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Chronic postoperative endophthalmitis from Staphylococcus aureus
Chronic postoperative endophthalmitis from Staphylococcus au reus John A. Seedor, M.D. Richard S. Koplin, M.D. Mahendra Shah, M.Sc. Emmanuel E. Almeda, Jr., M.D. Henry D. Perry, M.D.
ABSTRACT We recently treated a patient with chronic postoperative endophthalmitis caused by Staphylococcus aureus, which usually pl'esents with a fulminant clinical course, Because of the chronic course, the initial treatment was high dose steroids followed by lensectomy and vitrectomy, However, this was not effective, and intravitreal antibiotics and steroids were ultimately required. We now recommend that in patients with chronic postoperative inflammation unresponsive to high dose steroids, intraocular cultures followed by injection of inh'aocular antibiotics be considered . Key Words: chronic endophthalmitis , intraocular 1 ns, intravitreal antibiotics, Staphylococcus aureus
Microbial organisms generally considered to be of low virulence, such as Propionibacterium acnes and coagulase negative Staphylococcus, may have an etiologic role in some cases of chronic postoperative inflammation after cataract extraction and intraocular lens (IOL) implantation. 1,2 We recently treated a patient with chronic postoperative endophthalmitis caused by Staphylococcus au reus , an organism more commonly associated with a fulminant clinical course.
eye after uneventful extracapsular cataract extraction (ECCE) and posterior chamber IOL implantation was performed on September 15, 1987. When first seen on November 18, 1987, the patient's best corrected visual acuity in the right eye was 20/200. There were small keratic precipitates inferiorly with 1 + cell and 2 + flare in the anterior chamber. The posterior chamber IOL was well centered. The posterior capsule was intact with two areas of fluffy white material in the superior fornix of the capsule. The anterior vitreous had 1 + cells; posterior structures were normal. The patient was started on oral prednisone 60 mg daily, and prednisolone acetate 1 % drops hourly. The inflammation did not improve, and on January 7, 1988, aqueous and vitreous aspirates were inoculated onto appropriate culture media followed by total capsulectomy, IOL removal, and pars plana vitrectomy. Capsular remnants were also placed in appropriate culture media. However, no intraocular or systemic antibiotics or steroids were administered at the time of surgery. Postoperatively the eye quieted rapidly on topical corticosteroids. Forty-eight hours after surgery, cultures of the aqueous, vitreous, and lens capsule were all positive for S. aureus (coagulase positive, hemolysis positive; novobiocin sensitive, methicillin sensitive). Numerous gram positive cocci were noted on pathologic sections of the lens capsule (Figure 1). However, because of the minimal amount of inflammation present, no additional medications were administered. Ten days postoperatively visual acuity was correctable to 20/25 with only an occasional cell seen in the anterior chamber. When next examined on February 24, 1988, the patient's best corrected visual acuity was reduced to 20/100. The anterior chamber had 2.5 mm hypopyon with 1 +
CASE REPORT A 52-year-old woman was referred to us for persistent postoperative inflammation of the right From the Departments of Ophthalmology and Pathology, New York Eye and Ear Infirmary, New York. Reprint requests to John A. Seedor, M.D., 310 East 14th Street, New York, New York 10003. 512
Fig. 1.
(Seedor) Gram positive cocci (arrows) in section oflens capsule (gram stain, original magnification X 1000).
J CATARACT REFRACT SURG-VOL 16, JULY 1990
cells in the anterior vitreous. The patient was taken to the operating room where aqueous and vitreous cultures were obtained, with intravitreal injection of gentamicin 300 mcg, vancomycin 1000 mcg, and dexamethasone 360 mcg. Smears and cultures of the aspirate were negative for microorganisms. Postoperatively the patient was placed on cefazolin 1 mg IV every six hours and topical cefazolin and prednisolone. The eye quieted quickly. When last seen on April 14, 1988, the eye had no cells in the anterior chamber and corrected visual acuity was 20/30.
