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BRIEF REPORT
Year : 2000  |  Volume : 48  |  Issue : 1  |  Page : 50-2

Micrococcal endophthalmitis following extracapsular cataract extraction with foldable silicone intraocular lens implantation


Medical and Vision Research Foundation, 18 College Road, Chennai-600 006, India

Correspondence Address:
R Fogla
Medical and Vision Research Foundation, 18 College Road, Chennai-600 006
India
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Source of Support: None, Conflict of Interest: None


PMID: 11271937

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Keywords: Adult, Antibiotics, Combined, therapeutic use, Drug Therapy, Combination, Endophthalmitis, drug therapy, microbiology, Eye Infections, Bacterial, drug therapy, microbiology, Female,


How to cite this article:
Fogla R, Biswas J, Parikh S, Madhavan H N. Micrococcal endophthalmitis following extracapsular cataract extraction with foldable silicone intraocular lens implantation. Indian J Ophthalmol 2000;48:50

How to cite this URL:
Fogla R, Biswas J, Parikh S, Madhavan H N. Micrococcal endophthalmitis following extracapsular cataract extraction with foldable silicone intraocular lens implantation. Indian J Ophthalmol [serial online] 2000 [cited 2019 Oct 21];48:50. Available from: http://www.ijo.in/text.asp?2000/48/1/50/14852

Gram-positive, coagulase-negative cocci are a well recognised cause of endophthalmitis.[1] Most of the cases reported are due to Staphylococcus epidermidis.[2] Micrococci are ubiquitous gram-positive, coagulase-negative cocci, which are part of the normal lid margin and conjunctival flora in humans and are also present in the soil. Traumatic endophthalmitis due to Micrococcus has been reported following penetrating injury with retained metallic intraocular foreign body.[3]


  Case report Top


A 44-year-old woman underwent phacoemulsification with foldable silicone IOL implantation in the left eye on 22 January 1997. She had visual acuity of 6/5 on the first postoperative day. Four days later she developed persistent inflammation, which responded to topical mydriatics, and subconjunctival and systemic steroids. Attempts to reduce the steroids however led to a recurrence of intraocular inflammation.

She presented to us on 11 March with complaints of decreased vision and pain in the left eye. Her visual acuity was 6/6 in the right and light perception in the left eye. Slitlamp biomicroscopy of the left eye revealed mild circumcorneal congestion, severe anterior chamber reaction, and 1 mm hypopyon and fibrin membranes across the pupillary area and on the surface of the intraocular lens. The intraocular pressure (IOP) was raised on digital tonometry. On rundus examination the optic disc was seen hazily. B-scan ultrasonography revealed low reflective echoes in the inferior vitreous cavity with retina in normal position and absence of choroidal thickening. Anterior chamber tap was performed which, on a direct smear, revealed plenty of polymorphonuclear cells and several gram-positive cocci in pairs and tetrads, suggestive of Micrococcus. On culture, there was growth aerobically on blood agar (BA) and no growth anaerobically. On BA, opaque, circular, yellow, smooth and non-haemolytic colonies about 1-3 mm diameter were present on the inoculated area [Figure - 1]. Smears from the colonies showed non-motile, large, gram-positive cocci arranged mostly in tetrads. Biochemically the bacterium was coagulase-negative, catalase and oxidase-positive, produced acid oxidatively from glucose, and was sensitive to novabiocin. The isolated bacterium was identified as Micrococcus spp. The isolated Micrococcus bacterium was sensitive to cefotaxime, ampicillin, tetracycline, and gentamicin. She was put on systemic cefotaxime 1 gm bd, gentamicin 80mg bd and topical ciprofloxacin 0.3%, tobramycin 0.3%, betamethasone 0.1% one hourly and atropine 1% and betaxolol 0.5% twice daily. She was also given vancomycin (10mg/ml) intravitreally 0.05cc and intracamerally 0.02cc. Oral prednisolone 40 mg/ day was started a day later. Intracameral vancomycin was repeated two days later.

Her clinical condition improved with resolution of fibrin in the anterior chamber and a good view of the fundus. However, when reviewed a week later the inflammation had again increased, necessitating vitrectomy and removal of the IOL along with the capsule via clear corneal incision. Intra-operatively, intravitreal vancomycin 1mg, amikacin 375mg and dexamethasone 300mg was given. Lens capsule and the explanted IOL were submitted for microbiological and histopathological examination. Haematoxylin and eosin-stained preparation revealed the presence of lens capsule along with lens epithelial cells and uveal pigments. Gram stain showed, within the folds of the capsule, mutiple colonies of gram-positive cocci [Figure - 2]. Examination of the explanted IOL revealed collections of lymphocytes, epithelioid cells and uveal pigments on the surface. Gram stain showed clumps of gram-positive cocci on the surface of the IOL [Figure - 3]. The vitreous aspirate showed growth of Micrococci organisms on culture.

