RECURRENT PSEUDOMONAS AERUGINOSA ENDOPHTHALMITIS Seema Gupta, MD, Geoffrey G. Emerson, MD, PhD, Christina J. Flaxel, MD
Purpose: To report a case of recurrent endophthalmitis resulting from Pseudomonas aeruginosa requiring removal of the intraocular lens and lens capsule to eradicate the infection. Methods: Evaluation for management of presumed endophthalmitis after uneventful cataract surgery with intraocular lens implantation. Results: Eventual resolution of P. aeruginosa intraocular infection after pars plana vitrectomy 3 times and removal of the intraocular lens and lens capsule with final visual acuity of 20/30. Conclusion: P. aeruginosa is an aggressive organism that often presents in a fulminant manner, requiring vitrectomy and repeated injections of intravitreal antibiotics. Rarely, the organism can be harbored in the lens capsule, requiring intraocular lens explantation and capsule removal for complete eradication and best visual recovery. RETINAL CASES & BRIEF REPORTS 4:11–13, 2010
From the Casey Eye Institute, Oregon Health & Science University, Portland, Oregon. Dr. Emerson is now in private practice in St. Paul, Minnesota.
Recurrent endophthalmitis is even less common. To our knowledge, only two cases of recurrent endophthalmitis caused by P. aeruginosa have been previously reported.2,3 We report an unusual case of postoperative recurrent endophthalmitis resulting from P. aeruginosa.
P
ostoperative endophthalmitis is an uncommon but potentially devastating complication of modern cataract surgery that often results in severe visual loss. Infectious endophthalmitis is most commonly caused by Gram-positive bacteria; however, in larger reported series, Gram-negative organisms have been isolated in 6% to 29% of cases.1 Pseudomonas aeruginosa is a Gram-negative rod that has frequently been associated with nosocomial infections involving multiple organ systems with the most common ocular manifestation being keratitis. To date, the largest reported case series of P. aeruginosa endophthalmitis is from the Bascom Palmer Eye Institute. The authors report an association of the infection with poor visual outcome despite prompt treatment with intravitreal antibiotics to which the organisms are sensitive.1
Case Report An 80-year-old man was referred to the retina service at Casey Eye Institute 2 days after uncomplicated cataract extraction and intraocular lens (IOL) implantation in the right eye. He was referred for diagnosis and management of presumed endophthalmitis. On the day of presentation, visual acuity measured hand motion and tension measured 15 mmHg in the right eye. Examination demonstrated ecchymotic lids, hyperemic conjunctiva, cloudy cornea, and 4-mm hypopyon in the anterior chamber with a hazy view of the iris and the posterior chamber IOL. The right fundus could not be visualized. Examination of the left eye anterior segment and fundus was within normal limits with a mild nuclear sclerotic lens opacity. B-scan ultrasound of the right eye demonstrated mild intravitreal opacities and a small superotemporal serous choroidal detachment with an attached retina and no definite choroidal thickening. Vitreous tap was performed with intravitreal injection of 1 mg vancomycin and 2.25 mg ceftazidime. Hourly moxifloxacin therapy was begun immediately, and when the clinical picture appeared slightly improved the next day with retraction of the hypopyon, hourly prednisolone acetate therapy was added. Gram stain demonstrated no epithelial cells and many polymorphonuclear leukocytes. Vitreous culture grew P. aeruginosa that was sensitive to all antibiotics except trimethoprim/sulfamethoxazole.
Supported, in part, by an unrestricted grant to Casey Eye Institute from Research to Prevent Blindness, New York, New York. No authors have any proprietary interest in materials discussed herein. Reprint requests: Christina J. Flaxel, MD, 3375 SW Terwilliger Blvd., Portland, OR 97239-4197; e-mail: [email protected]
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Fig. 1. Right eye of an 80-year-old man with postoperative endophthalmitis 6 weeks after cataract surgery and lens implantation and 4 days after pars plana vitrectomy. Vitreous aspirate and pupillary membrane grew Pseudomonas aeruginosa.
