Treatment strategies for postoperative Propionibacterium acnes endophthalmitis

Purpose: Propionibacterium acnes endophthalmitis after cataract extraction and posterior chamber intraocular lens (IOL) implantation is characterized by a chronic indolent course, frequently associated with recurrence after s tandard endophthalmitis treatment. This study was designed to evaluate the efficacy of various therapeutic methods in the treatment of primary and rec urrent episodes of postoperative P. acnes endophthalmitis. Design: Retrospective, noncomparative case series. Participants: Twenty-five patients treated at Wills Eye Hospital for P, acn es endophthalmitis. Methods: The authors retrospectively reviewed the clinical charts and micro biology files of all patients treated at Wills Eye Hospital between January 1991 and April 1998 with culture-proven P. acnes endophthalmitis after cat aract extraction and posterior chamber IOL implantation. Main Outcome Measures: Results of cultures and microbiologic examinations, efficacy of various treatment methods in the prevention of recurrent inflam matory episodes, and final visual outcome. Results: Twenty-five patients who met inclusion criteria were identified; i nitial therapy consisted of 1 of the following. intraocular antibiotic (IOA B) injections alone (2 patients); IOAB combined with pars plana vitrectomy (PPV) (10 patients); IOAB and PPV combined with partial capsulectomy (9 pat ients); and IOAB, PPV, total capsulectomy, and IOL exchange (4 patients). N early half of the patients (10 of 21, or 48%) initially treated with IOAB a lone (1 of 2), IOAB and PPV (5 of 10), and IOAB combined with PPV and parti al capsulectomy (4 of 9) required further therapeutic interventions for rec urrent disease. Retreatment with IOAB alone or combined with PPV and partia l capsulectomy in these patients failed to eradicate the infection in three (75%) of four patients. None of the patients (0 of 4) treated initially wi th total capsulectomy and IOL exchange required additional surgical interve ntion, Furthermore, none of the patients (0 of 13) who underwent total caps ulectomy with IOL removal or exchange or IOL exchange alone as an initial, secondary, or tertiary treatment required further intervention. Conclusion: In the authors' series, approximately half of the patients with P, acnes endophthalmitis were treated successfully initially with nonsurgi cal or limited surgical intervention. All patients treated with total capsu lectomy and IOL exchange or removal, either as an initial treatment or for recurrent disease, were cured. Removal of the entire capsular bag and the I OL may be performed as a definitive initial therapy and should be performed for recurrent inflammation.