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Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 41-43

Chronic postoperative endophthalmitis with an unusual organism: Unconventional approach

1 Department of Ophthalmology, Command Hospital (NC), Chandimandir, Haryana, India
2 Department of Ophthalmology, INHS Dhanvantari, Port Blair, Andaman and Nicobar Islands, India

Date of Submission03-Apr-2019
Date of Decision02-Dec-2020
Date of Acceptance28-Dec-2020
Date of Web Publication10-Apr-2021

Correspondence Address:
Kapil Gopal Shahare
Department of Ophthalmology, INHS Dhanvantari, Minnie Bay, Port Blair - 744 103, Andaman and Nicobar Islands
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcor.jcor_26_19

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Chronic postoperative endophthalmitis (CPE) following cataract surgery with the appearance of distinct plaques is most commonly caused by Propionibacterium acnes and the standard treatment is intraocular lens (IOL) explant and complete capsulectomy. We report a case of CPE who presented with an indolent recurrent course, manifested numerous typical plaques in the capsular bag, and was treated with an IOL explant, re-implant, and two-port 23G pars plana vitrectomy under direct vision with good results. The organism grown was Bacillus species which is the most common known cause of posttraumatic endophthalmitis and typically has a rapidly devastating course. It is very rare to detect Bacillus species as an incriminating organism in CPE.

Keywords: Bacillus species, chronic endophthalmitis, intraocular lens re-implan

How to cite this article:
Maggon R, Shahare KG. Chronic postoperative endophthalmitis with an unusual organism: Unconventional approach. J Clin Ophthalmol Res 2021;9:41-3

How to cite this URL:
Maggon R, Shahare KG. Chronic postoperative endophthalmitis with an unusual organism: Unconventional approach. J Clin Ophthalmol Res [serial online] 2021 [cited 2022 Jun 27];9:41-3. Available from: https://www.jcor.in/text.asp?2021/9/1/41/313471

Endophthalmitis is one of the most devastating complications of intraocular surgeries, leaving patients with permanently poor vision. With advances in ophthalmic care and cataract surgery, the postoperative complications have reduced to a considerable extent. However, chronic postoperative endophthalmitis (CPE) still remains uncommon but potentially dangerous and underdiagnosed complication of cataract surgery. CPE is often misdiagnosed as noninfectious uveitis where it improves initially with topical corticosteroid therapy while flaring whenever corticosteroids are tapered or stopped.[1] It is usually caused by indolent bacteria or fungus with low virulence and Propionibacterium acnes is the most commonly implicated organism.

We present the rare case of Bacillus sp. presenting as low-grade CPE with plaque-like precipitates over the intraocular lens (IOL) and in the bag.

  Case Report Top

A 31-year-old male patient underwent uneventful phacoemulsification cataract surgery in the left eye (LE) for posterior subcapsular cataract in August 2017 and recovered well. He reported two episodes of redness and blurring in the operated eye at 7 and 10 months after surgery with hypopyon in the second episode and both the episodes were managed somewhere else with topical medications. He presented to our center in September 2018 with a painless diminution of vision in LE for 3 months. The eye was externally quiet and had a vision of 6/18 (6/9 with − 1.0 Diopter Cylinder at 155°), cells in the anterior chamber (AC), fine keratic precipitates, well-dilating pupil, and centered IOL with multiple circular plaques on both the surfaces. The capsular bag also had plaques and vitreous was hazy [Figure 1]. Indirect ophthalmoscopy revealed hazy media with only IIIrd order vessels visible and ultrasound showed multiple low reflectivity echoes in vitreous. He improved partially with topical steroids and cycloplegics. The right eye was normal. He was diagnosed as chronic postoperative endophthalmitis (CPE) and was taken up for surgery. He underwent AC wash, IOL explantation, endocapsular posterior chamber IOL re-implantation, and two-port 23G pars plana vitrectomy (PPV) under direct vision with posterior capsulectomy [Figure 2]. Intravitreal vancomycin 1 mg/0.1 ml and ceftazidime 2.25 mg/0.1 ml were injected. Gram staining of AC aspirate revealed Gram-positive spore-bearing bacilli[Figure 3]a. Explanted IOL was inoculated on Robertson's cooked meat broth and blood agar. After aerobic incubation, confluent smooth cream-colored colonies of Bacillus species with aerobic spores were seen on blood agar [Figure 3]b. The organism was sensitive to vancomycin, amikacin, and ceftazidime while resistant to clindamycin and ampicillin. Postoperatively, he was started on topical moxifloxacin 0.5% four times/day and prednisolone acetate 1% six times/day. Postoperative recovery was uneventful and his vision improved to 6/6 on the 2nd postoperative day [Figure 4]. The eye was quiet with well-centered IOL and vision maintained at 6/6 at 6-month follow-up.
Figure 1: Preoperative photographs of the left eye showing (a and b) externally quiet eye. (c) Multiple circular plaques on both surfaces of intraocular lens and in the bag. (d) Vitreous cells (white arrow)

