September 2018

CATARACT

Research highlight
When endophthalmitis continues to strike


by Maxine Lipner EyeWorld Senior Contributing Writer


Hypopyon and anterior chamber fibrinous reaction without significant conjunctival injection in an eye with recurrent Enterococcus faecalis endophthalmitis following cataract surgery
Source: Cynthia Chiu, MD

The case of recurring Enterococcus faecalis

Dealing with one endophthalmitis occurrence can be challenging enough, but what about multiple, bilateral reoccurrences of Enterococcus faecalis in an elderly patient? Such was the case that was reported in an issue of Retinal Cases and Brief Reports.1
Most cases of endophthalmitis are Staphylococcus epidermidis, which is skin flora, according to Cynthia Chiu, MD, FACS, professor of ophthalmology, University of California, San Francisco. Meanwhile, the Enterococcus species are a common—almost ubiquitous—gut flora, she noted.
The unusual case of Enterococcus faecalis endophthalmitis involved an elderly Asian man who was already aphakic in the left eye. “He had surgery decades ago when the procedure was to remove the whole lens capsule, and he never had an implant placed,” she said, adding that now he was 89 years old and wanted to be able to read. To enable this, Dr. Chiu discussed a secondary anterior chamber lens implant with the patient. “It turned out that after the procedure, one of the legs of the anterior chamber lens wasn’t positioned right and was rubbing on the iris and causing problems,” she said.
A few weeks later Dr. Chiu took the patient back and repositioned the lens. “He was doing great, then 6 weeks after the repositioning surgery he came in with a drop in vision and a hypopyon,” Dr. Chiu said. “He had his first episode of endophthalmitis.” Dr. Chiu’s colleague injected intravitreal antibiotics but after seeing him the next day, it became clear he wasn’t doing much better so a pars plana vitrectomy was performed and antibiotics injected again. “The patient recovered completely and got his vision back to 20/50, which is unusual,” Dr. Chiu said. “The culture grew Enterococcus, which shocked us because when people get Enterococcus endophthalmitis, their vision usually never recovers.” For this, Dr. Chiu credits her colleague who promptly took the patient to the operating room.

Multiple occurrences

Several years later, the elderly man returned to her with a cataract in his right eye. “We were cautious because this had already happened to one eye, so we delayed cataract surgery as much as we could,” Dr. Chiu said, adding that at some point they decided that the time had come. Unfortunately, they could not give him any intracameral antibiotics because at the University of California, San Francisco, they used cefuroxime and the patient was allergic to penicillin. “The surgery went well, and he did well the first day after surgery,” Dr. Chiu said. “Three days later, he came in at night with vision loss.” Once again, the eye that was infected had a hypopyon. The patient was given intravitreal antibiotics and a culture performed. “It grew out that same species of Enterococcus,” Dr. Chiu said. However, once again the intravitreal antibiotics proved insufficient. By postoperative day 5, he was taken to get a pars plana vitrectomy on the right eye. But even after the vitrectomy, in conjunction with multiple courses of intravitreal antibiotics, he kept having further episodes of endophthalmitis in that eye.
“He would recover for a few weeks, then it would come back,” Dr. Chiu said, adding that the patient came in with endophthalmitis again at weeks 10, 13, 17, and 21. Finally, the decision was made to get rid of both the implant and the capsule. Scanning electron microscopy showed the capsule was full of Enterococcus organisms, as well as macrophages that were eating the Enterococcus sequestered within it. “There was a reservoir inside the eye that was harboring the organisms, which is why it would clear up for awhile, then it would come back; the organism was protected within the lens capsule and the antibiotics could not get to it,” she said.
While that seemed to solve the problem for the right eye, suddenly the patient came in with a hypopyon in the left eye, which hadn’t been surgically touched for years. “Something was going on where he was auto-inoculating from inside the body,” Dr. Chiu said.

Unraveling the mystery

An immunology consultation determined he was immunosuppressed as a result of prior chronic lymphocytic leukemia and a history of rheumatoid arthritis, and he had spent more than a decade on prednisone. “He was elderly, and they found out that his lymphocyte count was very low,” Dr. Chiu said. “They put him on intravenous immunoglobulin treatment.” In addition, he was given a 6-week course of oral moxifloxacin.
Given the nature of the Enterococcus bacteria, which resides in the gut, Dr. Chiu had a heart-to-heart conversation with the patient. “I closed the door and I said, ‘After you use the bathroom, are you good about washing your hands?’” The patient confessed that he had not been washing his hands. Dr. Chiu stressed the importance of good hygiene in keeping endophthalmitis at bay.
Ultimately, the patient ended up with 20/50 corrected acuity in the right eye and 20/100 vision in the left. “That is extremely unusual because Enterococcus usually leaves patients with hand motions or light perception vision,” she said.
Dr. Chiu advises others in this situation to think about the lens capsule as a sequestrum of bacteria. She recommends looking for a systemic source of immunocompromise in such patients. It can also be important not to get hung up on endophthalmitis signs. “The classic teaching in endophthalmitis causes not only loss of vision but pain and redness,” Dr. Chiu said, adding that this patient had minimal redness and only came in saying his vision was somewhat different.
Dr. Chiu also noted that ultimately not all cases of Enterococcus endophthalmitis need to end up with a loss of vision. “But you have to be vigilant and aggressive in terms of trying to take these patients back to surgery, clearing out their vitreous,” she said. “I think because aggressive measures were taken and we saw him frequently given his history, we were able to catch these episodes and treat them promptly, which contributed to his good outcome.”

Reference

1. Aderman CM, et al. Bilateral Enterococcus faecalis endophthalmitis with multiple recurrences. Retin Cases Brief Rep. 2018. Epub ahead of print.

Editors’ note: Dr. Chiu has no financial interests related to her comments.

Contact information

Chiu
: Dr.cynthia.chiu@gmail.com

When endophthalmitis continues to strike When endophthalmitis continues to strike
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