mail: aaldave@pol.net. Dr. Aldave has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
  • Aldave AJ, Stein JD, Deramo VA, et al. Treatment strategies for postoperative Propionibacterium acnes endophthalmitis. Ophthalmology. 1999;106: 2395-2401.