Ophthalmic Surgery, Lasers and Imaging Retina

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Case Report 

Resolution of Pigmented Keratic Precipitates Following Treatment of Pseudophakic Endophthalmitis Caused by Propionibacterium Acnes

Golnaz Javey, MD; Thomas A. Albini, MD; Harry W. Flynn Jr, MD

Abstract

Propionibacterium acnes is a well-recognized cause of chronic postoperative endophthalmitis after cataract surgery. The subtle clinical signs of this infection and its initial favorable response to topical steroids may lead to delayed diagnosis and treatment. Two patients with culture proven P. acnes endophthalmitis after cataract surgery that presented with prominent pigmented keratic precipitates (KPs) and low-grade iritis in the involved eye were managed. Both cases had initial treatment with diagnostic pars plana vitrectomy (PPV) with intraocular antibiotic (IOAB) injection. Secondary treatment for recurrence was required in both patients. The KPs and iritis resolved after removal of intraocular lens (IOL) and capsular bag.

Abstract

Propionibacterium acnes is a well-recognized cause of chronic postoperative endophthalmitis after cataract surgery. The subtle clinical signs of this infection and its initial favorable response to topical steroids may lead to delayed diagnosis and treatment. Two patients with culture proven P. acnes endophthalmitis after cataract surgery that presented with prominent pigmented keratic precipitates (KPs) and low-grade iritis in the involved eye were managed. Both cases had initial treatment with diagnostic pars plana vitrectomy (PPV) with intraocular antibiotic (IOAB) injection. Secondary treatment for recurrence was required in both patients. The KPs and iritis resolved after removal of intraocular lens (IOL) and capsular bag.

Resolution of Pigmented Keratic Precipitates Following Treatment of Pseudophakic Endophthalmitis Caused by Propionibacterium Acnes

From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Thomas Albini, MD, 900 NW 17 Street, Miami, FL 33136.

Accepted: July 24, 2009
Posted Online: March 09, 2010

Introduction

Propionibacterium acnes, an anaerobic, gram positive bacillus, is a frequent cause of chronic endophthalmitis after cataract surgery.1 The diagnosis of P. acnes endophthalmitis can be difficult, given the indolent low-grade uveitis with latent onset and initial response to topical steroids. A characteristic clinical feature in this infection is the presence of peripheral white plaques within the capsular bag that are composed of sequestered organisms. Other clinical signs may include conjunctival injection, vitritis, and keratic precipitates (KPs), often described as being white.5 Two patients are presented with P. acnes endophthalmitis. In addition to the usual signs, pigmented granulomatous KPs were present initially and resolved after pars plana vitrectomy (PPV), intraocular antibiotic (IOAB) injection, and intraocular lens (IOL) and capsular bag removal.

Case Reports

Case 1

A 69-year-old man with progressive, low-grade intraocular inflammation following cataract surgery had suspected chronic endophthalmitis. Initial treatment was vitreous tap and IOAB injection. Initial vitreous cultures were negative. The treatment course was complicated by rhegmatogenous retinal detachment occurring 1 month after YAG laser capsulotomy (Table 1). Because of persistent inflammation with pigmented granulomatous KPs, hypopyon, and dense vitritis (Fig. 1A), he underwent PPV, removal of IOL and capsular bag, and IOAB injection (Table 2). Microbiology demonstrated P. acnes from the capsular bag and vitreous. Intraocular inflammation and KPs resolved and vision improved to 20/25 (Fig. 1B; Table 2).

Baseline Data and Initial Treatment

Table 1: Baseline Data and Initial Treatment

(A) Conjunctival Injection, Hypopyon, and Pigmented Granulomatous KPs (Patient 1, Table 1). (B) Complete Resolution of KPs Following Successful Surgical Management (Patient 1, Table 2).

Figure 1. (A) Conjunctival Injection, Hypopyon, and Pigmented Granulomatous KPs (Patient 1, Table 1). (B) Complete Resolution of KPs Following Successful Surgical Management (Patient 1, Table 2).

