OSLI Retina

January 2021

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44 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina ■ C A S E R E P O R T ■ Initial Presentation of Cutibacterium (Formerly Propionibacterium) acnes Endophthalmitis Twenty-One Years After Cataract Surgery Justin P. Ma, BS; Cason B. Robbins, BS; Avni P. Finn, MD, MBA; Henry L. Feng, MD; Sharon Fekrat, MD; Lejla Vajzovic, MD ABSTRACT: The authors report a case of an 81-year- old female who presented with sudden onset of light perception vision and intraocular inflamma- tion. After several months of continuing symptoms despite antibiotics, an aqueous tap culture grew Cutibacterium acnes. The patient had cataract sur- gery 21 years prior, and had no intervening trauma, intraocular procedure, or endogenous source. The presumed diagnosis was C. acnes endophthalmi- tis with significantly delayed onset. Capsulectomy and intraocular lens removal resolved the patient's symptoms. In rare cases, C. acnes endophthalmitis may present as recurrent inflammation despite an extremely remote history of cataract surgery, mim- icking a virulent, acute-onset endophthalmitis de- spite antibiotic administration. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:44-46.] INTRODUCTION Cutibacterium acnes (C. acnes, formerly known as Propionibacterium acnes or P. acnes) has been implicated in chronic endophthalmitis following in- traocular lens (IOL) surgery. 1 Although typical post- operative endophthalmitis presents acutely with eye pain, conjunctival injection, and chemosis, chronic endophthalmitis may involve persistent low-grade inflammation, often with delayed onset and absence of these hallmark symptoms. 1 This is attributed to the relatively low virulence of C. acnes, and sequestration within capsular remnants after IOL surgery. 2 Without capsulectomy and IOL removal, C. acnes activity of- ten recurs despite treatment of flares with intravitreal antibiotics and corticosteroids. 1 CASE REPORT An 81-year-old woman with a history of bilateral cataract surgery and intraocular lens (IOL) place- ment (1996 in the left eye [OS], 2001 in the right eye [OD]), retinal detachment (RD) (OD, status post scleral buckle in 1985), and peripheral retinal tears (OS, status post laser retinopexy), presented in No- vember 2016 with sudden onset of light perception vision in the left eye (Figure 1). At presentation, the left eye showed 3+ conjunctival injection, diffuse anterior chamber fibrin, and a layered hypopyon. No white plaque was observed on the IOL or lens cap- sule. Dilated fundus exam revealed an attached reti- na. She had no recent or intervening history of ocular trauma, intraocular surgery, or intravitreal injection. She received intravitreal vancomycin (1 mg/0.10 mL), ceftazidime (2.25 mg/0.10 mL), and topical cor- ticosteroids. An aqueous humor sample showed 1+ leukocytes without bacterial growth. To assess pos- sible endogenous endophthalmitis, a blood culture was obtained, which showed no growth. One month later, the patient developed total RD in the left eye with tractional membranes. Examina- tion showed improved anterior chamber inflamma- tion, but significant vitreous debris remained. She underwent a diagnostic pars plana vitrectomy (PPV) prior to RD repair in order to determine the cause of endophthalmitis (December 2016). Vitreous biopsy from this PPV did not grow pathogens. The patient subsequently underwent RD repair (Figure 2). Mul- tiple postoperative follow-up examinations revealed persistent mild inflammation with varying degrees fibrin or hypopyon. Six weeks after RD repair and PPV, the patient presented again with acute vision loss in the left eye (counting fingers at 4 feet) with a 1-mm hypopyon. She received intravitreal vancomycin (1 mg/0.10 mL) and an aqueous tap grew C. acnes after 1 week (Febru- From Duke University School of Medicine, Durham, North Caronlina (JPM, CBR); Northern California Retina Vitreous Associates, Mountain View, California (APF); and Duke Eye Center, Duke University, Durham, North Carolina (HLF, SF, LV). Originally submitted June 22, 2020. Revision received October 11, 2020. Accepted for publication November 9, 2020. Dr. Vajzovic has received personal fees from Guidepoint, Evolve Medical Education, and Oculus, as well as grants from AGTC, Aldeyra, and Heidel- berg Engineering, outside the submitted work. The remaining authors report no relevant financial disclosures. Address correspondence to Lejla Vajzovic, MD, Duke University School of Medicine, Durham, NC 27705; email: Lejla.vajzovic@duke.edu. doi: 10.3928/23258160-20201223-08

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