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Chronic Postoperative Endophthalmitis

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Title: Chronic Postoperative Endophthalmitis
Author: Mark R Johnson, University of Alabama, Heersink School of Medicine, MS4
Date:7/8/2022
Keywords/Main Subjects: Endophthalmitis; post-op endophthalmitis, uveitis, postoperative infection
Diagnosis: Chronic Postoperative Endophthalmitis

Case 1:

A 65 year old male with no relevant past medical history and past ocular history of bilateral cataract surgery with lens implantation and Ahmed valve in the right eye presented with complaints of very hazy vision with a large central floater, 6/10 stabbing pain, and tearing/discharge. 14 months prior to presentation, the patient had cataract surgery in the right eye followed by the same in the left eye one week later. 10 months ago, he presented with pain and loss of vision in the right eye and was seen by his cataract surgeon. Inflammation was noted in the right eye which was managed with topical steroid. 6 months ago he was seen by a local retina specialist and injected with dexamethasone intravitreal implant (Ozurdex) which improved his symptoms initially. Subsequently, however, his symptoms worsened. He was taken to surgery for a pars plana vitrectomy with vitreous biopsy and treated with fluconazole by his retina specialist. His vitreous biopsy was ‘negative’. 3 months ago he was given intravitreal amphotericin, and 4 days later given intravitreal voriconazole. He was seen by a local rheumatologist for presumed ocular inflammatory disease and started on prednisone and methotrexate with no improvement. Upon presentation to our office he was on prednisone 15mg PO daily, methotrexate with rising liver enzymes, prednisolone drops every hour in the right eye, brimonidine, Timolol, Dorzolamide, and Diamox.

He had no social history/exposure except for exposure to a pet turtle. Review of systems was positive for essential tremor made worse on prednisone, easy bruising on prednisone, and urinary urgency with Diamox.

On physical exam he was light perception in the right eye with a minimally reactive 4mm pupil and intraocular pressure of 24 with Tonopen. On slit lamp examination, his tube shunt was clogged by fibrin and corneal edema was present. Examination of his right anterior chamber was significant for a 2.5mm hypopyon and 4+ cell and fibrin, neovascularization of the iris, a PCIOL, and in his vitreous 2+ cell, condensation, and 4+ haze with no view for a fundus exam (figure 1).

Figure 1: Injection and hypopyon

Laboratory workup included HLA-B27, lysozyme, MPO/PR3 (ANCA) abs, RPR, FTA-ABS, ACE, CBC, and CMP. He was taken to the operating room the same day for PPV, IOL removal and intravitreal vancomycin, ceftazidime, voriconazole, amphotericin, clindamycin and foscarnet.

His vitreous cultures from surgery were positive for 4+ PMNs, 2+ Propionibacterium acnes. His PCR sequencing was positive 16S rRNA for P. acnes. His other laboratory testing was unremarkable except for WBC elevated at 13.18 (ref range 4.3-11.3) felt to be consistent with neutrophilia from systemic glucocorticoid dosing.

6 months later, the patient presented again with recurrent episodes of inflammation. He had received 3 injections of intravitreal vancomycin over the past 9 weeks by an outside physician. On physical exam he was CF @ 3ft with irregular 7mm pupil and IOP of 19. On slit lamp exam he had a 2.5mm hypopyon, 4+ cell, and fibrin in the AC. B scan showed a lens capsule without deposits, fluffy material attached to the temporal ciliary body suspicious for vegetation, and anterior vitreous hemorrhage (figure 2). He was taken to the operating room for vitrectomy with removal of capsular remnants, synechialysis, cyclitic membranectomy and intravitreal vancomycin injection. The recurrence was presumed to be due vegetations on capsular remnants. The patient was subsequently lost to follow up.

Figure 2: vitreous opacities

Case 2:

A 75 year old female with a history of glaucoma requiring trabeculectomy in the right eye 2 years ago as well as bilateral cataract surgery 6 years ago, and rosacea was referred for evaluation of chronic anterior chamber inflammation in the right eye. 2 months ago she began complaining of  throbbing pain in the right eye and was started on topical steroids and ofloxacin. Her vision gradually worsened over the course of several weeks, and she could no longer see fingers by 1 month to her presentation with us. She was known to be a steroid responder and complained of intermittent pain in the right eye. Ocular medications included Durezol and prednisolone in the right eye.

Her past medical history was relevant for nephrolithiasis and rosacea. Review of systems was positive for headaches which she thinks are from her eye. She has extensively traveled outside the US and lived in France as a child.

On examination, visual acuity was 20/200  in the right eye, the intraocular pressure was 31. On slit lamp exam, a clear superior bleb was noted with trace cell in the anterior chamber. The lens was seen to have a whitish plaque. Dense vitritis, and a hazy posterior view were noted(figure 3).

Figure 3: Notice the white plaques coating the PCIOL

Due to suspicion for chronic endophthalmitis, the patient was taken to surgery for pars plana vitrectomy, vitreous biopsy, posterior capsulotomy and intravitreal injection of vancomycin, ceftazidime, and voriconazole. A portion of the vitreous sample was sent to the University of Washington for multiplex PCR. Staphylococcus epidermidis was identified. All labs otherwise were within normal limits. Postoperatively she was placed on 10 days of oral moxifloxacin. Her eye has remained uninflamed since this intervention with best corrected visual acuity at 20/50.

