BILATERAL ENTEROCOCCUS FAECALIS ENDOPHTHALMITIS WITH MULTIPLE RECURRENCES.

PURPOSE: To describe the first case report of a bilateral recurrent Enterococcus faecalis endophthalmitis postcataract surgery. METHODS: Case report with a description of the timeline, diagnosis, and management of a patient with bilateral recurrent E. faecalis endophthalmitis. RESULTS: An 89-year-old man presented 6 weeks' postcataract surgery with pain, tearing, and blurred vision in the left eye. B-scan ultrasonography revealed vitritis and cultures postvitrectomy grew E. faecalis. There was gradual improvement in vision postintravitreal vancomycin administration. Four years later, the patient experienced another episode of E. faecalis endophthalmitis in the right eye postcataract extraction, followed by several additional episodes in both eyes posttreatment. CONCLUSION: Enterococcus faecalis is a rare but highly virulent cause of endophthalmitis that may remain sequestered in the capsular bag, despite aggressive treatment. Even after recurrent episodes, early vitrectomy and aggressive antibiotic therapy may prove to be effective in preventing vision loss.

Analysis of Intraocular Lens Biofilms and Fluids After Long-Term Uncomplicated Cataract Surgery.

PURPOSE: Postoperative endophthalmitis is a potentially sight-threatening complication of cataract surgery. However, the pathophysiological mechanisms are not completely understood. We sought to study and evaluate the intraocular environment (aqueous and vitreous humors), the capsular tissue, and the intraocular lens (IOL) surfaces of normal eyes after long-term uncomplicated cataract surgery. DESIGN: Experimental laboratory investigation. METHODS: We studied 69 eyes donated for transplantation that had previously undergone cataract surgery with posterior chamber IOL implantation and that had no recorded clinical history of postoperative inflammation. We assessed the intraocular environment (DNA traces and biofilm formation) by microbiological evaluation of intraocular fluids using conventional microbiology and molecular techniques, including assessment for the presence of microbes (biofilm formation) on the IOL surface by scanning electron microscopy and ultrastructural capsular remnants by transmission electron microscopy. RESULTS: Isolated or aggregated cocci were probable in 18.8% of IOL optic surfaces (n = 13) studied by scanning electron microscopy, suggesting the presence of bacterial biofilm. In 3 intraocular fluid samples for IOLs with biofilm, we identified 16S rDNA by polymerase chain reaction and sequencing. No microbial contamination was found in intraocular fluids by conventional microbiological methods. CONCLUSIONS: Our data suggest the possibility of bacterial biofilm formation on the optic surface of IOLs in normal eyes after long-term uncomplicated cataract surgery even in the absence of clinical or subclinical symptoms.

Propionibacterium acnes in capsular bag distension syndrome.

We report a case of capsular bag distension syndrome that developed 6 years after uneventful phacoemulsification with implantation of a foldable, single-piece acrylic intraocular lens (IOL) (AcrySof MA60BM). Slitlamp microscopy revealed a deep anterior chamber with no flare or cells. The posterior capsular bag was distended by a homogeneous milky substance between the back of the IOL and the capsular bag. Using a pars plana approach, a 23-gauge bimanual capsulotomy and anterior vitrectomy were performed. Microbiological analysis revealed Propionibacterium acnes in the material inside the capsular bag. The postoperative period was uneventful. Four weeks after surgery, visual acuity was restored and there were no signs of intraocular inflammation. The origin of late capsular bag distension is not fully understood; it may involve an infectious component with propionibacteria. A surgical approach and removal of the potentially infectious material can be considered as an alternative to neodymium:YAG capsulotomy.

Contribution of secreted proteases to the pathogenesis of postoperative Enterococcus faecalis endophthalmitis.

PURPOSE: To determine how a secreted protease contributes to the pathogenesis of post-cataract endophthalmitis caused by Enterococcus faecalis using an aphakic rabbit endophthalmitis model. SETTING: Department of Ophthalmology, Ehime University School of Medicine, Ehime, Japan. METHODS: The pathogenesis of E faecalis OG1S (secreted protease-positive) and E faecalis OG1X (secreted protease-negative derivative of OG1S) was compared. After lens removal by phacoemulsification, either strain was inoculated into the lens bag. Changes in bacterial growth, electroretinography (ERG), and pathology of eyes were comparatively monitored throughout the course of the infection. Alternatively, culture fluid from either strain was injected into the vitreous body and ERG and pathology of the eyes were also examined. RESULTS: The levels of growth in the anterior chamber and vitreous cavity were similar for both strains. However, infection with OG1S resulted in a significantly greater reduction in ERG b-wave amplitude than OG1X. Histological examination showed that the posterior lens capsules were severely affected in eyes infected with OG1S, and inflammatory cells and cocci were found in the anterior vitreous cavity 24 hours after the infection. By 48 hours, the retina architecture was profoundly affected in eyes infected with OG1S. In contrast, few pathological changes were noted in the posterior lens capsules and retina of eyes infected with OG1X. Culture fluid in which OG1S had grown decreased ERG b-wave amplitude and caused morphological changes of the posterior capsule and retina similar to those in the infected eye. CONCLUSION: An extracellular protease plays a major role in the pathogenesis of E faecalis-induced postoperative endophthalmitis.

