Streptococcus mitis/oralis endophthalmitis management without phakic intraocular lens removal in patient with iris-fixated phakic intraocular lens implantation

Chung and Lee BMC Ophthalmology 2014, 14:92 http://www.biomedcentral.com/1471-2415/14/92 CASE REPORT Open Access Streptococcus mitis/oralis endophthalmitis management without phakic intraocular lens removal in patient with iris-fixated phakic intraocular lens implantation Jin Kwon Chung and Sung Jin Lee* Abstract Background: To report a case of Streptococcus mitis/oralis endophthalmitis management which had developed after complicated iris-fixated phakic intraocular (pIOL) lens implantation. Case presentation: A 23-year-old-woman received pIOL implantation followed secondary intraocular intervention to lower intraocular pressure. The patient presented with severe pain and decreased visual acuity and was managed with intravitreal and intracameral antibiotic injection with topical applications of fortified antibiotics. Culture of aqueous humor was positive for S. mitis/oralis, which was sensitive to the empiric antibiotic regimen. Clinical features started to improve 5 days after treatment and the pIOL was left in place. The uncorrected distant visual acuity and endothelial cell count were 20/32 and 3143cells/mm2 four weeks after treatment, respectively. Conclusion: S. mitis/oralis endophthalmitis after pIOL implantation could be managed with appropriate antibiotic administration without pIOL removal if accompanied by rapid clinical improvement after the initial intensive management in the absence of vitreous involvement. Keywords: Streptococcus mitis/oralis, Endophthalmitis, Iris-fixated phakic intraocular lens, Antibiotic injection Background Phakic intraocular lenses (pIOLs) are generally accepted as effective and safe treatment options in the correction of moderate to high myopia [1]. Different from LASER assisted vision correction, a pIOL implantation into the anterior or posterior chamber is a reversible operation. This is a strong advantage of pIOL implantation, especially in the context of intra- or postoperative complication. However, intraocular surgery places patients at risk for endophthalmitis, which could lead to permanent visual loss. Although the rate of endophthalmitis is lower in pIOL implantation than in other types of intraocular surgery such as phacoemulsification and posterior chamber (PC) IOL implantation, early diagnosis and proper management is still important in the management of this potentially devastating complication [2,3]. We report a * Correspondence: Department of Ophthalmology, Soonchunhyang University Hospital, 59, Daesagwan-gil, Seoul 140-743, Yongsan-gu, Republic of Korea case of infectious endophthalmitis treated successfully without pIOL removal. Case presentation A 23-year-old-woman was referred to our hospital for severe pain and decreased visual acuity started one day ago in the right eye. Two days prior to this, the patient had foldable iris-fixated pIOL (Artiflex; Ophtec BV, Groningen, the Netherlands) implanted in both eyes at an outside clinic. On postoperative day one, she had undergone anterior chamber (AC) irrigation to remove residual viscoelastics which caused intraocular pressure (IOP) spike in the right eye. On examination, uncorrected distant visual acuity (UDVA) was hand motion with IOP of 21 mmHg for the right eye. Biomicroscopy of the eye revealed severe conjunctival injection, corneal edema, corneal infiltration at superior main incision, membrane formation around the pIOL, and a deep AC with a 1.5 mm hypopyon, which © 2014 Chung and Lee; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Chung and Lee BMC Ophthalmology 2014, 14:92 http://www.biomedcentral.com/1471-2415/14/92 were thought to represent infectious endophthalmitis (Figure 1A). Posterior segment evaluations such as vitreous cell grading and fundus examination were impossible because of severe corneal edema and AC inflammation. B-scan ultrasonography showed no definite vitreous involvement, and the left eye was normal. Immediate management involved AC irrigation, obtaining aqueous humor for culture and stain, and intravitreal vancomycin (1.0 mg/0.1 cc) and amikacin (0.4 mg/0.1 cc) injection. Gram and KOH stain smear revealed no bacteria or fungus. The patient was also treated with systemic (flomoxef 1.0 g every 12 hours) and topical (fortified vancomycin (50 mg/mL) and amikacin (20 mg/mL) hourly) antibiotics, prednisolone 1.0% four times daily, and homatropine 2% twice daily eye drops for a week, then the frequency was reduced according to the clinical response, culture, and sensitivity results. After 5 days of incubation, cultures became positive for Streptococcus mitis/oralis. By day 2 of admission, the patient did not improve so that AC irrigation, intracameral vancomycin (1.0 mg/0.1 cc) and amikacin (0.4 mg/0.1 cc) injection, and subtenon triamcinolone injection (40 mg/1.0 cc) were performed. After the second round of intervention, the patient began to improve clinically. On day 5, UDVA improved to 20/100, and biomicroscopy revealed moderate AC reaction without hypopyon and decreased inflammatory membrane behind the pIOL (Figures 1B, C). At 2 weeks, UDVA was 20/40 and IOP was 11 mmHg (Figure 1D). Page 2 of 3 Endothelial cell density was measured at 3143cells/mm2. At 1 month, UDVA improved to 20/32, and biomicroscopy showed minimal AC reaction and corneal edema. Conclusion Infectious postoperative endophthalmitis is rare but serious complication. Previously, there have been two reported cases of endophthalmitis after iris-fixated pIOL implantation. One case was of an Aspergillus endophthalmitis, which was managed with pIOL removal, lensectomty, and anterior vitrectomy with antifungal administration [4]. A second case was caused by Streptococcus pneumonia resulting in phthisis bulbi and was managed through therapeutic keratoplasty, removal of the pIOL, lensectomy, and repeated intravitreal injection of antibiotics [5]. For PC pIOL, the rate of endophthalmitis has been reported as approximately 1 case of endophthalmitis per 6000 implantable collamer lens implantation [2]. Oum et al. [6] reported Pseudomonas endophthalmitis after PC pIOL implantation. That patient was managed by removal of pIOL, lensectomy, vitrectomy with intravitreal antibiotics injection, and demonstrated CDVA of 20/30 at the end of treatment. To our knowledge, this report represents the first case of infectious endophthalmitis caused by S.mitis/oralis after iris-fixated pIOL implantation. S. mitis/oralis is an α-hemolytic gram-positive coccus belonging to the viridians streptococcus group and is commonly found in the oropharynx, gastroint (...truncated)