Lactobacillus acidophilus endophthalmitis after intravitreal bevacizumab injection requiring intraocular lens explantation

The use of anti-vascular endothelial growth factor (anti-VEGF) agents has become a mainstay in the treatment of chronic vascular retinal diseases such as proliferative diabetic retinopathy, exudative macular degeneration, and retinal vein occlusion. Patients receive anti-VEGF agents via intravitreal injection (IVI) on a recurrent, often monthly basis. Acute endophthalmitis is the most feared potential complication of IVI. Patients receiving repeated IVIs have cumulative per-patient endophthalmitis rates of up to 0.84%, with the incidence increasing with the number of IVI episodes.Daien V Nguyen V Essex RW et al.Incidence and outcomes of infectious and noninfectious endophthalmitis after intravitreal injections for age-related macular degeneration. This is not an inconsequential rate of occurrence given the potentially devastating long-term visual deficits associated with endophthalmitis despite prompt intervention.Of culture-positive anti-VEGF IVI endophthalmitis cases, the most common cultured pathogens include commensal conjunctival and oral flora such as coagulase-negative staphylococci and streptococci.Fileta JB Scott IU Flynn Jr, HW Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. Lactobacillus is a gram-positive facultatively anaerobic microaerophilic rod that constitutes part of the human gastrointestinal and vaginal microbiome. Here we present a unique case of acute Lactobacillus sp. endophthalmitis following anti-VEGF IVI that was unresponsive to conventional therapy and ultimately required explantation of the intraocular lens (IOL) and capsular bag complex (CBC) for resolution of intraocular inflammation.

A 90-year-old pseudophakic woman with long-standing exudative age-related macular degeneration managed with monthly bevacizumab IVIs presented to our clinic 4 days after bilateral IVIs with acute development of pain, floaters, and blurry vision OS. OS visual acuity (VA) was decreased to HM from 20/30 at baseline, whereas OD VA was unchanged. The OS anterior chamber (AC) demonstrated 3+ cells and 3+ flare with a sliver hypopyon, and subconjunctival hematoma was present. Posteriorly, vitreous debris prevented adequate viewing of the fundus, though the IOL was without opacity and adequate red reflex was produced. A vitreous tap was attempted, but no aspirate could be obtained. Intravitreal vancomycin and ceftazidime were administered, and the patient was given hourly ciprofloxacin drops, Cyclogyl drops (cyclopentolate hydrochloride ophthalmic solution; McKesson Corp, Irving, Texas) 3 times daily, and Maxitrol drops (neomycin, polymyxin B, and dexamethasone; Novartis Pharmaceuticals UK Ltd, London, UK) every 3–4 hours. Significant posterior capsular opacification developed 3 weeks later, though VA improved to 20/200 within 1 month with trace residual cell and flare present in the AC and anterior vitreous.

Five weeks after initial presentation, the patient developed worsened blurry vision OS with VA of counting fingers (CF) and worsened cell and flare in the ocular media. No pain, conjunctival erythema, or hypopyon were present. Successful pars plana vitrectomy, posterior capsulotomy, and vitreous biopsy were performed. Vancomycin, ceftazidime, and dexamethasone were injected into the vitreous cavity. Culture of the vitreous fluid grew L. acidophilus. Postoperatively, the patient was started on moxifloxacin 0.5% drops tid and hourly prednisolone drops. VA improved to 20/70 with trace vitreous cells present 9 days after vitrectomy. Moxifloxacin was discontinued with resolution of inflammation.

Two weeks after vitrectomy, the patient again presented with painless worsening vision to CF and marked increased intraocular inflammation. The patient was started on oral moxifloxacin 400 mg bid and hourly prednisolone drops with improvement of VA to 20/100 after 3 weeks. Oral moxifloxacin was discontinued after resolution of the intraocular inflammation. Unfortunately, the patient once again returned 2 weeks later with a similar presentation: painless blurry vision with CF VA and 4+ cells in the AC and anterior vitreous. Because of recurrent endophthalmitis following intravitreal antibiotic, pars plana vitrectomy, and systemic antibiotic therapy, it was presumed that the infectious source had not been properly eradicated and that the lens was possibly harbouring residual infection. IOL and CBC explantation with IVI of ceftazidime and vancomycin were then performed, 4 months after initial presentation. No cultures or microbiological studies were performed on the explanted IOL. Following IOL explantation, signs of intraocular inflammation subsided within 2 weeks. No bevacizumab was administered OS following the initial inflammatory event, and the patient developed progression of age-related macular degeneration in that eye while being treated for recurrent endophthalmitis. The patient was left aphakic and was able to achieve 20/100 VA with a rigid gas-permeable contact lens.

