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Mycotic infection of the capsular bag in postoperative endophthalmitis
Mycotic infection of the capsular hag in postoperative endophthalmitis Andrea Cusumano , M.D. Massimo Busin, M.D. Manfred Spitznas, M.D.
cases, instruments and notes
ABSTRACT A case of mycotic infection after uncomplicated extracapsular cataract extraction with implantation of a posterior chamber modified C-loop intraocular lens (IOL) is reported. Severe postoperative intraocular inßammation, diagnosed by aqueous cultures as secondary to Staphylococcus aureus endophthalmitis, did not respond to antibiotic therapy. Despite IOL and capsular bag removal and further antibiotic treatment, the inflammation persisted and phthisis followed. Retrospective electron microscopic examination of the explanted material demonstrated the presence of abundant fungal elements in the capsular bag and spores on the IOL surface. Vitreous taps performed at the time of explantation were negative for bacteria and fungi, confirming the localized nature of the mycotic infection. To our knowledge this report represents the first observation of a mycotic infection confined to the capsular bag after cataract surgery with implantation of a posterior chamber IOL.
Key Words: extracapsular cataract extraction, mycotic intraocular infection, POSterior chamber intraocular lens
Endophthalmitis following extracapsular cataract extraction (ECCE) with or without implantation of an intraocular lens (IOL) is a rare complication that occurs from a few days to up to six months after From the University Eye Hospital , University of Bonn , Gennany. Sllpported in part by a grant fro1ll Clillica OClllistica, Universitd di Roma Tor Vergata (Cus umano). Reprint requests to Andrea Cusumano , M.D., UniversitätsAugenklinik Bonn, Sigmund Freud Strasse 25, 5300 Bonn 1, Germany. J CATARACT REFRACT SURG-VOL 17, JULY 1991
503
A 73-year-old man had uncomplicated ECCE with implantation of a modified C-loop posterior chamber IOL in the ciliary sulcus of the left eye. The postoperative course was uneventful and three days after surgery visual acuity was 20/200. One week later the patient complained of decreased vision without pain. On examination an anterior chamber reaction with a 20% hypopyon and a fibrin clot was detected. The eye was hypotonous and vision had dropped to counting fingers. Gentamicin and cephazolin topical therapy was begun and a paracentesis was performed the same day. The aqueous was cultured for bacteria (agar blood, agar chocolate, and thyglycolate media) and fungi
(Sabouraud medium). Since Staphylococcus aureus was demonstrated and fungal cultures were negative, systemic antibiotics were added to the topical treatment. After no substantial improvement, the IOL and the capsular bag were removed one week later and an open sky vitrectomy was performed. Vitreous taps performed intraoperatively were negative for both bacteria and fungi. The IOL and capsular bag were submitted for electron microscopic examination. A total retinal detachment occurred three weeks later and was not treated. Antibiotic treatment was continued over the following six weeks, with amikacin replacing gentamicin for the final three weeks. During this time intraocular inflammation persisted with minor improvement. Four months after surgery the intraocular pressure was 4 mm Hg. Low grade intraocular inßammation was still present. Based on the clinical and ultrasonic findings the diagnosis of phthisis bulbi was made. Retrospective examination ofthe material submitted for electron microscopy showed an intensive serofibrinous reaction on the IOL surface and in the capsular bag. Rounded or ellipsoid cellular elements, identified as fungal spores, with diameters of 5 to 7 mm were observed adhering to the IOL surface (Figure 1) and inside the capsular bag (Figure 2). The capsular bag also contained confined colonies of hyphomycetes (Figure 3). We identified primary hyphes with diameters of about 7 mm and secondary, branched ones of about 1.6 mm diameters with typical septate structures.
Fig. 1.
Fig . 2.
surgery.l The clinical picture varies from pronounced intraocular re action with massive fibrinous exudation and hypopyon to low grade chronic inßammation. Aqueous taps are routinely performed in these cases since they help identify the infection source in 75% of cases. 2 Piest et al.3 have described the presence of bacteria in the capsular bag of patients who had ECCE with IOL implantation and presented with chronic intraocular inßammation. The eyes quieted only after IOL and capsular bag removal. To our knowledge we report the first case in which hyphomycetes were confined in the capsular bag of a patient who had had ECCE with posterior chamber IOL implantation and subsequently developed endophthalmitis. CASE REPORT
504
(C usumano) Fungal spores adhe ring to the IOL surface which is partially covered by exudative material (original magnification x 500).
(C usumano) Fungal colonization of the capsular bag (original magnification x 200).