Two weeks after administration of intravitreal antibiotics, the patient was comfortable; his visual acuity remained hand motion. Examination showed persistent inflammation and fibrin. A posterior subtenon’s injection of 40 mg triamcinolone acetanide was given. The patient initially did well, and inflammation decreased. However, he returned to the clinic 3.5 weeks after steroid injection (5.5 weeks after cataract surgery) with a 1-day history of pain and vision reduced to light perception. Examination disclosed recurrent hypopyon and fibrin in the anterior chamber. The posterior chamber IOL was obscured by a pupillary membrane. B-scan ultrasound showed an increase in both vitreous and subvitreous debris with unchanged choroidal elevation in the superotemporal quadrant. The retina and choroid were otherwise intact. Recurrent endophthalmitis was presumed and the patient underwent pars plana vitrectomy, anterior chamber washout with pupillary membranectomy, and injection of intravitreal 1 mg vancomycin and 2.25 mg ceftazidime. Vitreous aspirate and pupillary membrane again grew P. aeruginosa with the same sensitivities as the original isolate. The patient received a repeat injection of 2.25 mg ceftazidime 3 days after these procedures as a result of the positive vitreous culture results. Four days after vitrectomy (6 weeks after cataract surgery), his visual acuity had returned to hand motion. Intraocular pressure remained low at 4 mmHg (Figure 1). Recurrent fibrin plaque on the posterior surface of the IOL prompted a repeat pars plana vitrectomy, IOL explantation with capsulectomy, and intravitreal injection of 200 g amikacin. Culture of the vitreous aspirate from this surgery was negative; however, the lens capsule grew P. aeruginosa with the same sensitivities as the original isolate. The eye remained hypotonous and, as a result of concern for progressive phthisis, the patient underwent a third pars plana vitrectomy with silicone oil tamponade and injection of 2 mg intravitreal ceftazidime and 200 g amikacin. Vitreous aspirate cultures were negative (Figure 2A–B). After these procedures, the condition of the eye remained stable, with resolution of all inflammation. The patient underwent removal of silicone oil and implantation of an anterior chamber IOL. Sixteen months after the initial cataract surgery, his visual acuity is 20/30. The results of examination are within normal limits, and there is no evidence of inflammation.
Fig. 2. (a) Right eye of an 80-year-old man after second and third pars plana vitrectomies for recurrent endophthalmitis. Vitreous aspirate cultures were negative after the third vitrectomy. (b) Fundus photograph of right eye of an 80-year-old man (same date as Figure 2a), before silicone oil removal showing attached retina and normal vascular appearance. The blurriness of the photograph is the result of the presence of retained silicone oil.
Discussion Recurrent endophthalmitis has previously been described by Stern et al.2 The authors describe 5 cases of recurrent endophthalmitis occurring 10 to 21 days after initial intravitreal antibiotic injections. One of these five cases was the result of P. aeruginosa. The authors conclude that Gram-negative bacillus infection is a risk factor for recurrent infection. Our case is similar to this in the initial recurrence; however, the patient in the previously reported case was treated successfully by vitrectomy and repeat antibiotic injection, whereas in our case, the patient required removal of the IOL and lens capsule to eradicate the infection. Fong and Pesavento3 reported one case of Pseudomonas causing subacute inflammation in a patient after surgery, but in that case, the infection subsided after a single intravitreal antibiotic injection. The largest reported series of Pseudomonas endophthalmitis is from
13
RECURRENT PSEUDOMONAS ENDOPHTHALMITIS
