Journal of Ophthalmic Diseases

Chronic Post-operative Endophthalmitis due to Propionibacterium Acnes

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Published Date: March 24, 2016

Chronic Post-operative Endophthalmitis due to Propionibacterium Acnes

Asaf Achiron1,2* and Mohamad Midlij1,2

1Department of Ophthalmology, The Edith Wolfson Medical Center, Holon, Israel

2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

*Corresponding authorAsaf Achiron, MD, Department of Ophthalmology, The Edith Wolfson Medical Center, Holon, Israel, 58100, Tel: +972-3-5028706, Fax: +972-3-5028703; E-mail: AchironAsaf@gmail.com

Citation: Achiron A, Midlij M (2016) Chronic Post-operative Endophthalmitis due to Propionibacterium acnes. J Ophth Dis 1(1): 104.

 

An 82-year-old female presented with a four month history of left eye glare and visual acuity disturbance. History included dyslipidemia and hypertension. The patient’s ocular history included left eye open angle glaucoma, which was diagnosed about three years earlier; she had undergone bilateral cataract removal ten years earlier.

Upon examination we observed left eye hyperemic conjunctiva, disperse white keratic precipitates (KP) with cells in the anterior chamber, and sparkling posterior capsule opacification behind the artificial intraocular lens (Figure 1).

 

Figure 1: Through the pupil, we notice the white opacifications on the posterior capsule behind the intraocular lens. These white plaques can appear as a manifestation of chronic endophthalmitis due to Propionibacterium Acnes. They contribute to the decrease in visual acuity.

 

These findings (the insidious onset anterior uveitis and the posterior capsule’s appearance) are suggestive of chronic post-operative endophthalmitis (CPE) caused by Propionibacterium acnes (P. acnes). The patient subsequently underwent vitreous tap (which was negative), received an empirical therapy with intra-vitreal injections of Vancomycin and Ceftazidime and was released with ocular steroidal drops and PO Ciproxin. During the follow-up we noted improved visual acuity (from counting fingers to 6/45) and decreased opacity of the capsule (Figure 2).

 

Figure 2: Notice the decreased posterior capsule opacifications, after injections of Vancomycin and Ceftazidime.

 

The reported incidence rate of CPE is up to 5 per 10000, with more than half of the CPE cases are caused by P. ances [1]. P. ances is a gram positive, pleomorphic anaerobic bacillus that is normally found on the eyelid skin, the conjunctiva and ocular surfaces, oral cavity, intestinal tract, and external ear canal. It is associated with chronic inflammation and contamination of various prosthetic devices, which include intra-ocular lens (IOL) (Figure 3), neurosurgical implants, breast implants, cardiovascular devices, and spine implants [2].

 

Figure 3: Each bacterium is attached by biofilm-like material to other bacteria and the IOL haptic, with permission from [5]

 

The remarkable adherence of P. ances to prosthetic devices is due to its ability to tolerate exposure of oxygen level for several hours, and in vitro, P. ances can survive under anaerobic conditions for up to eight months [2]. The presence of white plaques on the posterior capsule or on the IOL is a characteristic finding for P. ances endophthalmitis [3].

The diagnosis of CPE is confirmed by obtaining bacterial and fungal cultures of the aqueous, capsular plaques, or vitreous. Gram and Giemsa stains of undiluted specimens, capsular plaques and vitreous snowballs should also be obtained [4]. The localized nature of P. ances inside the capsular bag may lead to a vitreous sampling that fails to detect the organism; advanced polymerase chain reaction (PCR) techniques may be employed to enhance the identification rate of P. ances in vitreous samples with specific primers. Hykinet al. had succeeded to detect fragments of P. ances DNA in vitreous sample of three patients that had clinical presentations of CPE due to P. ances while their cultures were negative [5]. In addition, direct capsule bag biopsy and fluid sampling may increase detection rates of P. acnes. Pars Plana vitrectomy and injection of intravitreal and endocapsular Vancomycin may be therapeutic in more complicated cases. In refractory cases with recurrent inflammation, vitrectomy with total capsular bag removal, intraocular Vancomycin injection, and IOL exchange or removal should be taken into consideration [6]. Figure 4 summarize a stepladder approach or treating chronic endophthalmitis due to P. acnes.

 

Figure 4: Step wise approach to treatment of suspected CPE due to P. acnes. PPV-pars plana vitrectomy; Inj-injection of Vancomycin

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References

 

  1. Maalouf F1, Abdulaal M, Hamam RN. Chronic Postoperative Endophthalmitis: A Review of Clinical Characteristics, Microbiology, Treatment Strategies, and Outcomes. Int J Inflam. 2012;2012:313248. doi: 10.1155/2012/313248.
  2. Portillo ME1, Corvec S, Borens O, Trampuz A. Propionibacterium acnes: An Underestimated Pathogen in Implant-Associated Infections. Biomed Res Int. 2013: 804391. doi:10.1155/2013/804391
  3. Basic and Clinical Science Course (BCSC). Retina and Vitreous. Section 12, 2014-2015 American Academy of Ophthalmology; pp. 356.
  4. Basic and Clinical Science Course (BCSC). Intraocular Inflammation and Uveitis. Section 9, 2014-2015. American Academy of Ophthalmology; pp. 269-272.
  5. Hykin PG, Tobal K, McIntyre G, Matheson MM, Towler HM, Lightman SL. The diagnosis of delayed post-operative endophthalmitis by polymerase chain reaction of bacterial DNA in vitreous samples. J Med Microbiol. 1994 Jun;40(6):408-15.
  6. Hayashi Y, Eguchi H, Miyamoto T, Inoue M, Mitamura Y. A Case of Delayed-Onset Propionibacterium acnes Endophthalmitis after Cataract Surgery with Implantation of a Preloaded Intraocular Lens. Case Rep Ophthalmol. 2012 Sep;3(3):291-7. doi: 10.1159/000342460.

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Copyright: © 2016 Achiron A, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.