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Figure 2: Intraoperative photographs showing (a and b) intraocular lens being dialed out in the anterior chamber. (c and d) Intraocular lens is cut partially using vannas scissor. (e) Intraocular lens being explanted through original incision. (f) Foldable intraocular lens is implanted in the bag and wound sutured. (g) Two-port 23G pars plana vitrectomy done under direct vision. (h) Posterior capsulectomy done using 23G cutter

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Figure 3: Gram staining of anterior chamber aspirate revealed (a) Gram-positive spore bearing bacilli. Explanted intraocular lens was inoculated on Robertson's cooked meat broth and blood agar. After aerobic incubation, confluent smooth cream-colored colonies (b) of Bacillus species with aerobic spores were seen

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Figure 4: Postoperative appearance of the same eye. (a and b) Day 1 showing clear cornea with well-centered intraocular lens in the bag. (c and d) Day 3 showing clear visual axis

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  Discussion Top

CPE is misdiagnosed as noninfectious uveitis due to mild symptoms and indolent course.[1] Propionibacterium species accounts for a majority (41%–63%) followed by coagulase-negative Staphylococci and fungi.[2] Plaques are typically observed in Propionibacterium infection, and IOL explant with removal of the bag is the standard treatment.[2],[3] Bacillus species infection cause 15%–46% of posttraumatic endophthalmitis and it is extremely rare to grow Bacillus species in cases of CPE. We have come across only one such case report.[4] They are spore-forming Gram-positive rods, ubiquitous in soil, and are noteworthy for rapid destruction in a few days.[5],[6],[7] This is a very rare presentation of Bacillus sp. causing smoldering CPE with typical plaques. The good vision with no associated symptoms and relatively quiet eye posed the challenge in taking the decision for surgery. Explant with re-implant of IOL and two-port 23 G PPV with capsulectomy under direct visualization achieved an excellent result.

  Conclusion Top

CPE may also be caused due to Bacillus species and treatment with IOL explantation, lavage, re-implantation, and limited two-port PPV with capsulectomy may suffice.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Fox GM, Joondeph BC, Flynn HW, Pflugfelder SC, Roussel TJ. “Delayed-onset pseudophakic endophthalmitis.” Am J Ophthalmol 1991;111:163-73.  Back to cited text no. 1
Al-Mezaine HS, Al-Assiri A, Al-Rajhi AA. “Incidence, clinical features, causative organisms, and visual outcomes of delayed-onset pseudophakic endophthalmitis.” Eur J Ophthalmol 2009;19:804-11.  Back to cited text no. 2
Roussel TJ, Olson ER, Rice T, Meisler D, Hall G, Miller D. “Chronic postoperative endophthalmitis associated with Actinomyces species.” Arch Ophthalmol 1991;109:60-2.  Back to cited text no. 3
Chen JC, Roy M. Epidemic Bacillus endophthalmitis after cataract surgery ii1: Chronic and recurrent presentation and outcome. Ophthalmology 2000;107:1038-41.  Back to cited text no. 4
Miller JJ, Scott IU, Flynn HW Jr. Endophthalmitis caused by Bacillus species. Am J Ophthalmol 2008;145:883-8.  Back to cited text no. 5
Callegan MC, Kane ST, Cochran DC. Bacillus endophthalmitis: Roles of bacterial toxins and motility during infection. Invest Ophthalmol Vis Sci 2005;46:3233-8.  Back to cited text no. 6
Safneck JR. Endophthalmitis: A review of recent trends. Saudi J Ophthalmol 2012;26:181-9.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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