Eifrig et al.1 These authors report 28 cases with no cases of recurrence. In this series, visual outcomes were generally poor, with 19 of the 28 patients having final visual acuity of no light perception and only 2 patients having 5/200 or better visual acuity.1 The authors conclude that despite prompt treatment with intraocular antibiotics to which the organism is sensitive, endophthalmitis resulting from P. aeruginosa resulted in poor visual outcomes.1 The Endophthalmitis Vitrectomy Study reported only 4 of 420 confirmed cases of P. aeruginosa endophthalmitis and no recurrent cases. Three of these 4 patients in these cases had final visual acuity of less than 5/200.4 We are not aware of any previously reported cases in which P. aeruginosa has recurred and subsequently been isolated from the IOL and lens capsule. Microorganisms have been found on IOLs and within capsular material in eyes with chronic pseudophakic endophthalmitis.5 This finding explains the severity and the refractory nature of infection in the cases studied. However, these were all cases of low-virulence organisms, and patients presented with low-grade inflammation that had been present for longer than 6 months in most cases. In our case, the patient presented with fulminant disease on the second presentation, which was within 6 weeks of his initial cataract surgery. Like in these cases, P. aeruginosa grew from the lens capsule. After IOL explantation and capsulectomy, our patient’s disease subsided. It is likely that the organism was sequestered in the lens capsule, which served as a nidus of infection, leading to recurrence, as noted in the case series by Adan et al.5 The P. aeruginosa isolated from our case was sensitive to all the antibiotics tested other than trimethoprim/sulfamethoxazole. It is possible that this was a less virulent strain of P. aeruginosa; however,
the majority of the organisms in the series by Eifrig et al were also sensitive to all antibiotics tested and there were no cases in their series that recurred or in which patients required IOL explantation. It is also not likely in our case that there was significant sequestration around the IOL, because ultrasound biomicroscopy was done at the time of the first disease recurrence. The results of ultrasound testing showed no evidence of debris around the IOL or in the capsular bag. It seems more likely that the organism was not cleared completely by the initial intravitreal antibiotic injection and was thus subsequently sequestered around the IOL. In summary, a high level of suspicion should be maintained in cases of presumed typical endophthalmitis when patients present with recurrent hypopyon, increased pain, or further visual loss. These may be signs of recurrent endophthalmitis, which could require aggressive management to prevent phthisis. Key words: endophthalmitis, IOL explantation, Pseudomonas aeruginosa, recurrent pars plana vitrectomy. References 1. 2. 3.
4.
5.
Eifrig C, Scott I, Flynn H, Miller D. Endophthalmitis caused by Pseudomonas aeruginosa. Ophthalmology 2003;110:1714–1717. Stern G, Engel H, Driebe W. Recurrent postoperative endophthalmitis. Cornea 1990;9:102–107. Fong D, Pesavento R. Pseudomonas endophthalmitis presenting as subacute inflammation. Arch Ophthalmol 1995;113: 265. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995;113:1479 –1496. Adan A, Casaroli-Marano RP, Gris O, et al. Pathological findings in the lens capsules and intraocular lens in chronic pseudophakic endophthalmitis. Eye 2008;22:113–119.
Purpose: To report a case of recurrent endophthalmitis resulting from Pseudomonas aeruginosa requiring removal of the intraocular lens and lens capsule to eradicate the infection. Methods: Evaluation for management of presumed endophthalmitis after uneventful cataract surgery with intraocular lens implantation. Results: Eventual resolution of P. aeruginosa intraocular infection after pars plana vitrectomy 3 times and removal of the intraocular lens and lens capsule with final visual acuity of 20/30. Conclusion: P. aeruginosa is an aggressive organism that often presents in a fulminant manner, requiring vitrectomy and repeated injections of intravitreal antibiotics. Rarely, the organism can be harbored in the lens capsule, requiring intraocular lens explantation and capsule removal for complete eradication and best visual recovery. RETINAL CASES & BRIEF REPORTS 4:11–13, 2010
From the Casey Eye Institute, Oregon Health & Science University, Portland, Oregon. Dr. Emerson is now in private practice in St. Paul, Minnesota.
Recurrent endophthalmitis is even less common. To our knowledge, only two cases of recurrent endophthalmitis caused by P. aeruginosa have been previously reported.2,3 We report an unusual case of postoperative recurrent endophthalmitis resulting from P. aeruginosa.
