<p>Clinical Presentations and Comparative Outcomes of Delayed-Onset Low-Grade Endophthalmitis Managed with or Without Intraocular Lens Explantation</p>

Abstract

Purpose: To compare the outcomes of delayed-onset low-grade endophthalmitis managed with and without intraocular lens (IOL) explantation. Setting: Tertiary eye-care research institute in southern India. Design: Retrospective comparative case series. Methods: The study included all cases of post-cataract surgery delayed-onset endophthalmitis from January 1990 to January 2019. Time to endophthalmitis, duration of symptoms, presenting visual acuity, time to IOL explantation when performed, resolution after explantation, number of intravitreal injections, and final visual acuity were compared in the IOL nonexplanted and IOL explanted groups. Results: There were 115 eyes-61 eyes in the IOL non-explant and 54 eyes in the IOL explant group. Between the two groups there was no statistically significant difference in age (58.37 ± 14.05 and 56.04 ± 14.96 years, respectively; p=0.35), vision at presentation (>20/400 in 29.5% and 29.6% eyes, respectively; p=0.98), and the duration of follow-up (14.38 ± 16.05, median 8.5 months and 7.06 ± 3.55, median 6 months respectively; p=0.43). There was a statistically significant difference between the IOL non-explant and IOL-explant groups in the time to resolution of inflammation (92.70 ± 36.28 and 45.33±11.2 days, respectively; p <0.0001) and the number of intravitreal injections (4.57 ± 0.75, median 5 and 2.79 ±2.11, median 2 respectively, p=0.005). Persistent/recurrent inflammation at 6 months was recorded in 18.03% and 5.55% in the IOL non-explant and IOL explant eyes, respectively (p=0.04). Favorable functional outcome was seen in 50.81% vs 68.51% in IOL non-explant and explant eyes, respectively (p=0.05). Conclusion: IOL explantation in delayed-onset endophthalmitis helps in earlier resolution of inflammation, need for lesser number of intravitreal injections and a trend towards better functional outcomes.

Propionibacterium acnes–associated Delayed-onset Pseudophakic Endophthalmitis

“…Studies of delayed-onset pseudophakic endophthalmitis that are inclusive of pathogens other than P. acnes appear to report less favorable visual outcomes in eyes affected by pathogens other than P. acnes particularly in those eyes with fungal endophthalmitis. 3,24 Al-Mezaine et al, 3 for example, reported that 5 of 7 eyes infected with P. acnes had a final visual acuity > 20/60, while 2 of 3 eyes with fungal pathogens had a final visual acuity of <2/200. '…”

“…40 A large subset of patients with delayed-onset postoperative endophthalmitis after cataract surgery will eventually require capsulectomy or IOL explantation, but the optimal timing of this intervention is not known and is made on a case by case basis. While not focused specifically on P. acnes, a series by Dave et al 24 compared outcomes of primary versus deferred IOL explantation in delayed-onset endophthalmitis (66 cases postcataract surgery and 77 total cases). These authors found that early lens explantation leads to fewer repeated intraocular injections and faster resolution of inflammation, but that there was no significant difference in final visual acuity.…”

“…In an institutional review of all cases of delayed-onset postcataract surgery endophthalmitis from 2009 to 2019 an LV Prasad Eye Institute, only 38 of 115 (33%) were culture positive. 24 The diagnosis of P. acnes endophthalmitis can be challenging due to the difficulty of growing P. acnes in conventional culture. 4 The series by Aldave and Clark suggest that time in culture and site of culture are important variables for successful culture positivity.…”

“…Culture positivity in delayed-onset pseudophakic endophthalmitis may be even lower. In an institutional review of all cases of delayed-onset postcataract surgery endophthalmitis from 2009 to 2019 an LV Prasad Eye Institute, only 38 of 115 (33%) were culture positive 24…”

Intraocular lens removal or not during vitrectomy for acute infectious endophthalmitis after cataract surgery

“…In cases with very severe inflammatory reaction, including corneal swelling and obscure, small pupil, and unclear capsule bag, it is necessary to extract IOL for subsequent appropriate vitrectomy. In a chronic or fungi infectious endophthalmitis after cataract surgery, IOL removal can be performed in most cases [4][5] . The necessity of silicone oil use in the case series is questionable.…”