DISCUSSION
REFERENCES 1. Piest KL, Kincaid MC, Tetz MR, et al. Localized endophthalmitis: a newly described cause of the so-called toxic lens syndrome. J Cataract Refract Surg 1987; 13:498-510 2. Ficker L, Meredith TA, Wilson LA, et al. Chronic bacterial endophthalmitis. Am J Ophthalmol1987; 103:745-748 3. Meisler DM, Palestine AG, Vastine DW, et al. Chronic Propionibacterium endophthalmitis after extracapsular cataract extraction and intraocular lens implantation. Am J Ophthalmol 1986; 102:733-739 4. Manka RH, Nozik RA, Stern WHo Intraocular Staphylococcus aureus abscess masquerading as chronic uveitis. Am J Ophthalmol 1988; 105:555-556 5. Zambrano W, Flynn HW Jr, Pflugfelder SC, et al. Management options for Propionibacterium acnes endophthalmitis. Ophthalmology 1989; 96:1100-1105
Microorganisms of low virulence such as P. acnes or coagulase negative Staphylococcus may be sequestered in the lens capsule following ECCE, causing a chronic postoperative endophthalmitis. Removal of the lens capsule and IOL, in some cases without intraocular antibiotics, can be effective,I,3 S. aureus when inoculated intraocularly typically results in a severe, destructive endophthalmitis. This may not always be the cause, however, as a recent report described a patient with chronic postoperative inflammation caused by an S. au reus suture abscess in the anterior chamber.4 Our case highlights the difficulties the clinician faces when trying to determine whether postoperative inflammation is sterile, such as a reaction to retained lens protein, or infectious. From routine laboratory tests it did not appear that the pathogenicity of the organism recovered from our patient had been altered. Whether the atypical chronic inflammation resulted from capsular sequestration or antigenic modification of the bacteria (which has been reported with other microorganisms3) is not known. While we could not demonstrate microorganisms on the second vitreous biopsy in our patient, it seems probable that bacteria or bacterial by-products remained in the eye after removal of the capsule and IOL. Because of the possibility that potentially virulent organisms may be the cause of chronic postoperative inflammation, we agree with others 2 ,3 that in cases of postoperative inflammation initially unresponsive to high dose steroids, intraocular cultures followed by intraocular antibiotics should be considered. Intraocular lens removal and capsulectomy should be reserved for cases resistant to all other forms of therapy. A recent report indicated good visual results were obtained with limited capsulectomy and retention of the IOL in cases of P. acnes endophthalmitis resistant to intraocular antibiotics alone. 5 We are currently evaluating this regimen, reserving total capsulectomy and IOL removal for cases recalcitrant to all other forms of therapy. J CATARACT REFRACT SURG-VOL 16, JULY 1990
513
ABSTRACT We recently treated a patient with chronic postoperative endophthalmitis caused by Staphylococcus aureus, which usually pl'esents with a fulminant clinical course, Because of the chronic course, the initial treatment was high dose steroids followed by lensectomy and vitrectomy, However, this was not effective, and intravitreal antibiotics and steroids were ultimately required. We now recommend that in patients with chronic postoperative inflammation unresponsive to high dose steroids, intraocular cultures followed by injection of inh'aocular antibiotics be considered . Key Words: chronic endophthalmitis , intraocular 1 ns, intravitreal antibiotics, Staphylococcus aureus
Microbial organisms generally considered to be of low virulence, such as Propionibacterium acnes and coagulase negative Staphylococcus, may have an etiologic role in some cases of chronic postoperative inflammation after cataract extraction and intraocular lens (IOL) implantation. 1,2 We recently treated a patient with chronic postoperative endophthalmitis caused by Staphylococcus au reus , an organism more commonly associated with a fulminant clinical course.
eye after uneventful extracapsular cataract extraction (ECCE) and posterior chamber IOL implantation was performed on September 15, 1987. When first seen on November 18, 1987, the patient's best corrected visual acuity in the right eye was 20/200. There were small keratic precipitates inferiorly with 1 + cell and 2 + flare in the anterior chamber. The posterior chamber IOL was well centered. The posterior capsule was intact with two areas of fluffy white material in the superior fornix of the capsule. The anterior vitreous had 1 + cells; posterior structures were normal. The patient was started on oral prednisone 60 mg daily, and prednisolone acetate 1 % drops hourly. The inflammation did not improve, and on January 7, 1988, aqueous and vitreous aspirates were inoculated onto appropriate culture media followed by total capsulectomy, IOL removal, and pars plana vitrectomy. Capsular remnants were also placed in appropriate culture media. However, no intraocular or systemic antibiotics or steroids were administered at the time of surgery. Postoperatively the eye quieted rapidly on topical corticosteroids. Forty-eight hours after surgery, cultures of the aqueous, vitreous, and lens capsule were all positive for S. aureus (coagulase positive, hemolysis positive; novobiocin sensitive, methicillin sensitive). Numerous gram positive cocci were noted on pathologic sections of the lens capsule (Figure 1). However, because of the minimal amount of inflammation present, no additional medications were administered. Ten days postoperatively visual acuity was correctable to 20/25 with only an occasional cell seen in the anterior chamber. When next examined on February 24, 1988, the patient's best corrected visual acuity was reduced to 20/100. The anterior chamber had 2.5 mm hypopyon with 1 +
CASE REPORT A 52-year-old woman was referred to us for persistent postoperative inflammation of the right From the Departments of Ophthalmology and Pathology, New York Eye and Ear Infirmary, New York. Reprint requests to John A. Seedor, M.D., 310 East 14th Street, New York, New York 10003. 512
Fig. 1.
