Postoperative endophthalmitis is a serious complication of cataract surgery. In cases in which endophthalmitis is delayed, ie, occurring more than 4 to 6 weeks after the surgery, Propionibacterium acne is the most common causative organism.1 We report a rare case of postoperative endophthalmitis caused by Corynebacterium species.
A 68-year-old woman with no prior medical or ocular history had uneventful cataract extraction by phacoemulsification with intraocular lens (IOL) placement in the left eye. A beveled incision was made with a 2.6 mm keratome. No intraoperative antibiotics were given. Four weeks after the surgery, the patient presented with a 3-day history of a red, scratchy left eye. She had completed the postoperative prednisolone acetate taper 5 days earlier. The corrected distance visual acuity (CDVA) was 20/25 in both eyes with round and reactive pupils. The right eye examination demonstrated pseudophakia but was otherwise normal. Slitlamp biomicroscopy of the left eye revealed 2+ conjunctival injection with a few keratic precipitates on the corneal endothelium and 2 to 3+ cells and flare in the anterior chamber. There was no wound leak, fibrin, hypopyon, or capsular plaque. Fundus examination was unremarkable, with no evidence of vitritis. Prednisolone acetate was restarted and resulted in improvement of the inflammation.
Three weeks later, the patient returned with worsening pain in the left eye while on prednisolone acetate. The CDVA was 20/30. A capsular plaque was noted in the superotemporal quadrant with persistent anterior chamber cells. No vitreous cells were present. An anterior chamber tap and washout were performed with intracameral injection of 0.2 mL of 1.0 mg/0.1 mL vancomycin.
Six days after the collection, the vitreous sample grew Corynebacterium species. The organism had intermediate susceptibility to ciprofloxacin but was susceptible to all other antibiotics including vancomycin. The capsular plaque was removed. Anterior chamber washout was repeated with an intracapsular injection of 0.2 mL of 1.0 mg/0.1 mL vancomycin and of moxifloxacin 0.1%. Intravitreal injection of 0.1 mL of 1.0 mg/0.1 mL vancomycin was also performed.
The postoperative course of prednisolone acetate taper was unremarkable. One month after the plaque removal, the CDVA was 20/25. The patient again presented with left eye irritation 3 days after completion of the prednisolone acetate taper. Rebound anterior chamber cells and flare were noted with no vitritis. A repeat anterior chamber tap and washout with injection of intracameral (0.2 mL) and intravitreal (0.1 mL) 1.0 mg/0.1 mL vancomycin were performed. The patient refused IOL removal.
Six months after the initial cataract surgery, the anterior inflammation with rare vitreous cells continued. A pars plana vitrectomy (PPV) with complete capsulectomy, removal of the posterior chamber IOL, and intravitreal vancomycin injection were performed. Secondarily, the IOL was sutured in the sulcus. The final CDVA was 20/30.
Corynebacterium is a genus of gram-positive pleomorphic rods comprising more than 46 species.2 According to Murube,2 it was first recognized in 1896 by Lehmann and Neumann. It shares many chemotaxonomic features with other gram-positive rods such as Propionibacterium. Both Propionibacterium and Corynebacterium species are catalase-positive non-spore-forming rods. These 2 species are distinguished by their oxygen tolerance. Propionibacterium is a facultative anaerobe; Corynebacterium is an aerobic organism.3 This distinguishing factor of Corynebacterium probably explains why the organism is rarely associated with intraocular infectious processes, although it is a common conjunctival flora, second only to coagulase-negative Staphylococcus.4
Corynebacterium is a rare causative agent of pseudophakic endophthalmitis.5 A retrospective study reported 1 of 19 delayed pseudophakic endophthalmitis cases caused by Corynebacterium species over a 10-year period.6 To our knowledge, only 5 cases of pseudophakic Corynebacterium endophthalmitis have been reported (Table 1).6–9
The onset of the inflammatory symptoms in Corynebacterium pseudophakic endophthalmitis in the reported cases ranged from 10 days to 16 weeks after surgery. The time to diagnostic culture was further delayed from 6 to 28 weeks.6–9 The diagnosis is often compounded by other complications, such as retinal detachment (RD), partial response to antiinflammatory drugs, and the fastidious growth of this organism (Table 1).
Of the 5 reported cases of Corynebacterium pseudophakic endophthalmitis, 2 cases followed uneventful intracapsular cataract extraction.7 A case series of delayed-onset pseudophakic endophthalmitis reported 1 case of Corynebacterium pseudophakic endophthalmitis after extracapsular cataract extraction with IOL implantation.6 One case of uneventful phacoemulsification with IOL implantation was complicated by RD surgeries prior to the diagnosis of Corynebacterium pseudophakic endophthalmitis.8 In another case after uneventful phacoemulsification and IOL placement, RD developed 3 days after neodymium:YAG capsulotomy; Corynebacterium pseudophakic endophthalmitis was eventually diagnosed.9
All the Corynebacterium cases reported pain and redness at the onset of symptoms, with delayed development of intense anterior chamber inflammation including hypopyon and fibrin. Two cases, including our case, demonstrated white capsular plaque similar to Propionibacterium endophthalmitis.6Corynebacterium species are known to incite macrophage reaction, again similar to Propionibacterium endophthalmitis cases; however, only 1 Corynebacterium pseudophakic endophthalmitis case demonstrated granulomatous inflammation.9,10
The choice of antibiotics for Corynebacterium endophthalmitis is not established. Penicillin and macrolides provide sufficient antibiotic coverage for Corynebacterium species.11 However, their resistance to antibiotics has become a concern recently. Suto et al.12 reported that 13 of 76 eyes with Corynebacterium conjunctival flora preoperatively were resistant to levofloxacin and/or tobramycin. The species in our case had intermediate sensitivity to ciprofloxacin and was sensitive to all other antibiotics including gentamicin and vancomycin. To ensure adequate coverage, intraocular vancomycin is recommended when Corynebacterium is isolated. Although resistance is always a concern, broad-coverage intracameral prophylaxis with vancomycin is reasonable in preventing Corynebacterium endophthalmitis.
The ideal surgical management of Corynebacterium pseudophakic endophthalmitis or delayed-onset endophthalmitis in general is controversial. The recurrence rate is highest when the initial treatment is intraocular antibiotics alone and lowest when PPV is combined with total capsulotomy.5 The treatment of the reported cases of Corynebacterium pseudophakic endophthalmitis is given in Table 2.6–9 Our case had persistent and recurrent inflammations despite repeat intracameral, intracapsular, and intravitreal antibiotics. The complete resolution of inflammation was achieved when PPV and total capsulectomy were performed. The case shows that partial capsulectomy and intraocular antibiotics may not be adequate in treating Corynebacterium pseudophakic endophthalmitis despite its presumed low virulence.
In conclusion, organisms other than P acne should be in the differential diagnosis of delayed pseudophakic endophthalmitis. Although generally thought to be less virulent than P acne or Staphylococcus epidermis endophthalmitis, Corynebacterium endophthalmitis may require aggressive surgical intervention.
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