Chronic or saccular endophthalmitis: diagnosis and management

Abstract

In a recent article, Dr. Teichmann1 refers to our paper2 as an example of a primarily aggressive approach to the treatment of chronic postoperative endophthalmitis (intraocular lens removal, total capsulectomy, anterior vitrectomy). Various conservative treatments have been tried but have had limited success. This is probably due to the fact that Propionibacterium and other bacteria may persist within inflammatory cells, thus being out of the reach of commonly used antibiotics. This, together with the fastidious growth requirements of Propionibacterium, may explain the low incidence of positive cultures in these cases. The availability of the polymerase chain reaction (PCR) test for the detection of suspected causative pathogens in chronic endophthalmitis3 together with the use of oral clarithromycin—an antibiotic that penetrates satisfactorily into the inflamed anterior chamber and is further potentiated by being concentrated intracellularly within polymorphonuclear cells and macrophages—as proposed by Warheker and coauthors,4 has made us change our strategy and we now follow a more conservative, staged approach (Figure 1). When we suspect a chronic or saccular endophthalmitis, we perform an anterior chamber tap to remove 0.1/mL of aqueous: 0.025/mL (1 drop) for the PCR test and 0.075/mL for bacterial and fungal cultures. Then, we start the treatment with oral clarithromycin. It is adjusted depending on the response and results of the cultures and PCR test. (Further steps include antibiotic irrigation of the capsular bag in culture-positive cases, vitrectomy with partial capsulectomy and intravitreal antibiotics, or even our “old” aggressive approach.)Figure 1.: (Abreu) Treatment protocol for chronic or saccular endophthalmitis.We have had 2 cases of chronic endophthalmitis with negative cultures and positive PCR tests (only nonspecific 16S rDNA PCR with broad-range bacterial primers was available at that time) that were successfully treated with clarithromycin. Resolution was confirmed with a negative PCR test after the treatment, along with clinical improvement. We congratulate Dr. Teichmann for reporting his experience with the treatment of these difficult cases of chronic postoperative endophthalmitis and also for his review of the management options. We invite him to consider our new treatment protocol when faced with future cases of chronic or saccular endophthalmitis. José Augusto Abreu MD, PhD Luis Cordovés MD aCanary Islands, Spain