(Seedor) Gram positive cocci (arrows) in section oflens capsule (gram stain, original magnification X 1000).
J CATARACT REFRACT SURG-VOL 16, JULY 1990
cells in the anterior vitreous. The patient was taken to the operating room where aqueous and vitreous cultures were obtained, with intravitreal injection of gentamicin 300 mcg, vancomycin 1000 mcg, and dexamethasone 360 mcg. Smears and cultures of the aspirate were negative for microorganisms. Postoperatively the patient was placed on cefazolin 1 mg IV every six hours and topical cefazolin and prednisolone. The eye quieted quickly. When last seen on April 14, 1988, the eye had no cells in the anterior chamber and corrected visual acuity was 20/30.
DISCUSSION
REFERENCES 1. Piest KL, Kincaid MC, Tetz MR, et al. Localized endophthalmitis: a newly described cause of the so-called toxic lens syndrome. J Cataract Refract Surg 1987; 13:498-510 2. Ficker L, Meredith TA, Wilson LA, et al. Chronic bacterial endophthalmitis. Am J Ophthalmol1987; 103:745-748 3. Meisler DM, Palestine AG, Vastine DW, et al. Chronic Propionibacterium endophthalmitis after extracapsular cataract extraction and intraocular lens implantation. Am J Ophthalmol 1986; 102:733-739 4. Manka RH, Nozik RA, Stern WHo Intraocular Staphylococcus aureus abscess masquerading as chronic uveitis. Am J Ophthalmol 1988; 105:555-556 5. Zambrano W, Flynn HW Jr, Pflugfelder SC, et al. Management options for Propionibacterium acnes endophthalmitis. Ophthalmology 1989; 96:1100-1105
Microorganisms of low virulence such as P. acnes or coagulase negative Staphylococcus may be sequestered in the lens capsule following ECCE, causing a chronic postoperative endophthalmitis. Removal of the lens capsule and IOL, in some cases without intraocular antibiotics, can be effective,I,3 S. aureus when inoculated intraocularly typically results in a severe, destructive endophthalmitis. This may not always be the cause, however, as a recent report described a patient with chronic postoperative inflammation caused by an S. au reus suture abscess in the anterior chamber.4 Our case highlights the difficulties the clinician faces when trying to determine whether postoperative inflammation is sterile, such as a reaction to retained lens protein, or infectious. From routine laboratory tests it did not appear that the pathogenicity of the organism recovered from our patient had been altered. Whether the atypical chronic inflammation resulted from capsular sequestration or antigenic modification of the bacteria (which has been reported with other microorganisms3) is not known. While we could not demonstrate microorganisms on the second vitreous biopsy in our patient, it seems probable that bacteria or bacterial by-products remained in the eye after removal of the capsule and IOL. Because of the possibility that potentially virulent organisms may be the cause of chronic postoperative inflammation, we agree with others 2 ,3 that in cases of postoperative inflammation initially unresponsive to high dose steroids, intraocular cultures followed by intraocular antibiotics should be considered. Intraocular lens removal and capsulectomy should be reserved for cases resistant to all other forms of therapy. A recent report indicated good visual results were obtained with limited capsulectomy and retention of the IOL in cases of P. acnes endophthalmitis resistant to intraocular antibiotics alone. 5 We are currently evaluating this regimen, reserving total capsulectomy and IOL removal for cases recalcitrant to all other forms of therapy. J CATARACT REFRACT SURG-VOL 16, JULY 1990
513