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Chronic inflammation presents after uncomplicated cataract surgery
The patient had cataract surgery in both eyes 1 year before presentation and experienced decreased vision, photophobia, redness and tearing in the left eye after surgery.
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An 82-year-old diabetic Asian man was referred for evaluation at the New England Eye Center for chronic inflammation in the left eye despite multiple injections of antibiotics and corticosteroids into the eye.
The patient was visiting from China and had a history of cataract surgery in the left eye 1 year prior. Several weeks after surgery, he noted decreased vision, photophobia, redness and tearing without significant pain in the left eye. He was told he had “inflammation in the eye” in China. There, he received multiple injections of antibiotics and steroids in the eye, the last time 3 months before presentation. He noted improvement in symptoms after the injections, but it was short-lived. Reportedly, he had positive intravitreal cultures in China, but he did not know the organism. The patient came to the United States in November and was seen by an ophthalmologist. He was started on Pred Forte (prednisolone acetate 1%, Allergan) and Vigamox (moxifloxacin 0.5%, Alcon) four times per day and atropine once daily in the left eye and referred for evaluation.
 Isabel M. Balderas |  Tom Hsu | ||
The patient’s ocular history was remarkable for cataract surgery in both eyes in 2007. He was diagnosed with diabetes 1 year ago. His ocular medications were Pred Forte and Vigamox four times a day and atropine once a day. He was on metformin and was allergic to penicillin. He was a professor of cardiology in China and denied tobacco or alcohol use. His family history and review of systems were noncontributory.
Examination
On examination, uncorrected visual acuity was 20/25 in the right eye and hand motions in the left eye. The vision in the right eye was improved to 20/20 with a manifest refraction of –1.75 +1.00 × 090 but was unable to be improved with refraction in the left eye. Pupils were equal, but the left eye was sluggishly reactive compared with the right. IOP was 17 mm Hg in the right eye and 19 mm Hg in the left eye. Extraocular movements were intact.
Slit lamp and dilated fundus exam of the right eye revealed a posterior chamber IOL and some mild retinal pigment epithelium changes and drusen in the macula. Examination of the left eye revealed mild conjunctival injection, fine diffuse keratic precipitates on the cornea, and 3+ cell and flare in the anterior chamber. The iris had significant posterior synechiae, and white plaques could be appreciated on the posterior lens capsule and IOL (Figures 1a to 1c). On dilated fundus exam, no red reflex was visible, and there was no view to the posterior segment. A B-scan revealed a posterior vitreous detachment and vitreous debris without evidence of retinal detachment.
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| Color photographs of the injected left eye. On slit beam view, notice the posterior chamber IOL with whitish plaques on the capsular bag. Images: Balderas IM, Duker JS | |||
What is your diagnosis?
Keratic precipitates, cell and flare
Considering the historical data and the examination findings, there was a high suspicion for delayed-onset chronic endophthalmitis, in particular caused by Propionibacterium acnes. Other conditions that were considered included a wide variety of primary uveitic conditions, including sarcoid, tuberculous and toxoplasmosis. In addition, lens-induced inflammation can occur in the postoperative period and be quite persistent. Exposure to a toxic substance in the operative or perioperative period must also be considered, as well as drug-induced inflammation. Rebound inflammation after tapering off anti-inflammatory medications is also in the differential.
Given the timing of onset of symptoms, the remitting and recurring pattern of symptoms when treated with intraocular antibiotic and corticosteroid injections, and the clinical findings, a presumptive diagnosis of chronic endophthalmitis was given. In particular, the white plaques on the lens capsule were highly suggestive of infection with P. acnes. A fungal etiology was also considered.
Discussion
Endophthalmitis is an intraocular inflammation involving the vitreous and anterior segment of the eye. It is one of the more serious complications of intraocular surgery, with incidence varying depending on the study and the type of procedure. In general, the rate of endophthalmitis is believed to be between 0.07% and 0.12% for cataract surgery, 0.11% for penetrating keratoplasty, 0.05% for pars plana vitrectomy, and between 0.2% and 9.6% for bleb-related conditions. The organisms responsible generally are part of the normal ocular surface and lid flora, but other sources of bacteria may include contaminated instruments, breaches in aseptic technique, and IOLs or other such implantable devices. When considering exogenous endophthalmitis, it is often classified as acute or chronic, with the onset of acute usually within days of surgery and chronic from weeks to months or even years after surgery. Acute endophthalmitis tends to run a fulminant course, and culprit organisms are virulent and aggressive (Staphylococcus aureus, Staphylococcus species, gram-negative organisms) with rapid diagnosis and treatment being paramount to success of treatment and visual outcome.
 | Color fundus photograph of the left eye (a). Notice the clear view of the fundus. Macular retinal pigment epithelium changes with edema. OCT demonstrating increased macular thickness and intraretinal fluid in the left eye (b and c). |
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Chronic endophthalmitis runs a more indolent course characterized by remitting and recurring episodes of inflammation and decreased vision. Further complicating matters is that this condition is often treated as a noninfectious inflammatory condition, which can hinder diagnosis. The organisms are generally more fastidious in nature and require special conditions or longer incubation periods for positive culture (P. acnes, coagulase-negative Staphylococcus, fungal species). It can present as chronic iritis or granulomatous uveitis with mild or severe vitritis, and hypopyon is generally less common. It is associated with decreased vision with little to no pain. There is generally a sequestrum of infectious agents in the eye.