Discussion:

Chronic Postoperative Endophthalmitis (CPE) is an indolent complication presenting months to years after intraocular surgery that is most often caused by Cutibacterium acnes. CPE had an incidence of 0.017% following cataract surgery in a single center study¹.

The explosive onset of acute-postoperative endophthalmitis is defined as appearing in less than 6 weeks following intraocular surgery, and generally appears within about 1 week². This is opposed to the more indolent course of CPE which manifests greater than 6 weeks following surgery². The mean time to presentation following intraocular surgery was 343 days in one study³. The pathophysiology of CPE generally involves perioperative inoculation with lower virulence organisms during intraocular surgery as compared to acute postoperative endophthalmitis. CPE is most commonly caused by Cutibacterium acnes (formerly known as Propionibacterium acnes⁴, a commensal species). However, other causes include coagulase negative Staphylococcus (eg Staphylococcus epidermidis), Anaerobic Streptococcus species, Nocardia asteroides, Corynebacterium species, Gram-negative organisms (eg Alcaligenes xylosoxidans), and fungi (Candida parapsilosis, Torulopsis candida)⁴. The pathophysiology is thought to involve growth of the microbes between the intraocular lens optic and the posterior capsule, which protects them from the immune system as well as antimicrobials⁴.

The signature clinical finding in C. acnes CPE is white plaque/capsular opacities on the lens capsule, which occurs in 40-100% of cases⁴. Hypopyon is present 1/3 to 2/3 of the time⁴. Granulomatous KPs are seen in 31-81% of eyes⁴. Vitritis is often seen, and “beaded fibrin strands” are seen about 1/3 of the time⁴. The differential for persistent postoperative inflammation beyond 6 weeks includes: poor postop steroid use/too rapid of a taper, retained lens fragments, uveitis-glaucoma-hyphema (UGH) syndrome, retinal detachment, epithelial downgrowth through surgical wounds, pre-existing uveitis, and sympathetic ophthalmia⁵.

Diagnosis of CPE is often delayed due to resemblance of sterile post-operative inflammation initially as well as initial improvement of inflammation on steroids⁶.  C. acnes in particular, often takes up to 14 days to grow on culture, and vitreous and aqueous can be culture negative due to sequestration of the organism in the capsular bag⁴. PCR of vitreous or aqueous contents is frequently used to aid in diagnosis of CPE and can be more sensitive than culture and microscopy⁷.

Upon treatment with intraocular antibiotics, the infection does not always resolve due to the location of the infection in the capsular bag⁶. Treatment generally involves pars plana vitrectomy with intravitreal antibiotics, systemic antibiotics, and often removal of the lens implant and capsular bag. Removal of the capsular bag reduces rates of recurrence significantly⁴. In a 36 patient study, 50% of patients retained vision better than or equal to 20/40 following surgical treatment⁶.

Summary of the Case:

• Chronic postoperative endophthalmitis is most commonly caused by Cutibacterium acnes (formerly known as Propionibacterium acnes) and presents months to years after surgery
• Chronic postoperative endophthalmitis can easily be confused with other causes of ocular inflammation due to its initial improvement with corticosteroids
• Definitive treatment involves vitrectomy, antibiotics, and often removal of the lens and capsular bag
• Patients have hope for a good visual outcome

References:

1. Al-Mezaine HS, Al-Assiri A, Al-Rajhi AA. Incidence, clinical features, causative organisms, and visual outcomes of delayed-onset pseudophakic endophthalmitis. Eur J Ophthalmol. 2009;19(5):804-811. doi:10.1177/112067210901900519
2. Johnson MW, Doft BH, Kelsey SF, et al. The Endophthalmitis Vitrectomy Study. Relationship between clinical presentation and microbiologic spectrum. Ophthalmology. 1997;104(2):261-272. doi:10.1016/s0161-6420(97)30326-1
3. Shirodkar AR, Pathengay A, Flynn HW Jr, et al. Delayed- versus acute-onset endophthalmitis after cataract surgery. Am J Ophthalmol. 2012;153(3):391-398.e2. doi:10.1016/j.ajo.2011.08.029
4. Deramo VA, Ting TD. Treatment of Propionibacterium acnes endophthalmitis. Curr Opin Ophthalmol. 2001;12(3):225-229. doi:10.1097/00055735-200106000-00015
5. Bagheri N, Wajda BN, eds. Section 12.14: Chronic Postoperative Uveitis. In: The Wills Eye Manual. 7^th Philadelphia, PA: Wolters Kluwer: 2017:369-370.
6. Clark WL, Kaiser PK, Flynn HW Jr, Belfort A, Miller D, Meisler DM. Treatment strategies and visual acuity outcomes in chronic postoperative Propionibacterium acnes endophthalmitis. Ophthalmology. 1999;106(9):1665-1670. doi:10.1016/S0161-6420(99)90348-2
7. Therese KL, Anand AR, Madhavan HN. Polymerase chain reaction in the diagnosis of bacterial endophthalmitis. Br J Ophthalmol. 1998;82(9):1078-1082. doi:10.1136/bjo.82.9.1078

Faculty Approval by: Akbar Shakoor, MD

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