July 2008

 

CATARACT/ IOL

 

Eliminating endophthalmitis


by Matt Young EyeWorld Contributing Editor

   

Technique involves aspirating endophthalmitis sequestered in the capsular bag

Two views of post-op endophthalmitis Source: Nick Mamalis, M.D.

Endophthalmitis is one of the most worrisome complications among cataract surgeons, but a new technique to test for—and then eliminate—the disease shows promise. The technique, proposed in the March/April 2008 issue of the Indian Journal of Ophthalmology, is recommended for endophthalmitis that has not yet spread to the vitreous, with pathogens sequestered in the capsular bag. “Chronic localized endophthalmitis (delayed onset endophthalmitis) is an important cause of chronic, recurrent inflammation in pseudophakic eyes caused by organisms sequestered between the intraocular lens (IOL) optic and posterior capsular bag of the equator,” according to lead study author Gopal Lingam, M.D., Vision Research Foundation, Chennai, India. The technique involves sampling the capsular bag material and aspirating it.

Case in point

Dr. Lingam examined a 64-year-old male six months after phacoemulsification. Four episodes of redness and pain began two months post-operatively. “According to the records, his vitreous was never involved,” Dr. Lingam wrote in the study. “Two anterior chamber taps done previously were negative on microbiological workup. The last aqueous tap was negative even on polymerase chain reaction (PCR) examination for Propionibacterium acnes genome and eubacterial genome.”

Still, six months post-operatively, his vision was 20/60 in the problematic eye. “There were keratic precipitates, aqueous flare, and cells,” Dr. Lingam reported. “The IOL was in situ, and there was no definitive plaque made out at the posterior capsule. At [the] 12 o‘clock meridian, some creamy material was suspected behind the anterior capsule.”

After dilating the patient’s pupil maximally using an operating microscope, Dr. Lingam inserted a 27-guage needle connected to a 2-ml syringe. It was inserted from the infero-temporal quandrant of the limbus. The anterior capsule was lifted delicately and the creamy material scraped. Under direct vision using the operating microscope, with maximum pupillary dilatation, a 27-gauge needle connected to a 2-ml syringe was introduced from the infero-temporal quadrant of the limbus under topical anesthesia. With the bevel of the needle facing forwards, the anterior capsule was lifted gently, and the creamy material was scraped.

This material was aspirated and subjected to smear and culture. “The smear showed plenty of gram-positive pleomorphic bacilli, which grew Propionibacterium acnes on Brucella blood agar, confirmed with PCR technique,” Dr. Lingam reported.

Clearly, this organism was the culprit of the patient’s condition. Vancomycin was then injected into the capsular bag and again after five days. “The infection was totally controlled, and he could be weaned off all the medications (moxifloxacin and prednisolone drops initially instilled eight times a day and tapered within one month),” Dr. Lingam wrote. “At the last examination one year after the intracapsular bag injection, his vision was 20/20, and the eye was quiet.”

As Dr. Lingam’s results were excellent, they could be extended to more endophthalmitis cases. The key appears to be catching the disease early and stopping the spread. Often, vitreous is not involved in the initial stages of endophthalmitis, Dr. Lingam noted. While this is good, it also means certain testing for endophthalmitis can lead surgeons to the wrong conclusion: That endophthalmitis is not present when, in fact, it is—it is simply sequestered within the capsular bag. “Even the aqueous tap can be negative for organisms—both by routine culture methods as well as PCR,” Dr. Lingam reported. “The technique described here aims at identifying the possible location of the organisms in the form of cheesy plaque-like colonies by careful slitlamp examination, followed by scraping of the sequestered organisms from the capsule or the equator with a needle tip before aspirating the material. We believe that the microbiological positivity can be substantially improved with this technique.”

Sure, it’s good to sequester endophthalmitis in the capsular bag if possible, but sometimes you just can’t, said Maged Habib, M.D., Boynton Beach, Fla.

Dr. Habib said he has experienced four cases of endophthalmitis, and one spread to the vitreous. In that case, the patient’s vision was reduced to only counting fingers as a result of retinal complications. But indeed, the three patients whose endophthalmitis was confined to the anterior chamber recovered perfectly. “That’s simply treated by removing the posterior capsule and washing whatever is there with antibiotics,” he said. However, he said, “By definition, endophthalmitis inflammation is of the entire globe, which means some is in the vitreous.” Propionibacterium acnes, however, can cause an exception in that the pathology can be sequestered oftentimes. “It’s not severely toxic,” he said. “Recovery usually is great.”

Editors’ note: Dr. Lingam has no financial interests related to this study. Dr. Habib has no financial interests related to his comments.

Contact Information

Habib: 561-742-1944, Habib1179@aol.com

Lingam: drlg@snmail.org

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