P. acnes in particular is an anaerobic, pleomorphic bacillus that produces a syndrome of indolent granulomatous uveitis occurring within weeks to months after surgery. The characteristic clinical feature is white intracapsular plaques that have been shown histologically to be composed of sequestered organisms. In addition, one can see keratic precipitates and vitritis. Management can be difficult for several reasons: It can resemble sterile inflammation early on and symptoms may be suppressed by corticosteroids; the intact posterior capsule allows the organism to grow in an anaerobic environment isolated from the host defense; adequate drug levels may not be present for sufficient time in the capsular bag to effect killing of the organism; and infection is not consistently resolved by injection of intraocular antibiotics and is usually associate with recurrent inflammation.
In terms of treatment, there are several retrospective non-comparative case series comparing treatment options. In 1999, Clark et al compiled 36 cases of culture-positive P. acnes presenting 8 weeks after cataract surgery. These 36 patients received one of three different initial treatment strategies. Twelve underwent intraocular injection with a standard antibiotic regimen alone (IOAB group), 10 patients underwent pars plana vitrectomy with injection of intraocular antibiotics (PPV group), and 14 patients underwent PPV with subtotal capsulectomy (PPV-PC group). The main outcome measures were final visual acuity and effectiveness of the various treatment procedures as either initial or follow-up therapy. Of the 12 patients receiving IOAB alone, 100% had recurrent or persistent inflammation. Five of the PPV patients (50%) and two of the PPV-PC (14%) had recurrent or persistent inflammation. The 12 IOAB patients underwent total capsular bag removal with IOL exchange with resolution of inflammation at a mean follow-up of 4.3 years. The five PPV patients with recurrent inflammation required one additional procedure before resolution of inflammation (mean follow-up of 2.4 years). The two patients in the PPV-PC group who failed initial therapy underwent total capsular bag removal with IOL exchange with resolution of inflammation (mean follow-up of 2 years). Of note, no significant difference in final visual acuity between treatment groups was detected – overall, 20/40 or better in 50% of patients and 20/400 or better in 75% of patients.
A similar study by Aldave et al was done using data from 25 patients with culture-proven P. acnes endophthalmitis after cataract extraction between January 1991 and April 1998. Both studies seem to point to the following conclusions: Intraocular injection of antibiotics alone or vitrectomy without capsulectomy is associated with high rates of persistent or recurrent inflammation; PPV, partial capsulectomy and intraocular injection of antibiotic without IOL exchange was usually successful on long-term follow-up; and in those with persistent or recurrent inflammation after partial capsulectomy, total capsular bag removal with IOL removal or exchange was uniformly successful.
Our patient underwent 23-gauge PPV with IOL removal and intravitreal injection of vancomycin and ceftazidime. Cultures have been negative to date. At his last visit, he had minimal anterior chamber cell with a clear view to the posterior segment showing macular edema (Figures 2a to 2c). Vision checked with potential acuity meter with a +13 lens in the left eye was 20/60.
For more information:
- Isabel M. Balderas, MD, and Jay S. Duker, MD, can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; Web site: www.neec.com.
- Edited by Isabel M. Balderas, MD, and Tom Hsu, MD. Drs. Balderas and Hsu can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; Web site: www.neec.com. Drs. Balderas and Hsu have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.
References:
- Aldave AJ, Stein JD, et al. Treatment strategies for postoperative Propionibacterium acnes endophthalmitis. Ophthalmology. 1999;106(12):2395-2401.
- Clark WL, Kaiser PK, et al. Treatment strategies and visual acuity outcomes in chronic postoperative Propionibacterium acnes endophthalmitis. Ophthalmology. 1999; 106(9):1665-1670.
- Opremcak EM. 2005-2006 Basic and clinical science course. Section 9: Intraocular inflammation and uveitis. San Francisco: American Academy of Ophthalmology; 2005:207-214.
- Winward KE, Pflugfelder SC, Flynn HW Jr, Roussel TJ, Davis JL. Postoperative Propionibacterium endophthalmitis. Treatment strategies and long-term results. Ophthalmology. 1993;100(4):447-451.