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45 year old lady who complained of decreased vision OS of one year duration after cataract surgery
Digital Journal of Ophthalmology 1998
Volume 4, Number 19
June 9, 1998
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DV Inglesby MB, BSc, FRCS, FRCOphth | Sunderland Eye Infirmary, Sunderland, United Kingdom LM Tong MB, BS | Sunderland Eye Infirmary, Sunderland, United Kingdom
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| Diagnosis and Discussion | Propionibacterium acnes subacute endophthalmitis
The cultured organism was identified as Propionibacterium acnes. The patient was started on oral ciprofloxacin and her steroid drops were progressively tapered down.
The patient's post operative corrected aphakic vision is 6/12 in the left eye. The intraocular pressure was 16 mmHg. An anterior chamber secondary lens implantation would be done when the eye showed no more signs of inflammation, with more prolonged follow-up.
P acnes is a gram positive microaerophilic bacillus, a common skin commensal present in the eyelids and ocular surface. The organism can be cultured in thioglycolate media under anaerobic conditions, but this needs to be kept for at least 7 days.(1)
It is known for causing delayed onset pseudophakic endophthalmitis, which is recurrent endophthalmitis due to sequestration of organisms within capsular remnants, where they survive topical, intravenous or even intraocular antibiotics. The endophthalmitis can be worsened by laser capsulotomy. After surgery, residual lens cortex can interact with the bacteria to cause a type of phacoanaphylactic response(2). The present patient is unusual in that the inflammation started immediately after surgery. Also, the large keratic precipitates of granulomatous uveitis, typical of this condition, were absent in this patient.
Previous sporadic cases of this condition has been reported recently.(3-5) A case of anterior chamber intraocular implant surgery associated with this condition has been reported.(6) An outbreak of 4 cases FROM the same surgeon over 2 years have also been reported.(7)
The largest series (22 culture positive cases) has been reported by Winward et al (8). The authors advocated the following approach for post operative endophthalmitis:
Acute cases (within a week of surgery) should be treated with vitreous biopsy and intravitreal antibiotics. These cases are generally not associated with P acnes.
Chronic cases (onset more than one month FROM surgery) can be treated with long term topical steroids if the visual acuity is good and there is minimal intraocular inflammation. Unresponsive cases should be treated surgically by performing pars plana partial capsulectomy (if the full extent of the white plaque is visible); or total capsulectomy through the limbus. The aim of the surgery is to remove all foci of infection. The intraocular lens should also be removed. The authors also favoured an exchange implant in the anterior chamber or in the posterior chamber with transcleral fixation.
Treatment with 100 percent oxygen and infusion of gentamicin and dexamethasone INTO the anterior chamber for 3 patients has been reported.(9) This has been a preliminary report and there is yet no other report of such treatment in the literature. | |
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