To our knowledge, a case of post-IVI endophthalmitis owing to Lactobacillus sp. and its response to conventional treatment has not been reported. Rayess et al.Rayess N Rahimy E Shah CP et al.Incidence and clinical features of post-injection endophthalmitis according to diagnosis. analyzed 119 cases of post-anti-VEGF IVI endophthalmitis and found one case caused by Lactobacillus sp., although this patient was lost to follow-up. Two reports of non-IVI-related Lactobacillus endophthalmitis also have been documented.Papaconstantinou D Georgalas I Karmiris T Ladas I Droutsas K Georgopoulos G. Acute onset Lactobacillus endophthalmitis after trabeculectomy: a case report.,Posttraumatic endophthalmitis caused by Lactobacillus. One report described a case of traumatic endophthalmitis that resolved following immediate pars plana lensectomy and vitrectomy with intravitreal gentamycin, clindamycin, and vancomycin.Posttraumatic endophthalmitis caused by Lactobacillus. Another involved post-trabeculectomy endophthalmitis successfully treated with vitrectomy and intravitreal vancomycin and amikacin followed by oral and topical fluoroquinolones.Papaconstantinou D Georgalas I Karmiris T Ladas I Droutsas K Georgopoulos G. Acute onset Lactobacillus endophthalmitis after trabeculectomy: a case report.

The case presented herein illustrates acute-onset endophthalmitis resulting from a rare microorganism with chronic recurrence of inflammation refractory to conventional treatment methods. Because the inflammation resolved following IOL explantation, it is possible that the IOL or CBC provided a nidus of ongoing infection despite removal of the vitreous and posterior lens capsule. Unfortunately, the explanted IOL was never sent for microbiologic studies. Thus, the question of whether the IOL or CBC continued to harbour Lactobacillus that was the definitive cause of ongoing inflammation remains unanswered. It is possible that the development of new capsular opacities in the initial inflammatory episode was a sign of lens involvement. Sequestration of another facultative anaerobic organism, Cutibacterium acnes (formerly Propionibacterium acnes), within an intracapsular plaque is a well-known cause of relapsing, often refractory chronic endophthalmitis. It is possible that Lactobacillus could survive and proliferate in the intracapsular space relatively protected against the immune system and the penetration of intravitreal antibiotics. However, the mechanism for bacterial spread to the intracapsular space following IVI is unclear.

Post-anti-VEGF IVI endophthalmitis poses a major threat to an enlarging patient population. We present a case of post-IVI endophthalmitis owing to a rare microorganism, L. acidophilus, refractory to conventional management and requiring IOL explantation for resolution of inflammation. Retinal specialists should be aware of the potential of post-IVI endophthalmitis owing to rare microorganisms such as Lactobacillus. It is worthwhile to maintain suspicion for IOL or CBC involvement in cases of post-IVI endophthalmitis refractory to standard therapy.

Footnotes and Disclosure

The authors have no proprietary or commercial interest in any materials discussed in this communication.

ReferencesDaien V Nguyen V Essex RW et al.

Incidence and outcomes of infectious and noninfectious endophthalmitis after intravitreal injections for age-related macular degeneration.

Ophthalmology. 125: 66-74Fileta JB Scott IU Flynn Jr, HW

Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents.

Ophthalmic Surg Lasers Imaging Retina. 45: 143-149Rayess N Rahimy E Shah CP et al.

Incidence and clinical features of post-injection endophthalmitis according to diagnosis.

Br J Ophthalmol. 100: 1058-1061Papaconstantinou D Georgalas I Karmiris T Ladas I Droutsas K Georgopoulos G.

Acute onset Lactobacillus endophthalmitis after trabeculectomy: a case report.

J Med Case Rep. 4: 203

Posttraumatic endophthalmitis caused by Lactobacillus.

Arch Ophthalmol. 111: 1169Article InfoPublication History

Published online: June 27, 2021

Accepted: June 1, 2021

Received: May 25, 2021

Publication stageIn Press Uncorrected ProofIdentification

DOI: https://doi.org/10.1016/j.jcjo.2021.06.002

Copyright

© 2021 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.

ScienceDirectAccess this article on ScienceDirect Related Articles

留言 (0)

沒有登入
gif