J CATARACT REFRACT SURG-VOL 17, JULY 1991
do not exclude the possibility of an associated mycotic infection. Highly selective culture media and specific techniques (slant cultures) should be used to detect fungi whose existence may account for the poor response to antibacterial treatment in so me patients with postoperative endophthalmitis. If this does not lead to identification of the microorganism involved, and IOL removal is planned, prompt and aggressive histopathology of the explanted capsular bag is essential to help determine therapy. This may be useful in cases like ours in which negative results of routinely performed cultures lessened the pos sibility of effective treatment. REFERENCES
Fig. 3.
(Cusumano) Primary (bigarrows) and seeondary (small arrows) septate hyphes in the eapsular bag. Spores (asterisks) are also present (original magnifieation x 2,000).
DISCUSSION
1. Carlson AN, Tetz MR, Apple DJ. Infeetious eomplieations of modern,cataraet surgery and intraoeular lens implantation. Infeet Dis Clin North Am 1989; 3:339-355 2. Driebe WT Jr, Mandelbaum S, Forster RK, et al. Pseudophakie endophthalmitis. Diagnosis and management. Ophthalmology 1986; 93:442-448 3. Piest KL, Kineaid MC, Tetz MR, et al. Loealized endophthalmitis: a newly deseribed eause of the so-ealled toxie lens syndrome. J Cataraet Refraet Surg 1987; 13:498-510
The diagnosis of postoperative fungal endophthalmitis is usually difficult because of the gradual onset. Mild intraocular inßammation and a relatively indolent eye are distinctive signs, while pronounced exudation with hypopyon formation and severe subjective symptoms are typical of postoperative bacterial endophthalmitis. Recently, however, bacteria of low virulence have been described in cases with mild signs of intraocular inßammation, usually identified as toxic lens syndrome. 3 Aqueous cultures had usually shown no growth and the bacteria were demonstrated only after microscopic examination of the removed IOL and capsular bag. In the case reported scanning electron microscopic analysis demonstrated the presence of hyphomycetes sequestered inside the capsular bag. Repeated failure to culture the fungi from both aqueous and vitreous taps, a routine diagnostic procedure at our institution, cannot be explained by poor laboratory technique. The association of pathogens easily grown from aqueous taps, such as Staphylococcus aureus, with other microorganisms, such as the hyphomycetes in our case, should be kept in mind when treating postoperative endophthalmitis after cataract surgery with IOL implantation. This is particularly true for those cases that do not respond to antibiotic therapy. As Piest et al. 3 have shown for low-virulence bacteria, fungal elements may be sequestered within the capsular bag at the time of IOL implantation. Our finding emphasizes that culture examinations positive for bacteria J CATARACT REFRACT SURG- VOL 17, JULY 1991
505
cases, instruments and notes
ABSTRACT A case of mycotic infection after uncomplicated extracapsular cataract extraction with implantation of a posterior chamber modified C-loop intraocular lens (IOL) is reported. Severe postoperative intraocular inßammation, diagnosed by aqueous cultures as secondary to Staphylococcus aureus endophthalmitis, did not respond to antibiotic therapy. Despite IOL and capsular bag removal and further antibiotic treatment, the inflammation persisted and phthisis followed. Retrospective electron microscopic examination of the explanted material demonstrated the presence of abundant fungal elements in the capsular bag and spores on the IOL surface. Vitreous taps performed at the time of explantation were negative for bacteria and fungi, confirming the localized nature of the mycotic infection. To our knowledge this report represents the first observation of a mycotic infection confined to the capsular bag after cataract surgery with implantation of a posterior chamber IOL.
Key Words: extracapsular cataract extraction, mycotic intraocular infection, POSterior chamber intraocular lens
Endophthalmitis following extracapsular cataract extraction (ECCE) with or without implantation of an intraocular lens (IOL) is a rare complication that occurs from a few days to up to six months after From the University Eye Hospital , University of Bonn , Gennany. Sllpported in part by a grant fro1ll Clillica OClllistica, Universitd di Roma Tor Vergata (Cus umano). Reprint requests to Andrea Cusumano , M.D., UniversitätsAugenklinik Bonn, Sigmund Freud Strasse 25, 5300 Bonn 1, Germany. J CATARACT REFRACT SURG-VOL 17, JULY 1991
503
A 73-year-old man had uncomplicated ECCE with implantation of a modified C-loop posterior chamber IOL in the ciliary sulcus of the left eye. The postoperative course was uneventful and three days after surgery visual acuity was 20/200. One week later the patient complained of decreased vision without pain. On examination an anterior chamber reaction with a 20% hypopyon and a fibrin clot was detected. The eye was hypotonous and vision had dropped to counting fingers. Gentamicin and cephazolin topical therapy was begun and a paracentesis was performed the same day. The aqueous was cultured for bacteria (agar blood, agar chocolate, and thyglycolate media) and fungi
(Sabouraud medium). Since Staphylococcus aureus was demonstrated and fungal cultures were negative, systemic antibiotics were added to the topical treatment. After no substantial improvement, the IOL and the capsular bag were removed one week later and an open sky vitrectomy was performed. Vitreous taps performed intraoperatively were negative for both bacteria and fungi. The IOL and capsular bag were submitted for electron microscopic examination. A total retinal detachment occurred three weeks later and was not treated. Antibiotic treatment was continued over the following six weeks, with amikacin replacing gentamicin for the final three weeks. During this time intraocular inflammation persisted with minor improvement. Four months after surgery the intraocular pressure was 4 mm Hg. Low grade intraocular inßammation was still present. Based on the clinical and ultrasonic findings the diagnosis of phthisis bulbi was made. Retrospective examination ofthe material submitted for electron microscopy showed an intensive serofibrinous reaction on the IOL surface and in the capsular bag. Rounded or ellipsoid cellular elements, identified as fungal spores, with diameters of 5 to 7 mm were observed adhering to the IOL surface (Figure 1) and inside the capsular bag (Figure 2). The capsular bag also contained confined colonies of hyphomycetes (Figure 3). We identified primary hyphes with diameters of about 7 mm and secondary, branched ones of about 1.6 mm diameters with typical septate structures.
