Cataract Surgery Complications Management

AUGUST 2007 I CATARACT & REFRACTIVE SURGERY TODAY I 29 RICHARD E . BR AUNSTEIN , MD This patient has a presentation consistent with postoperative P. acnes endophthalmitis. Caused by P. acnes, a gram-positive anaerobic bacillus, this condition presents as a white intracapsular plaque in the setting of decreased vision, conjunctival injection, intraocular inflammation with or without hypopyon, and keratic precipitates. The positive culture from the anterior segment of this patient solidifies the diagnosis. P. acnes endophthalmitis has traditionally been treated via a stepwise approach. Many patients are successfully managed with topical corticosteroids. This patient may benefit from a more frequent regimen of topical corticosteroids in conjunction with a topical NSAID. If topical therapy is ineffective at controlling her inflammation and improving her vision, the literature supports an intravitreal injection of vancomycin 1 mg/0.1 mL.1,2 Reviews of treatment strategies for P. acnes endophthalmitis reported a 50% to 100% failure rate for an intraocular antibiotic injection as a primary treatment.1,2 When intraocular antibiotics fail to control the inflammation, a pars plana vitrectomy and either a partial or a total capsulectomy with or without IOL exchange is indicated. Data from the aforementioned studies demonstrated a recurrence rate of 14% to 44% in patients treated with partial capsulectomy and a recurrence rate of zero in patients treated with total capsulectomy and IOL removal. For this culture-positive patient, I would recommend an intravitreal injection of vancomycin combined with frequent topical anti-inflammatory therapy. If this therapy failed to resolve the inflammation, I would attempt a pars plana vitrectomy with subtotal posterior capsulectomy, irrigation of the capsular bag, and a repeat intravitreal injection of vancomycin prior to performing a total capsulectomy and removing the IOL.