Chronic pseudophakic endophthalmitis versus saccular endophthalmitis

Jose Augusto Abreu, MD, PhD, Luis Cordoves, MD, Carmen Gloria Mesa, MD, PhD, Rafael Mendez, MD, PhD, Ana Dorta, MD, Manuel G. De la Rosa, MD, PhD

ABSTRACT

A retrospective survey of 1456 cataract operations done at one hospital from 1991 to 1994 found three cases of chronic pseudophakic endophthalmitis. In two of these cases and one referred from another center, microbiological studies from aqueous humor, capsular bag, and vitreous humor were performed using an identical technique. The histopathology in the three cases showed the presence of micro­organisms in the capsular wall, although the cultures were only positive in one case (for corynebacterium species). J Cataract Refract Surg 1997; 23: 1122-1125

Chronic endophthalmitis, also known as localized endophthalmitis1 and indolent endophthalmitis,2

has been referred to in recent literature as saccular

endophthalmitis3 because its appearance usually re­quires the presence of the capsular sac (bag), the place in which the micro-organisms take shelter.

When there is suspicion of chronic pseudophakic endophthalmitis and the decision has been made to perform diagnostic and therapeutic surgery, we follow an accepted protocol: sample extraction for microbio­logical and histopathologic studies, intraocular lens (IOL) extraction, capsulectomy after alpha-chymotrypsin instillation, anterior vitrectomy, secondary implanta-

From the Departments of Ophthalmology (Abreu, Cordoves, Mesa, De Ia Rosa), Pathology (Mendez), and Microbiology (Dorta), University of La Laguna, School of Medicine, Tenerift, Canary Islands, Spain.

Presented at the XIIIth annual meeting of the European Society of Cataract and Refractive Surgeons, Amsterdam, The Netherlands, Octo­ber 1995.

Reprint requests to Jose A. Abreu, MD, Ophthalmology Section, University Hospital of the Canary Islands, 38320 La Laguna, Tenerift, Canary Islands, Spain.

tion of an angle-supported anterior chamber 10L, and systemic antibiotics and corticosteroids.4

The aqueous and vitreous humor aspiration samples, together with a portion of the extracted lens capsule, are cultured within 2 hours of their collection. Following the common protocol of our laboratory, they are cultured in blood culture botdes for aerobes (with replanting at 24 hours and 3 and 7 days on blood agar, MacConkey agar, and Saboraud agar at 3rC, and chocolate agar at 37°C with 5 to 10% carbon dioxide) and anaerobes (with replanting at 3 and 7 days on Wilkins-Chalgren at 3rC).

Case Reports

In the three cases, the initial surgical technique consisted of manual extracapsular cataract extraction (ECCE) with one-piece poly(methyl methacrylate), posterior chamber IOL implantation. Surgeries were uneventful. Prophylaxis con­sisted of gentamicin eyedrops starting the day before surgery, preparation of the surgical field with povidone-iodine 5%, and gentamicin arid methylprednisolone subconjunctival injections at the end of the procedure. Postoperative treat­ment consisted in gentamicin, dexamethasone, or diclofenac eyedrops or a combination.

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Casel In October 1989, a 66-year-old man had ECCE in his

right eye one day and ECCE in his left eye the following day. Both surgeries were done using local anesthesia.

In December 1992, he came to the emergency ward with right anterior uveitis and a whitish plaque in the capsular bag at 12 o'clock (Figure 1). Topical and periocular corticosteroids were given. The condition slowly improved and visual acuity was restored. However, a relapse occurred when treatment was discontinued.

Thus, in March 1993 he was operated on using the standard protocol but without anterior chamber IOL im­plantation. After 5 days he was discharged with a best corrected visual acuity (BCVA) of 0.5.

The pathology department report of the capsular bag biopsy showed "lens capsule with coccoid elements and hemosiderin deposits." The microbiological report stated that the direct gram stain from the aqueous and vitreous humors and the cultures were negative.

Case 2 In February 1993, a 73-year-old man had ECCE in his

left eye under local anesthesia. Three months later, he developed anterior uveitis with a whitish plaque at 12 o'clock that resolved with topical corticosteroids but returned when treatment was discontinued. In September 1993, the patient had another surgery using the standard protocol with sec­ondary implantation of an angle-supported anterior chamber IOL. He obtained a BCVA of 0.16.

The pathological study of a portion of the capsular bag showed a lens capsule with discrete fibrosis, hemosiderin pigment, and bacterial colonies, apparently cocci with some small bacilli groups.(Figure 2). The gram stain smear and the cultures were negative.

Case 3 In September 1993, a 59-year-old man with bilateral

cataracts had surgery in both eyes during the same session starting with the right eye. General anesthesia was used.

Three months later, he developed anterior uveitis in his right eye and a whitish plaque in the capsular bag at 12 o'clock that improved with topical steroids but worsened when the steroids were tapered. In July 1994, the patient presented with acute worsening of the uveitis and cystoid macular edema (CME). He had surgery using the usual protocol but without anterior vitrectomy because the ante­rior hyaloid was not disrupted during surgery and the vitritis was not significant. The patient was discharged with a BCVA of 0.4.

The pathology service reported that a study of the capsular bag showed basophilic microbial collections. The microbiology service reported that the aqueous and vitreous humor cultures were negative but that the lens capsule culture was positive for corynebacterium species (Figure 3).

