Lens Capsular Bag Lavage as Minimal Invasive Procedure for Postoperative Low-Grade Endophthalmitis

Jost B. Jonas, M.D., Wido M. Budde,M.D., and Songhomitra Panda-Jonas, M.D.

Corresponding author: Dr. J. Jonas, Universitäts-Augenklinik, Schwabachanlage 6, 91054 Erlangen, Germany; Phone: **49-9131-853001; FAX **49-9131-854436; e-mail: Jost.Jonas@augen.med.uni-erlangen.de

Abstract

Purpose: To report on an minimally invasive surgical treatment for postoperative low-grade endophthalmitis.

Methods: A 66-year-old patient underwent uncomplicated cataract surgery with intraocular lens implantation into the capsular bag. Two weeks later, he presented with painful low-grade endophthalmitis with whitish precipitates in the capsular bag and anterior chamber inflammation. After unsuccessful topical and systemic antibiotic treatment, the lens capsular bag was irrigated with an antibiotica enriched intraocular solution.

Results: After two days, intraocular inflammation subsided. Visual acuity returned to 20/20 and has remained so up to now with a follow-up of more than one year.

Conclusions: Capsular bag lavage is a minimally invasive surgical treatment of postoperative low-grade endophthalmitis that can be performed under topical anesthesia in an out-patient setting.

Chronic low-grade endophthalmitis is a relatively rare and severe complication threatening vision after uneventful cataract surgery. It is usually caused by microorganisms of low pathogenicity such as Staphylococcus epidermidis, Propionibacterium acnes, Rhodococcus luteus, Ochrobactrum anthropi, and others (1,2). Usual methods of managing this condition include topical and systemic application of antibiotics, and if these procedures are unsuccessful, eventual removal of the intraocular lens and lens capsule. We have attempted to treat this condition with an alternative method of therapy that can be performed under local anesthesia in an out-patient setting.

Case Report:

We report on a 66-year-old patient who underwent unremarkable cataract surgery with scleral tunnel incision and implantation of a non-foldable intraocular lens into the capsular bag. The past medical history was significant for bronchial asthma that for two years had been treated with 8 mg prednisolone daily. Two weeks after the operation, he presented with moderate pain due to low-grade intraocular inflammation. Physical examination revealed 2+ inflammatory cells and 2+ flare in the anterior chamber without hypopyon. There were inflammatory precipitates on the corneal endothelium, whitish conglomerates between the intraocular lens and capsular bag, and moderate vitreous infiltration by inflammatory cells. The scleral incision was closed and covered by conjunctiva.

The patient was treated with topical tobramycin and erythromycin in standard concentrations every hour, and intravenous application of cefotiam and netilmicin for five days. Fortified concentrations of eye drops were not used, and topical or systemic steroids were not given. When despite medical treatment inflammation and pain increased, and visual acuity decreased from 10/20 to 5/20, we irrigated the lens capsular bag under local anesthesia consisting of topical cocaine 5% eye drops and subconjunctival injection of 2 ml mepivacaine 2%. Through a one millimeter wide paralimbal corneal incision, we introduced an intraocular irrigation needle into the anterior chamber, aspirated anterior chamber fluid for microbiological culture, opened the circular adhesions between the margin of the capsulorhexis and the optical part of the intraocular lens, and irrigated the capsular bag with 30 ml of Ringer`s solution combined with 0.12 mg/ml gentamicin and 0.03 mg/ml vancomycin. Postoperatively, systemic and topical medication was continued for four days. Steroids were not given.

After two days, the intraocular inflammation subsided. Without further treatment, the patient has remained free of symptoms for one year up to now. Visual acuity has increased to 20/20. The anterior chamber has been free of cells and flare, the intraocular lens is centered in the capular bag, and the inflammatory precipitates in the capsular bag and on the corneal endothelium have disappeared.

Comment:

Confirming previous studies (3-5), the present report suggests that lavage of the capsular bag including the intraocular lens is a minimally invasive surgical procedure for postoperative low-grade endophthalmitis. It can be performed under topical anesthesia in an out-patient setting without removal of the intraocular lens. Since medical treatment of postoperative low-grade endophthalmitis usually has a prolonged course and often does not obviate the need for surgery, capsular bag lavage is a minimally invasive procedure which may be performed early in the treatment of postoperative low-grade endophthalmitis.

References

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