Follow-Up Treatment

Table 2: Follow-Up Treatment

Case 2

An 85-year-old man with chronic anterior chamber inflammation, pigmented granulomatous KPs, and vitritis after cataract surgery had suspected P. acnes endophthalmitis (Figs. 2 and 3). He underwent diagnostic PPV with IOAB injection (Table 1), and the vitreous cultures were positive for P. acnes. Because the eye remained inflammed with persistent KPs, a second PPV, including IOL and capsular bag removal, with IOAB injection was performed. Intraocular inflammation and KPs resolved. However, the patient suffered an apositional choroidal hemorrhage postoperatively and visual acuity has remained hand motions (Table 2).

Pigmented Granulomatous KPs in Patient 2.

Figure 2. Pigmented Granulomatous KPs in Patient 2.

Pigmented Granulomatous KPs in Patient 2 Viewed with Retro-Illumination.

Figure 3. Pigmented Granulomatous KPs in Patient 2 Viewed with Retro-Illumination.

Discussion

P. acnes is a normal inhabitant of normal lids, conjunctiva, canaliculus, and cornea. The syndrome of indolent granulomatous uveitis weeks to months after extracapsular cataract surgery was described in 1986.2 Both patients in the current report had delayed onset of inflammation with initial favorable response to treatment with topical steroids. Both patients had diffuse pigmented granulomatous KPs. In both patients, inflammation persisted after the initial PPV and IOAB injection. Resolution of inflammation and KPs was achieved only after IOL and capsular bag removal.

The current study supports the findings of other investigators who have shown that complete eradication of the P. acnes endophthalmitis can be difficult in some patients without removal of the IOL and capsular bag.1,3,4 The emphasis of this report is the inclusion of chronic diffuse pigmented granulomatous KPs as a finding in P. acnes endophthalmitis and resolution of KPs as a sign of infection resolution. P. acnes endophthalmitis should be included in the differential diagnosis of chronic anterior segment inflammation with pigmented KPs following cataract surgery.

References

  1. 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;106:1665–1670. doi:10.1016/S0161-6420(99)90348-2 [CrossRef]
  2. Meisler DM, Palestine AG, Vastine DW, et al. Chronic Propinibacterium endophthalmitis after extracapsular cataract extraction and intraocular lens implantation. Am J Ophthalmol. 1986;102:733–739.
  3. Aldave AJ, Stein JD, Deramo VA, Shah GK, Fischer DH, Maguire JI. Treatment strategies for postoperative Propionibacterium acnes endophthalmitis. Ophthalmology. 1999;106:2395–2401. doi:10.1016/S0161-6420(99)90546-8 [CrossRef]
  4. Fox GM, Joondeph BC, Flynn HW Jr, et al. Delayed onset pseudophakic endophthalmitis. Am J Ophthalmol. 1991;111:163–173.

Baseline Data and Initial Treatment

Age/GenderTime From Cataract Surgery to Onset of SymptomsInitial Visual AcuityInitial ManagementComment
Case 169/male6 weeks20/60Tap + intravitreal vancomycin, ceftazidime, & dexamethasoneRetinal detachment
Case 285/male3 months20/50PPV + intravitreal vancomycinRecurrence

Follow-Up Treatment

Time to RecurrenceVA at RecurrenceTreatment for RecurrenceFinal VAFollow-up Duration After TreatmentComment
Case 13 months5/200PPV/removal of IOL/bag/intravitreal vancomycin/dexamethasone20/2512 monthsAphakia uses SCL
Case 26 weeks20/80PPV/removal of IOL/bag/Intravitreal vancomycinHM5 monthsSuprachoroidal hemorrhage
Authors

From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Thomas Albini, MD, 900 NW 17 Street, Miami, FL 33136.

10.3928/15428877-20100215-61

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