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Endophthalmitis, although rare, is one of the most vision threatening complication of cataract surgery. The majority of these infections are bacterial in the Western world. The occurrence of fungal endophthalmitis after cataract surgery is rare as well as polymicrobial infections.1
We report a case of chronic postoperative endophthalmitis caused by bacterial and fungal pathogenic agents.
A 73 year old woman was referred for pain and redness in the left eye. Her past history was remarkable for an extracapsular cataract extraction in the left eye with a posterior chamber intraocular lens implant that had been performed in Turkey in 1998. The patient had recurrent episodes of decreased vision and ocular pain in the postoperative course and was treated with peribulbar injections of corticosteroids over 2 years. On presentation, visual acuity was hand movements in the left eye. Slit lamp examination of the left eye showed a white corneal infiltrates involving the superior and nasal quadrant (Fig 1). There was a moderate anterior chamber reaction and a 1 mm hypopyon. The implant was in good position and no residual cortical material was seen. The vitreous showed 2+ cells. Intraocular pressure was normal. Examination of the right eye was normal except for a mild nuclear cataract. The diagnosis of chronic infectious endophthalmitis was suspected.
The aqueous cultures were sterile for bacteria and fungi. Intravitreal injections of vancomycin and amikacin were performed. Postoperatively, the patient was given intravenous ciprofloxacin, piperillin, and topical fortified ticarcillin, gentamicin, and vancomycin drops. The eye showed no improvement during the next 3 weeks and the patient subsequently underwent removal of the implant and capsular bag which grew Candida parapsilosis, Corynebacterium striatum, and Staphylococcus epidermidis.
Intravitreal injection of amphotericin B (5 μg, weekly), topical amphotericin B (7 mg/ml eye drops every 2 hours), and oral fluconazole (400 mg a day) were then added to the patient’s regimen. A decrease in intraocular inflammation and corneal infiltrates was noted after 1 month of treatment that was stopped by the patient. Six months later, visual acuity of the left eye was no light perception and biomicroscopic examination showed panophthalmitis. The patient refused medical treatment and enucleation was performed.
Species of candida, other than Candida albicans, are normal flora of cutaneous and mucocutaneous surfaces and are only rarely incriminated as agents of clinical disease in immunocompetent hosts. Candida parapsilosis is in fact one of the most common fungi cultured from the normal human external eye.2 However, it can cause infectious crystalline keratopathy or, more typically, suppurative stromal keratitis. Candida parapsilosis has also been reported as a cause of small epidemics of postoperative endophthalmitis.3 In the present case, Candida parapsilosis could be considered as a true pathogenic organism because of its localisation, in the capsular bag, and also because antifungal therapy was effective.
On the other hand, Staphylococcus and Corynebacterium species are frequently identified in postoperative endophthalmitis.1
This case is, to our knowledge, the first documented report of bacterial and fungal endophthalmitis following cataract surgery. The use of broad spectrum antibiotics, the administration of steroids, and the increased number of patients with local or systemic immunosuppression could explain the development of such infections which are frequent in post-traumatic endophthalmitis but extremely rare after cataract surgery.1,4 However, cross contamination by hospital personnel may also account for increase in yeast infections in certain environments. A recent survey of hospital personnel revealed that 70% of nurses and non-nursing hospital personnel carried yeasts on their hands, particularly subungual spaces, with Candida parapsilosis being those most frequently recovered.5
This case demonstrates the atypical presentation and the poor prognosis of polymicrobial endophthalmitis. Identification of all the organisms is essential before the onset of therapy, emphasising the need for complete microbiological evaluation of any postoperative endophthalmitis.