A case of polymicrobial keratitis violating an intact lens capsule.

PURPOSE: To report a case of polymicrobial keratitis resistant to topical and intraocular antibiotics with recurrence after penetrating keratoplasty. METHODS: Case report. RESULTS: We report a case of polymicrobial keratitis caused by Phialophora verrucosa, Candida tropicalis, and Propionibacterium acnes. Initial treatment included topical vancomycin, tobramycin, amphotericin B, voriconazole, and oral fluconazole, as well as subconjunctival amphotericin B. Penetrating keratoplasty was performed, and the infection seemed to have resolved until 4 weeks after keratoplasty. A second penetrating keratoplasty was performed, followed by 4 weekly intracameral injections of voriconazole. Two weeks after the fourth intracameral injection, the infection manifested as an active anterior-chamber reaction. The patient's eye was subsequently enucleated. Histopathologic evaluation showed penetration of the crystalline lens by fungus at the site of synechiae between the intact lens capsule and iris. CONCLUSIONS: To our knowledge, this is the first documented case of a polymicrobial keratitis caused by a bacterium, yeast, and a fungus. It is the first histopathologic demonstration of fungal penetration of intact lens capsule from infected iris.

Endocapsular cellulomonas as a cause of persistent postoperative endophthalmitis.

Sequestration of bacteria within the capsular fornices after cataract extraction with intraocular lens implantation can cause both acute and chronic inflammation. A case of persistent postoperative endophthalmitis caused by capsular sequestration of Cellulomonas is described. The patient underwent uncomplicated cataract extraction with intraocular lens implantation and subsequently developed acute postoperative endophthalmitis. Inflammation persisted despite several vitreous taps and the injection of intravitreal antibiotics. Definitive treatment required pars plana vitrectomy, intraocular lens explantation, capsular bag removal, and intravitreal and parenteral antibiotics. In patients with postoperative endophthalmitis, one must consider atypical organisms as the source and should consider explantation of the intraocular lens with capsular bag removal.

Direct aspiration of capsular bag material in a case of sequestered endophthalmitis.

Chronic recurrent endophthalmitis can occur following uncomplicated cataract surgery with intraocular lens implantation secondary to organisms sequestered in the capsular bag. There is a need to identify these sequestered organisms to facilitate appropriate management. Frequently, specimens from the anterior chamber and vitreous cavity could be unyielding, especially in the early cases in which the vitreous is still uninvolved. This article highlights the technique of directly sampling the capsular bag material in the effective diagnosis of the organism, which facilitates the total cure by irrigation with appropriate antibiotics into the capsular bag.

Pathological findings in the lens capsules and intraocular lens in chronic pseudophakic endophthalmitis: an electron microscopy study.

PURPOSE: The aim of this study was to describe the pathological findings in lens capsules and intraocular lens (IOL) studied by scanning and/or transmission electron microscopy (SEM and TEM, respectively) in a series of four eyes with chronic pseudophakic endophthalmitis (CPE). PATIENTS AND METHODS: We performed a retrospective study of four patients presenting CPE in whom surgical treatment with pars plana vitrectomy, capsulectomy with extraction of the IOL, and intravitreous antibiotic therapy was thereafter performed. The extracted IOL and the capsular remains were studied by SEM and/or TEM and microbiologic analysis of aqueous humour and vitreous aspirate was also carried out in all the cases. RESULTS: The presence of microorganisms was observed in the material analysed in all the cases studied. The use of TEM identified bacterial contamination by Staphylococcus spp and mixed contamination with microorganisms presenting a bacillar morphology suggestive of infection by Propionibacterium acnes in addition to the presence of cocci in the capsular remains. In another two cases, SEM localized colonies of Staphylococcus spp on the surface of the IOL in one case and mixed bacterial colonization with cocci plus filamentous bacteria in the other. The presence of macrophages associated with bacteria was observed in the capsular remains. CONCLUSIONS: Microorganisms were found in the IOL or the capsular material in the four cases studied, thereby explaining the refractoriness and severity of infection. The possible presence of polymicrobial infections, especially in the cases with filamentous bacteria, also explains the recurrence of infection.