Figure 1. (Abreu) Case 1: Fibrin over the IOL and a whitish plaque in the superior part of the capsular bag.

Figure 2. (Abreu) Case 2: A gram stain of the lens capsule shows discrete fibrosis, hemosiderin pigmentation, colonies of cocci, and a few small groups of bacilli.

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Figure 3. (Abreu) Case 3: A direct gram stain of the culture of the capsular bag shows corynebacterium species.

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Treatment with intravenous imipenem was started according to the antibiotic sensitivity studies.

In December 1994, visual acuity decreased, the vitritis recurred, and the CME intensified; lOP was 30 mm Hg with topical and systemic hypotensive medication. Five days later, the anterior chamber 10L was explanted and an anterior and medial pars plana vitrectomy, sulcus-sutured 10L implanta­tion, and trabeculectomy were performed. The cultures from the samples of aqueous and vitreous humor were negative.

At the last examination in September 1995, visual acuity was 0.4, lOP was 18 mm Hg with topical beta-blockers, and the CME was diminishing.

Discussion

The chronic pseudophakic endophthalmitis cases discussed in the literature show that the most fre­quently isolated organism is Propionibacterium acnes.5

In our series, this organism was not identified in aerobic and anaerobic cultures from the samples taken from aqueous humor, lens capsule, or vitreous humor. How­ever, we maintained the cultures for only 7 days; some authors recommend culturing for a minimum of 14 days.6 An ultrastructural diagnostic study with trans­mission electron microscopy of the capsular bag will demonstrate the presence or absence of P. acnes, detect­ing false positives or negatives.?

In all our cases, we performed a histopathologic study of the extracted lens capsule. In all, we observed the presence of cocci, bacillus groups, or microbial clumps of basophilic coloration, which implies that a negative culture does not rule out an infectious etiology.

Case 3 was bilateral surgery, with the endophthal­mitis occurring in the eye operated on first. In our environment, bilateral surgeries are sometimes required. Performing two independent procedures may have prevented bilateral endophthalmitis.

Histopathologic studies show that plaques seen in the periphery of the capsular bag, at approximately 12 o'clock, consist of residual lens matter and bacterial colonies.8 They were seen in our three cases and seem to be a characteristic sign of this process, probably because 12 o'clock is the area in which lens cortex most frequently remains after cataract surgery.

The term localized endophthalmitis is used because the micro-organisms are supposedly sequestered within the lens capsule fornices. This explains the recurrent course and the limited effectiveness of topical, periocu-

lar, and systemic antibiotics that barely reach their target. It is feasible, then, that many 10L explantations attributed to supposedly nonspecific uveitis, phaco­anaphylaxis, and toxic lens syndrome are really the result of localized endophthalmitis.9,10

The organisms isolated in postoperative chronic endophthalmitis, particularly P. acnes and corynebacte­rium species, are usually present in the conjunctival saphrophytic anaerobic flora. Thus, we stress the im­portance of presurgical asepsis with povidone-iodine 5% and proper draping of the eyelashes, especially when surgery is performed using local anesthesia be­cause of the expression of the contents of the conjunc­tival and palpebral glands produced by pressure during surgery.

In conclusion, the low incidence of positive cul­tures in pseudophakic chronic endophthalmitis has caused us to systematically carry out histopathologic studies of the lens capsule, which in our three cases showed the presence of organisms, although cultures showed bacterial growth in just one patient. As the appearance of this clinical situation ECCE usually requires the presence of the capsular bag (sac), we believe that the terms localized, chronic, or indolent endophthalmitis could be used rather than saccular endophthalmitis.

References

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2. Salvanet-Bouccara A, Cherifi M, Serrhini A, et al. Endophthalmies torpides chez Ie pseudophake: difficultes diagnostiques et therapeutiques. J Fr Ophtalmol 1990; 13:333-338

3. Abreu JA, Mesa CG, Santos RJ, et al. Endoftalmitis sacular. Microcirugfa Ocular 1992; 2:10-13

4. Thach AB, Das A, Lopez PF. En bloc capsulectomy in the diagnosis and treatment of refractory, chronic, recur­rent pseudophakic endophthalmitis. Ophthalmic Surg 1994; 25:361-364

5. Meisler OM, Mandelbaum S. Propionibacterium-asso­ciated endophthalmitis after extracapsular cataract ex­traction; review of reported cases. Ophthalmology 1989; 96:54-61

6. Zambrano W, Flynn HW Jr, pflugfelder SC, et al. Management options for Propionibacterium acnes endophthalmitis. Ophthalmology 1989; 96: 1100-1105

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7. Ouch A, Cafarena A, Iborra FJ, et al. Endoftalmitis cronica y pseudofaquia. Microcirugia Ocular 1994; 1:27-33

8. Mandelbaum S, Meisler OM. Postoperative chronic microbial endophthalmitis. Int Ophthalmol Clin 1993; 33(1):71-79

9. Solomon KO, Apple OJ, Mamalis N, et al. Complica-

tions of intraocular lenses with special reference to an analysis of 2500 explanted intraocular lenses (IOLs). Eur J Implant Refract Surg 1991; 3:195-200

10. Jaffe GJ, Whitcher JP, Biswell R, Irvine AR. Propioni­bacterium acnes endophthalmitis after extracapsular cata­ract extraction and intraocular lens implantation. Oph­thalmic Surg 1986; 17:791-793

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