Fig. 1.
Fig . 2.
surgery.l The clinical picture varies from pronounced intraocular re action with massive fibrinous exudation and hypopyon to low grade chronic inßammation. Aqueous taps are routinely performed in these cases since they help identify the infection source in 75% of cases. 2 Piest et al.3 have described the presence of bacteria in the capsular bag of patients who had ECCE with IOL implantation and presented with chronic intraocular inßammation. The eyes quieted only after IOL and capsular bag removal. To our knowledge we report the first case in which hyphomycetes were confined in the capsular bag of a patient who had had ECCE with posterior chamber IOL implantation and subsequently developed endophthalmitis. CASE REPORT
504
(C usumano) Fungal spores adhe ring to the IOL surface which is partially covered by exudative material (original magnification x 500).
(C usumano) Fungal colonization of the capsular bag (original magnification x 200).
J CATARACT REFRACT SURG-VOL 17, JULY 1991
do not exclude the possibility of an associated mycotic infection. Highly selective culture media and specific techniques (slant cultures) should be used to detect fungi whose existence may account for the poor response to antibacterial treatment in so me patients with postoperative endophthalmitis. If this does not lead to identification of the microorganism involved, and IOL removal is planned, prompt and aggressive histopathology of the explanted capsular bag is essential to help determine therapy. This may be useful in cases like ours in which negative results of routinely performed cultures lessened the pos sibility of effective treatment. REFERENCES
Fig. 3.
(Cusumano) Primary (bigarrows) and seeondary (small arrows) septate hyphes in the eapsular bag. Spores (asterisks) are also present (original magnifieation x 2,000).
DISCUSSION
1. Carlson AN, Tetz MR, Apple DJ. Infeetious eomplieations of modern,cataraet surgery and intraoeular lens implantation. Infeet Dis Clin North Am 1989; 3:339-355 2. Driebe WT Jr, Mandelbaum S, Forster RK, et al. Pseudophakie endophthalmitis. Diagnosis and management. Ophthalmology 1986; 93:442-448 3. Piest KL, Kineaid MC, Tetz MR, et al. Loealized endophthalmitis: a newly deseribed eause of the so-ealled toxie lens syndrome. J Cataraet Refraet Surg 1987; 13:498-510
The diagnosis of postoperative fungal endophthalmitis is usually difficult because of the gradual onset. Mild intraocular inßammation and a relatively indolent eye are distinctive signs, while pronounced exudation with hypopyon formation and severe subjective symptoms are typical of postoperative bacterial endophthalmitis. Recently, however, bacteria of low virulence have been described in cases with mild signs of intraocular inßammation, usually identified as toxic lens syndrome. 3 Aqueous cultures had usually shown no growth and the bacteria were demonstrated only after microscopic examination of the removed IOL and capsular bag. In the case reported scanning electron microscopic analysis demonstrated the presence of hyphomycetes sequestered inside the capsular bag. Repeated failure to culture the fungi from both aqueous and vitreous taps, a routine diagnostic procedure at our institution, cannot be explained by poor laboratory technique. The association of pathogens easily grown from aqueous taps, such as Staphylococcus aureus, with other microorganisms, such as the hyphomycetes in our case, should be kept in mind when treating postoperative endophthalmitis after cataract surgery with IOL implantation. This is particularly true for those cases that do not respond to antibiotic therapy. As Piest et al. 3 have shown for low-virulence bacteria, fungal elements may be sequestered within the capsular bag at the time of IOL implantation. Our finding emphasizes that culture examinations positive for bacteria J CATARACT REFRACT SURG- VOL 17, JULY 1991
505