P
ostoperative endophthalmitis is an uncommon but potentially devastating complication of modern cataract surgery that often results in severe visual loss. Infectious endophthalmitis is most commonly caused by Gram-positive bacteria; however, in larger reported series, Gram-negative organisms have been isolated in 6% to 29% of cases.1 Pseudomonas aeruginosa is a Gram-negative rod that has frequently been associated with nosocomial infections involving multiple organ systems with the most common ocular manifestation being keratitis. To date, the largest reported case series of P. aeruginosa endophthalmitis is from the Bascom Palmer Eye Institute. The authors report an association of the infection with poor visual outcome despite prompt treatment with intravitreal antibiotics to which the organisms are sensitive.1
Case Report An 80-year-old man was referred to the retina service at Casey Eye Institute 2 days after uncomplicated cataract extraction and intraocular lens (IOL) implantation in the right eye. He was referred for diagnosis and management of presumed endophthalmitis. On the day of presentation, visual acuity measured hand motion and tension measured 15 mmHg in the right eye. Examination demonstrated ecchymotic lids, hyperemic conjunctiva, cloudy cornea, and 4-mm hypopyon in the anterior chamber with a hazy view of the iris and the posterior chamber IOL. The right fundus could not be visualized. Examination of the left eye anterior segment and fundus was within normal limits with a mild nuclear sclerotic lens opacity. B-scan ultrasound of the right eye demonstrated mild intravitreal opacities and a small superotemporal serous choroidal detachment with an attached retina and no definite choroidal thickening. Vitreous tap was performed with intravitreal injection of 1 mg vancomycin and 2.25 mg ceftazidime. Hourly moxifloxacin therapy was begun immediately, and when the clinical picture appeared slightly improved the next day with retraction of the hypopyon, hourly prednisolone acetate therapy was added. Gram stain demonstrated no epithelial cells and many polymorphonuclear leukocytes. Vitreous culture grew P. aeruginosa that was sensitive to all antibiotics except trimethoprim/sulfamethoxazole.
Supported, in part, by an unrestricted grant to Casey Eye Institute from Research to Prevent Blindness, New York, New York. No authors have any proprietary interest in materials discussed herein. Reprint requests: Christina J. Flaxel, MD, 3375 SW Terwilliger Blvd., Portland, OR 97239-4197; e-mail: [email protected]
11
12
RETINAL CASES & BRIEF REPORTSℜ
●
2010
●
VOLUME 4
●
NUMBER 1
Fig. 1. Right eye of an 80-year-old man with postoperative endophthalmitis 6 weeks after cataract surgery and lens implantation and 4 days after pars plana vitrectomy. Vitreous aspirate and pupillary membrane grew Pseudomonas aeruginosa.
Two weeks after administration of intravitreal antibiotics, the patient was comfortable; his visual acuity remained hand motion. Examination showed persistent inflammation and fibrin. A posterior subtenon’s injection of 40 mg triamcinolone acetanide was given. The patient initially did well, and inflammation decreased. However, he returned to the clinic 3.5 weeks after steroid injection (5.5 weeks after cataract surgery) with a 1-day history of pain and vision reduced to light perception. Examination disclosed recurrent hypopyon and fibrin in the anterior chamber. The posterior chamber IOL was obscured by a pupillary membrane. B-scan ultrasound showed an increase in both vitreous and subvitreous debris with unchanged choroidal elevation in the superotemporal quadrant. The retina and choroid were otherwise intact. Recurrent endophthalmitis was presumed and the patient underwent pars plana vitrectomy, anterior chamber washout with pupillary membranectomy, and injection of intravitreal 1 mg vancomycin and 2.25 mg ceftazidime. Vitreous aspirate and pupillary membrane again grew P. aeruginosa with the same sensitivities as the original isolate. The patient received a repeat injection of 2.25 mg ceftazidime 3 days after these procedures as a result of the positive vitreous culture results. Four days after vitrectomy (6 weeks after cataract surgery), his visual acuity had returned to hand motion. Intraocular pressure remained low at 4 mmHg (Figure 1). Recurrent fibrin plaque on the posterior surface of the IOL prompted a repeat pars plana vitrectomy, IOL explantation with capsulectomy, and intravitreal injection of 200 g amikacin. Culture of the vitreous aspirate from this surgery was negative; however, the lens capsule grew P. aeruginosa with the same sensitivities as the original isolate. The eye remained hypotonous and, as a result of concern for progressive phthisis, the patient underwent a third pars plana vitrectomy with silicone oil tamponade and injection of 2 mg intravitreal ceftazidime and 200 g amikacin. Vitreous aspirate cultures were negative (Figure 2A–B). After these procedures, the condition of the eye remained stable, with resolution of all inflammation. The patient underwent removal of silicone oil and implantation of an anterior chamber IOL. Sixteen months after the initial cataract surgery, his visual acuity is 20/30. The results of examination are within normal limits, and there is no evidence of inflammation.
