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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 58  |  Issue : 3  |  Page : 200-202

Conservative approach in the management of chronic postoperative Propionibacterium acnes endophthalmitis: A case report with review of literature


1 Department of Vitreo-Retina, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
2 Department of Oculoplasty and Community Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
3 Department of Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, Assam, India

Date of Submission13-Mar-2020
Date of Decision06-Apr-2020
Date of Acceptance21-Apr-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. Ronel Soibam
Department of Vitreo-Retina, Sri Sankaradeva Nethralaya, 96, Beltola, Guwahati - 781 028, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_20_20

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  Abstract 


Chronic endophthalmitis can occur following uncomplicated cataract surgery with intraocular lens (IOL) implantation secondary to slow-growing organisms such as Propionibacterium acnes. A 68-year-old male presented with pain and diminution of vision 4 months after uneventful phacoemulsification with IOL implantation. Slit-lamp examination showed trace hypopyon, conjunctival congestion with anterior chamber cells and flare, vitreous haze, and posterior capsular plaque-like deposits suggestive of probable P. acnes endophthalmitis. Intravitreal antibiotics did not provide any relief. The diagnosis was confirmed using PCR on the aqueous aspirate. Intracameral and in-the-bag injection of antibiotic caused the resolution of infection and improvement in visual acuity. This report thus highlights that in-the-bag antibiotics can help conservatively manage this condition without the need for an invasive procedure like vitrectomy and IOL explantation.

Keywords: Chronic postoperative endophthalmitis, in-the-bag antibiotic, polymerase chain reaction, Propionibacterium acnes


How to cite this article:
Deshmukh S, Soibam R, Bawankar P, Bhattacharjee H, Hawaibam S, Gupta K, Kumar J, Desai C. Conservative approach in the management of chronic postoperative Propionibacterium acnes endophthalmitis: A case report with review of literature. TNOA J Ophthalmic Sci Res 2020;58:200-2

How to cite this URL:
Deshmukh S, Soibam R, Bawankar P, Bhattacharjee H, Hawaibam S, Gupta K, Kumar J, Desai C. Conservative approach in the management of chronic postoperative Propionibacterium acnes endophthalmitis: A case report with review of literature. TNOA J Ophthalmic Sci Res [serial online] 2020 [cited 2020 Sep 25];58:200-2. Available from: http://www.tnoajosr.com/text.asp?2020/58/3/200/294976




  Introduction Top


Endophthalmitis is a severe vision-threatening complication of intraocular surgery.[1] It can either be endogenous or exogenous. The first case of postoperative Propionibacterium acnes endophthalmitis was reported by Forster et al. in 1976.[2] According to the Endophthalmitis Vitrectomy Study (EVS), postoperative endophthalmitis can be divided into two types: acute and chronic.[1] The term chronic postoperative endophthalmitis (CPOE) was first used by Meisler et al. in 1987 and is most often caused by low-virulent bacteria such as P. acnes.[3] Herein, we report the case of chronic postoperative P. acnes endophthalmitis treated conservatively and successfully with intracameral and in-the-capsular bag antibiotic injection.


  Case Report Top


A 68-year-old male presented with pain, redness, and diminution of vision in the left eye for 4 days. He underwent uneventful phacoemulsification with intraocular lens (IOL) implantation 4 months back. His visual acuity was 20/20 right eye (OD) and 20/60 left eye (OS). Intraocular pressure was 14 mmHg OD and 20 mmHg OS. Slit-lamp examination OS showed trace hypopyon, conjunctival congestion, anterior chamber cells and flare, vitreous haze, and posterior capsular plaque-like deposits suggestive of probable P. acnes endophthalmitis [Figure 1]b. Ultrasound B-scan OS was suggestive of low-grade endophthalmitis. Hence, a diagnosis of chronic endophthalmitis was made. Intravitreal antibiotics vancomycin (1 mg/0.1 ml) and ceftazidime (2.25 mg/0.1 ml) were administered, and the patient was started on topical moxifloxacin (0.5%) eye drop six times a day, atropine (1%) eye drop three times a day, and prednisolone (1%) eye drop 1 hourly. There was a reduction in anterior chamber cells, flare, and vitreous haze suggestive of improvement. Recurrence was observed after 4 days in the form of increased anterior chamber cells, flare, and vitreous haze. Aqueous aspirate direct smear examination showed plenty of pus cells and pigment cells. Aqueous aspirate PCR was positive for P. acnes genome and negative for the panfungal genome. The patient was then administered intracameral and in-the-bag vancomycin (1 mg/0.1 ml) [Figure 1]a and continued on topical moxifloxacin (0.5%) eye drop six times a day, atropine (1%) eye drop three times a day, and prednisolone (1%) eye drop 1 hourly. The vision improved to 20/30 over 1 month and maintained until one year of follow-up [Figure 1]c and [Figure 1]d. Thus, this conservative approach proved to be effective and eliminated the need for vitrectomy and IOL explantation.
Figure 1: (a) Schematic diagram showing in-the-bag injection of antibiotics. Slit lamp photographs (b) of the left eye showing anterior chamber reaction with the presence of whitish plaques over the posterior lens capsule behind the intraocular lens. (c) Resolution and organization of the plaque 2 weeks after intracameral and in-the-bag injection of antibiotic. (d) 1-month post intracameral and in-the-bag injection of antibiotic, showing resolution of anterior chamber reaction and whitish plaques