Staphylococcus hominis endophthalmitis associated with a capsular hypopyon.

PURPOSE: To report a case of Staphylococcus hominis endophthalmitis associated with a capsular hypopyon. DESIGN: Interventional case report. METHODS: A 51-year-old man presented with chronic postcataract extraction inflammation and underwent vitrectomy, partial capsulectomy, and intravitreal antibiotic injections, followed by explantation of the intraocular lens and capsule. RESULTS: A capsular hypopyon in the absence of an anterior chamber hypopyon was noted. Cultures of the vitreous and capsule revealed Staphylococcus hominis, a coagulase-negative gram-positive organism. CONCLUSIONS: We are unaware of previous reports of endophthalmitis caused by Staphylococcus hominis, and could find none in a computerized search using MEDLINE. This case adds Staphylococcus hominis to the list of causative organisms in chronic endophthalmitis and illustrates the rare finding of a capsular hypopyon.

Chronic postoperative endophthalmitis due to pseudomonas oryzihabitans.

PURPOSE: To report a case of chronic postoperative endophthalmitis caused by the gram-negative bacterium Pseudomonas oryzihabitans. DESIGN: Interventional case report. METHODS: A 77-year-old man was referred to our service for nonpainful uveitis in the right eye accompanied by increased intraocular pressure of 2 years' duration with onset 4 months after uncomplicated extracapsular cataract extraction and posterior chamber intraocular lens implantation. The uveitis partially responded to topical corticosteroid therapy but was recurrent with tapering of steroids. An anterior chamber tap and vitreous biopsies sent for cultures were negative. Owing to the persistence of inflammation despite intraocular vancomycin injection, the lens implant and capsule were removed and culture of the latter revealed the bacterium P. oryzihabitans. RESULTS: There was no recurrence of inflammation after removal of the lens implant and capsule. CONCLUSIONS: Unlike other gram-negative organisms, which are associated with poor outcomes, P. oryzihabitans may masquerade as chronic uveitis because of its low virulence.

[Enterococcal endophthalmitis following cataract surgery]. / Enterokokkenassoziierte Endophthalmitis nach Kataraktoperation.

BACKGROUND: Postoperative endophthalmitis can be subdivided into acute and chronic forms which are typically caused by different organisms. Enterococcus faecalis is an organism which normally causes an acute form of endophthalmitis. PATIENTS AND METHODS: We report on four cases of different forms of endophthalmitis following cataract extraction and intraocular lens (IOL) implantation who had been referred to our institution between 1998 and 2001. Enterococcus faecalis was the causative organism in all of them. RESULTS: Two patients presented with an acute form and were immediately treated in our hospital after symptom onset utilizing pars plana vitrectomy with and without IOL explantation. The two other patients were initially treated with subconjunctival and/or systemic antibiotics and steroids over a period of about two months before referral to our hospital. After initial improvement the inflammation exacerbated in these two patients and vitrectomy with or without IOL and capsular bag explantation was performed. The explanted IOL and capsular bag of one patient were examined using scanning electron microscopy and it was shown that the enterococci were adherent to the IOL and the capsular bag. CONCLUSION: Enterococcus faecalis can be the causative organism both of an acute and of a recurrent form of postoperative endophthalmitis. The recurrent form may be caused by organisms which tend to adhere to the IOL and the capsular bag. This should be kept in mind when considering different treatment options.

Optic disk edema as a presentation of Propionibacterium acnes endophthalmitis.

PURPOSE: To report a patient with an initial presentation of optic disk edema secondary to Propionibacterium acnes endophthalmitis. METHODS: Interventional case report. The patient had surgery and treatment related to endophthalmitis. Nine months after cataract surgery with posterior chamber lens implant, a 79-year-old man receiving topical corticosteroids in the same eye presented with best-corrected visual acuity of 20/60, a superior visual field defect, and optic nerve edema without intraocular inflammation. One year postoperatively, the eye presented a further decrease in best-corrected visual acuity, and a dense white plaque was noted on the posterior capsule. RESULTS: One year postoperatively, a partial capsulectomy with vitrectomy and injection of intravitreal antibiotics was performed. Hematoxylin and eosin stain of the posterior capsule plaque revealed gram-positive coccobacilli characteristic of P. acnes. CONCLUSION: Propionibacterium acnes endophthalmitis may present after cataract surgery with intraocular lens implant with decreased vision, optic disk edema, and a visual field defect.

Bacillus circulans endophthalmitis.

