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Combined treatment most successful in managing P. acnes endophthalmitis
A review of 2 decades of endophthalmitis caused byPropionibacterium acnes offers clues to effective treatment.
MIAMI – Pars plana vitrectomy, partial capsulectomy and intraocular antibiotic injection was the most successful initial treatment for patients with chronic Propionibacterium acnes endophthalmitis, according to a review of records at two institutions. Other treatment regimens were associated with high rates of recurrent or persistent intraocular inflammation.
The evaluation of a 22-year series of postoperative endophthalmitis caused by P. acnes provides a basis for effective treatment strategies and visual acuity expectations, said W. Lloyd Clark, MD, and colleagues, who reported their findings in Ophthalmology [1999; 106:1665-1670]. Records from the Bascom Palmer Eye Institute from 1974 through 1996 and from the division of ophthalmology at the Cleveland Clinic Foundation from 1981 through 1996 yielded 36 cases of P. acnes endophthalmitis.
“Although the results of this study may suggest a treatment algorithm for a staged approach to patients with chronic P. acnes endophthalmitis, we must stress the importance of addressing each patient on an individual basis,” Dr. Clark reported.
A characteristic clinical feature of P. acnes is the presence of a white intracapsular plaque, which has been shown histologically to be composed of sequestered organisms inside the peripheral capsular bag, according to Dr. Clark. Other important clinical findings that mark the presence of P. acnes include conjunctival injection, keratic precipitates and uveitis. In contrast to other types of endophthalmitis, hypopyon occurs infrequently with P. acnes.
What worked
In this series of chronic P. acnes endophthalmitis, initial treatment with intraocular antibiotic injection alone or vitrectomy without capsulectomy was associated with high rates of recurrent or persistent intraocular inflammation. Pars plana vitrectomy, partial capsulectomy and intraocular antibiotic injection without IOL exchange was usually successful on long-term follow-up. In patients with recurrent intraocular inflammation, pars plana vitrectomy, total capsular bag removal, intraocular antibiotic injection and IOL exchange or removal was a uniformly successful strategy.
All study patients had documented follow-up of at least 6 months following their last intraocular procedure, and 33 of the 36 or 92% had follow-up of at least nine months. Patients underwent three different initial treatments: intraocular antibiotic injection alone; pars plana vitrectomy and intraocular antibiotic injection; and pars plana vitrectomy with subtotal capsulectomy and intraocular antibiotic injection. Of the 12 patients who had intraocular antibiotics alone, all had recurrent or persistent inflammation after treatment. Five (50%) of those who had pars plana vitrectomy had recurrent or persistent inflammation after treatment; and two (14%) of the 14 who had pars plana vitrectomy with subtotal capsulectomy had recurrent or persistent inflammation after treatment.
None of the patients that underwent subsequent pars plana vitrectomy, total capsular bag removal, intraocular antibiotic injection, and either IOL exchange or removal had persistent or recurrent intraocular inflammation. Overall final acuity was 20/40 or better in 18 (50%) of patients, and a total of 28 patients (78%) retained 20/400 or better vision.
Combination of procedures
Mean follow-up after the last treatment was 2.9 years. No patients underwent pars plana vitrectomy, total capsulectomy, intraocular antibiotic injection and either intraocular lens exchange or removal as initial treatment, but 17 subsequently underwent combinations of these procedures, according to Dr. Clark.
In contrast to other types of postoperative endophthalmitis, IOL exchange can be considered in these patients after total capsular bag removal, Dr. Clark reported.
There was no significant difference in visual acuity outcomes between treatment groups. Overall final visual acuity was 20/40 or better in 18 of 36 patients and 20/400 or better in 28. Severe visual loss, defined as final visual acuity of less than 5/200 at final follow-up, occurred in six patients and was felt to be caused by age-related macular degeneration in two patients, uncontrolled glaucoma in two patients, retinal detachment in one patient and phthisis bulbi in one patient.
For Your Information:
W. Lloyd Clark, MD, can be reached at Bascom Palmer Eye Institute, 900 N.W. 17 Street, Miami, FL 33136; e-mail:
hflynn@bpei.med.miami.edu. Dr. Clark did not participate in the preparation of this article.