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  Discussion Top


Endophthalmitis is a devastating diagnosis associated with dreaded visual outcomes. It can either be endogenous or exogenous. According to the EVS study, it can either be acute or chronic. Acute postoperative endophthalmitis is defined as infections within 6 weeks of surgery, and CPOE is defined as infections after 6 weeks of surgery.[1] Literature review shows that the incidence of acute postoperative endophthalmitis is around 0.093% for all intraocular procedures, and for CPOE is unknown.[4]

CPOE due to sequestered organisms in the capsular bag is a common complication of otherwise uncomplicated cataract surgery with IOL implantation.[3],[5]P. acnes is the most commonly isolated organism in the cases of CPOE. The other common organisms being Acinetobacter calcoaceticus, Torulopsis candida, Corynebacterium minutissimum, and Alcaligenes xylosoxidans.[6]

P. acnes is a pleomorphic Gram-positive rod with a cell wall that is resistant to macrophages or polymorphonuclear leukocytes. This ability of P. acnes to survive in lens capsular remnants may account for its chronicity. It may be released intermittently either spontaneously, as postulated by Meisler et al. or after Nd: YAG laser posterior capsulotomy.[7]P. acnes endophthalmitis is characterized by a chronic, indolent course that responds transiently to steroids. Clinical findings include granulomatous inflammatory precipitates on the corneal endothelium or IOL surface or white plaques on the posterior capsule. Histopathologic studies of lens capsular remnants suggest that these plaques represent the colonies of organisms sequestered within the residual lens material.[8] It has been found that P. acnes stimulate inflammation in the presence of lens protein, which acts as an adjuvant. Hence, it is assumed that the presence of lens capsular remnants is a prerequisite for the development of P. acnes endophthalmitis.[8]

Culture and PCR techniques have been used for the successful isolation of P. acnes from the aqueous and vitreous samples with variable results.[9] In our case, the diagnosis was based on PCR of the aqueous aspirate.

Treatment modality suggested in the literature is pars plana vitrectomy, with partial to total capsulectomy and removal of the IOL, giving a variable outcome in the long-term follow-up. Meisler et al. noted that vitrectomy with an injection of intravitreal antibiotics might not be sufficient because organisms can be sequestered within the capsule, and total removal of lens material and the IOL may be required.[3] It is suggested that if the plaque is central in location, perform pars plana vitrectomy with partial capsulectomy. If the plaque extends into the capsule periphery, vitrectomy with total capsulectomy and IOL removal or exchange may be tried.[10]

Although, in our case, the first time we administered intravitreal antibiotics, there was a transient improvement with recurrence later on. One possible reason why the first approach did not work as expected is that the antibiotic which was administered in the vitreous cavity may not have achieved the bactericidal concentration in the capsular bag. Second, it is possible that a sufficient amount of antibiotics did not reach to the capsular bag as it was sealed around the IOL.


  Conclusion Top


P. acnes endophthalmitis should be considered in all pseudophakic patients with chronic intraocular inflammation with a white posterior capsular plaque. The present case report stresses the fact that CPOE can be accurately and rapidly diagnosed using the PCR technique, and it can be conservatively managed without the need for vitrectomy and explantation of IOL using intracameral and in-the-bag injection of antibiotics.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to thank Sri Kanchi Sankara Health and Educational Foundation, Guwahati, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Johnson MW, Doft BH, Kelsey SF, Barza M, Wilson LA, Barr CC, et al. The Endophthalmitis Vitrectomy Study. Relationship between clinical presentation and microbiologic spectrum. Ophthalmology 1997;104:261-72.  Back to cited text no. 1
    
2.
Forster RK, Zachary IG, Cottingham AJ Jr., Norton EW. Further observations on the diagnosis cause, and treatment of endophthalmitis. Am J Ophthalmol 1976;81:52-6.  Back to cited text no. 2
    
3.
Meisler DM, Zakov ZN, Bruner WE, Hall GS, McMahon JT, Zachary AA, et al. Endophthalmitis associated with sequestered intraocular Propionibacterium acnes. Am J Ophthalmol 1987;104:428-9.  Back to cited text no. 3
    
4.
Maalouf F, Abdulaal M, Hamam RN. Chronic postoperative endophthalmitis: A review of clinical characteristics, microbiology, treatment strategies, and outcomes. Int J Inflamm 2012;2012:313248.  Back to cited text no. 4
    
5.
Winward KE, Pflugfelder SC, Flynn HW Jr, Roussel TJ, Davis JL. Postoperative Propionibacterium endophthalmitis. Treatment strategies and long-term results. Ophthalmology 1993;100:447-51.  Back to cited text no. 5
    
6.
Gopal L, Ramaswamy AA, Madhavan HN, Saswade M, Battu RR. Postoperative endophthalmitis caused by sequestered Acinetobacter calcoaceticus. Am J Ophthalmol 2000;129:388-90.  Back to cited text no. 6
    
7.
Chien AM, Raber IM, Fischer DH, Eagle RC Jr, Naidoff MA. Propionibacterium acnes endophthalmitis after intracapsular cataract extraction. Ophthalmology 1992;99:487-90.  Back to cited text no. 7
    
8.
Maguire HC Jr, Cipriano D. Immunopotentiation of cell-mediated hypersensitivity by Corynebacterium parvum (Propionibacterium acnes). Int Arch Allergy Appl Immunol 1983;70:34-9.  Back to cited text no. 8
    
9.
Buggage RR, Callanan DG, Shen DF, Chan CC. Propionibacterium acnes endophthalmitis diagnosed by microdissection and PCR. Br J Ophthalmol 2003;87:1190-1.  Back to cited text no. 9
    
10.
Deramo VA, Ting TD. Treatment of Propionibacterium acnes endophthalmitis. Curr Opin Ophthalmol 2001;12:225-9.  Back to cited text no. 10
    


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