An 80-year-old woman presented with right endophthalmitis, characterized by chalky white deposits covering her posterior capsule. This occurred 17 months after uncomplicated right cataract surgery. A three-port pars plana vitrectomy and partial posterior capsulectomy isolated Bacillus circulans, and the patient made a rapid and full recovery on topical cephalothin and prednisolone acetate 1%. The case demonstrates that, unlike endophthalmitis due to other Bacillus spp., B. circulans endophthalmitis does not necessarily follow a fulminant course. It is the first report describing a subacute presentation, and response to posterior capsulectomy and simple antibiotic therapy It is also the first description of B. circulans causing white plaques in the posterior capsule, a finding characteristic of chronic endophthalmitis and previously considered pathognomonic of Proprionibacterium acnes endophthalmitis.

Nocardia endophthalmitis following uncomplicated phacoemulsification and implantation of a posterior chamber intraocular lens.

A patient developed endophthalmitis 15 days after uncomplicated cataract extraction. Excised infectious material sequestered in the capsular bag revealed Nocardia on culture. She required multiple intravitreal injections of Amikacin and dexamethasone, pars plana vitrectomies with explantation of the lens, and chronic topical and oral sulfonamide antibiotics to control the infection. Clinicians should also consider Nocardia when the suspicion of fungal endophthalmitis is entertained, as Nocardia are resistant to antifungals, but respond to intravitreal amikacin and chronic topical and oral sulfonamides.

Postoperative endophthalmitis caused by sequestered Acinetobacter calcoaceticus.

PURPOSE: To describe postoperative endophthalmitis caused by sequestered Acinetobacter calcoaceticus. METHOD: Case report. A 40-year-old woman developed recurrence of inflammation after extracapsular cataract extraction with intraocular lens (IOL) implantation. At last recurrence, the capsular bag was studded with white deposits. Intraocular lens was removed along with capsular bag during pars plana vitrectomy. RESULTS: The capsular bag, when cultured, grew A calcoaceticus. The media remained clear with no evidence of recurrence of infection over a 3-month follow-up. CONCLUSION: Postoperative endophthalmitis similar to that caused by sequestered Propionibacterium acnes can be caused by A calcoaceticus.

Recurrent enterococcal endophthalmitis following cataract surgery: a case report.

Recurrent post-cataract endophthalmitis is a well-recognized postoperative complication that has been attributed to various organisms and different mechanisms. To our knowledge, there is no case of recurrent postoperative endophthalmitis reported where the organism was found to be sequestered in the posterior capsule, escaping total eradication and thus producing the recurrence. The following is a case report of such recurrent postoperative endophthalmitis caused by Enterococcus faecalis sequestered in the posterior capsule.

Ocular manifestations of Whipple disease: an atypical presentation.

A 62-year-old man developed bilateral granulomatous iridocyclitis after uncomplicated cataract surgery. On ophthalmic examination, we found moderate inflammation in the anterior chamber and vitreous, with granular crystalline deposits on the iris, intraocular lens, and capsular bag. Biopsy of the lens capsule and vitreous revealed periodic acid-Schiff-positive, diastase-resistant bacilli consistent with Tropheryma whippelii. Electron microscopy and polymerase chain reaction confirmed the diagnosis of Whipple disease. A jejunal biopsy specimen also revealed T whippelii. Treatment with trimethoprim-sulfamethoxazole, cefixime, rifampin, and doxycycline resulted in improvement of systemic symptoms, but intraocular inflammation persisted. Intraocular inflammation was eventually reduced with the intravenous administration of ceftriaxone sodium.

Pathological findings in lens capsule and silicone intraocular lens extracted from eye with chronic infectious endophthalmitis.

The lens capsule and silicone intraocular lens (IOL) extracted from the eye of a patient with chronic infectious endophthalmitis was examined histopathologically to evaluate the pathology of a capsule and IOL surfaces in the presence of bacterial infection. A 69-year-old man developed an infection in his right eye 4 months after phacoemulsification and aspiration of a cataract and implantation of a silicone IOL. During vitrectomy, the capsule and IOL were extracted and processed for light or scanning electron microscopy. Cryosections of the capsule were subjected to Gram staining and immunohistochemical tests for extracellular matrix components. The lens capsule contained an accumulation of extracellular matrix, including collagen types and fibronectin. A colony of Gram-positive rod bacteria was detected inside the capsular bag. Scanning electron microscopy failed to detect any microorganisms on the IOL surface. Histological examination of cryosections of the extracted capsule confirmed the presence of infection during surgery even though preoperative cultures of intraocular fluid were negative. Immediate antibacterial treatment could be initiated.