Fig. 2. (a) Right eye of an 80-year-old man after second and third pars plana vitrectomies for recurrent endophthalmitis. Vitreous aspirate cultures were negative after the third vitrectomy. (b) Fundus photograph of right eye of an 80-year-old man (same date as Figure 2a), before silicone oil removal showing attached retina and normal vascular appearance. The blurriness of the photograph is the result of the presence of retained silicone oil.
Discussion Recurrent endophthalmitis has previously been described by Stern et al.2 The authors describe 5 cases of recurrent endophthalmitis occurring 10 to 21 days after initial intravitreal antibiotic injections. One of these five cases was the result of P. aeruginosa. The authors conclude that Gram-negative bacillus infection is a risk factor for recurrent infection. Our case is similar to this in the initial recurrence; however, the patient in the previously reported case was treated successfully by vitrectomy and repeat antibiotic injection, whereas in our case, the patient required removal of the IOL and lens capsule to eradicate the infection. Fong and Pesavento3 reported one case of Pseudomonas causing subacute inflammation in a patient after surgery, but in that case, the infection subsided after a single intravitreal antibiotic injection. The largest reported series of Pseudomonas endophthalmitis is from
13
RECURRENT PSEUDOMONAS ENDOPHTHALMITIS
Eifrig et al.1 These authors report 28 cases with no cases of recurrence. In this series, visual outcomes were generally poor, with 19 of the 28 patients having final visual acuity of no light perception and only 2 patients having 5/200 or better visual acuity.1 The authors conclude that despite prompt treatment with intraocular antibiotics to which the organism is sensitive, endophthalmitis resulting from P. aeruginosa resulted in poor visual outcomes.1 The Endophthalmitis Vitrectomy Study reported only 4 of 420 confirmed cases of P. aeruginosa endophthalmitis and no recurrent cases. Three of these 4 patients in these cases had final visual acuity of less than 5/200.4 We are not aware of any previously reported cases in which P. aeruginosa has recurred and subsequently been isolated from the IOL and lens capsule. Microorganisms have been found on IOLs and within capsular material in eyes with chronic pseudophakic endophthalmitis.5 This finding explains the severity and the refractory nature of infection in the cases studied. However, these were all cases of low-virulence organisms, and patients presented with low-grade inflammation that had been present for longer than 6 months in most cases. In our case, the patient presented with fulminant disease on the second presentation, which was within 6 weeks of his initial cataract surgery. Like in these cases, P. aeruginosa grew from the lens capsule. After IOL explantation and capsulectomy, our patient’s disease subsided. It is likely that the organism was sequestered in the lens capsule, which served as a nidus of infection, leading to recurrence, as noted in the case series by Adan et al.5 The P. aeruginosa isolated from our case was sensitive to all the antibiotics tested other than trimethoprim/sulfamethoxazole. It is possible that this was a less virulent strain of P. aeruginosa; however,
the majority of the organisms in the series by Eifrig et al were also sensitive to all antibiotics tested and there were no cases in their series that recurred or in which patients required IOL explantation. It is also not likely in our case that there was significant sequestration around the IOL, because ultrasound biomicroscopy was done at the time of the first disease recurrence. The results of ultrasound testing showed no evidence of debris around the IOL or in the capsular bag. It seems more likely that the organism was not cleared completely by the initial intravitreal antibiotic injection and was thus subsequently sequestered around the IOL. In summary, a high level of suspicion should be maintained in cases of presumed typical endophthalmitis when patients present with recurrent hypopyon, increased pain, or further visual loss. These may be signs of recurrent endophthalmitis, which could require aggressive management to prevent phthisis. Key words: endophthalmitis, IOL explantation, Pseudomonas aeruginosa, recurrent pars plana vitrectomy. References 1. 2. 3.
4.
5.
Eifrig C, Scott I, Flynn H, Miller D. Endophthalmitis caused by Pseudomonas aeruginosa. Ophthalmology 2003;110:1714–1717. Stern G, Engel H, Driebe W. Recurrent postoperative endophthalmitis. Cornea 1990;9:102–107. Fong D, Pesavento R. Pseudomonas endophthalmitis presenting as subacute inflammation. Arch Ophthalmol 1995;113: 265. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995;113:1479 –1496. Adan A, Casaroli-Marano RP, Gris O, et al. Pathological findings in the lens capsules and intraocular lens in chronic pseudophakic endophthalmitis. Eye 2008;22:113–119.
