Localized endophthalmitis: A newly described cause of the so-called toxic lens syndrome

Abstract

We report five cases of post-extracapsular cataract extraction infection in which subsequent pathologic analyses identified the organisms and found the infection to be localized or confined to the lens capsular sac. The most common offending organisms were gram-positive pleomorphic bacilli. In one case, we were able to identify the bacteria as Propionibacterium acnes. We designate this condition a localized endophthalmitis. It should be considered any time a persistent, smoldering, postoperative inflammation occurs, and in the differential diagnosis of phacoanaphylactic endophthalmitis. The condition itself is not new, but undoubtedly many such cases have gone unrecognized or have been misdiagnosed as the so-called toxic lens syndrome. In localized endophthalmitis, a clinically visible inflammatory process may occur even when multiple diagnostic taps are negative, although when the cases first appeared, the surgeons were not aware of the entity and anaerobic cultures were not always obtained. A negative tap may be explained by the fact that metabolic products from the organisms are released from the bag into the anterior segment and vitreous. A synergistic reaction may occur between these organisms and retained lens cortical remnants that may cause or exacerbate a hypersensitivity reaction. The condition may be worsened by Nd:YAG capsulotomy. The pathogenesis of localized endophthalmitis has nothing to do with the type of intraocular lens fixation (lens capsular sac or ciliary sulcus); rather, the simple presence of a capsular sac after extracapsular cataract extraction is the prerequisite for the clinical condition.

Peroperative microbial contamination of anterior chamber aspirates during extracapsular cataract extraction and phacoemulsification

“…However, the true figure is likely to be higher than this, many milder cases being both unrecognised and unreported and considered as sterile postoperative inflammation. The normal flora of the ocular surface and conjunctiva, especially CNS, is well known to produce postoperative inflammation and infections1 3 and is thought to be the main source of contamination. Irrigation of the conjunctiva before and during surgery introduces more micro-organisms from the conjunctival crypts onto the surface 7.…”

Chronic Postoperative Endophthalmitis: A Review of Clinical Characteristics, Microbiology, Treatment Strategies, and Outcomes

“…They are usually indolent bacteria or fungus with low virulence. CPE was originally considered to be a reaction to the remaining native lens tissue and was consequently called toxic lens syndrome or phacoanaphylactic endophthalmitis [17]. However, studies of removed lens capsules revealed small gram-positive rods, consistent with Propionibacterium acnes , adherent to the capsular remnants [17].…”

Treatment of Postoperative Endophthalmitis

“…The growing incidence o f endophthalmitis after extra capsular surgery, the increased occurrence of infections due to low-virulence agents such as S. epidermidis and Propio nibacterium acneis, as well as the existence o f what has been termed 'localized endophthalmitis' [6,23], calls the role o f the capsule as a barrier to infection into question [22].…”