The postoperative period was uneventful. At review four months later her best-corrected visual acuity with +13.00 Dsph with -3.00 Dcyl @ 180 axis was 6/6 without any evidence of inflammation. She was given soft contact lens for her left eye.


  Discussion Top


Micrococci are commensals of the ocular surface and are considered non-pathogenic. However, they can cause endophthalmitis following trauma.[3] Persistent inflammation following IOL implantation responding transiently to steroids can be due to delayed onset of endophthalmitis; some of the organisms responsible are coagulase-negative Staphylococci, Propioniobacterium acnes, and Cornyebacterium spp.[2] Micrococcal endophthalmitis has been described in rare cases. It might be that their presence in such cases of endophthalmitis could have been considered as mere culture contamination.[3]

Cartwright et al[3] have described a case of micrococcal endophthalmitis associated with an intraocular metallic foreign body. They postulate that the micrococci entered the eye through the traumatic wound and the intraocular foreign body served as a nidus of infection. On removal, the intravitreal foreign body was found to be encapsulated and surrounded by a large collection of yellowish exudative material.

The IOL can become contaminated during the surgical procedure with organisms from the conjunctival cul de sac or periocular structures such as the lids and there by act as a vehicle, introducing them into the eye. This is followed by colonisation of the lens and capsular bag.[4] These micro-organisms generally are of low virulence and therefore incite a mild to moderate inflammatory response. The low-virulence bacteria may also act as adjuvants, resulting in autoimmune reaction that causes low-grade inflammation. As the organisms are sequestered within the capsular bag, the aqueous aspirate fails to show a positive result in most cases. However the aqueous aspirate in our case was positive, possibly due to release of sequestered organisms from the capsular bag with the associated inflammation. Despite intensive administration of topical and systemic antibiotics, this type of endophthalmitis is often not responsive to medical therapy. Intraocular antibiotics are unable to reach the organisms, which escape eradication resulting in a persistent inflammation with intermittent release of these sequestered organisms. Massimo[5] has reported successful results in three cases, where antibiotic irrigation of the capsular bag was applied to resolve low-grade endophthalmitis. The advantages of this technique are minimal surgical trauma and retention of the IOL, but the rate of recurrence following such treatment needs to be evaluated in a larger series of cases.

The surgical management of delayed-onset endophthalmitis is pars plana vitrectomy with or without IOL removal or exchange. Recurrence of endophthalmitis has not been seen in patients in whom IOL was removed with total capsulectomy in a large series.[6] It is therefore justifiable to remove the entire capsular bag and the IOL in such cases. The removed material should be subjected to microbiological and histopathological examination.

For micrococcal endophthalmitis, initially a broad-spectrum coverage with cefazolin and gentamicin is adequate but should be followed by modification based on the organism's antibiotic sensitivity pattern to achieve effective treatment along with surgical management.

Our case illustrates a rare organismal infection following foldable silicone IOL implantation.



 
  References Top

1.
Omerod LD, Becker LF, Cruise RJ, Grohar IH, Paton BG, Fredrick AR, et al. Endophthalmitis caused by coagulase negative Staphylococci: Factors influencing presentation after cataract surgery. Ophthalmology 1993;100:724-29.  Back to cited text no. 1
    
2.
Bode DD, Gelender H, Forster RK. A retrospective review of endophthalmitis due to coagulase negative Staphylococci. Br J Ophthalmol 1985;69:915.  Back to cited text no. 2
    
3.
Cartwright MJ. King MH, Weinberg RS, Guerry RK. Micrococcus endophthalmitis. Arch Ophthalmol 1990;108:1523-24.  Back to cited text no. 3
    
4.
Cusumano A, Busin M, Spitznas M. Is chronic intraocular inflammation after lens implantation of bacterial origin? Ophthalmology 1991;98:1703-10.  Back to cited text no. 4
[PUBMED]    
5.
Massimo B. Antibiotic irrigation of the capsular bag to resolve low grade endophthalmitis. J Cat Ref Surg 1996;22:385-89.  Back to cited text no. 5
    
6.
Winward KE, Pflugfelder SC, Flynn HW Jr, Roussel TJ, Davis JL. Postoperative Propioniobacterium endophthalmitis: Treatment strategies and long term results. Ophthalmology 1993;100:447-51.  Back to cited text no. 6
[PUBMED]    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]


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