Umut Karaca, Murat Kucukevcilioglu, Gokhan Ozge, Ali Hakan Durukan

1Department of Ophthalmology, Isparta Suleyman Demirel University Faculty of Medicine, Isparta 32040, Turkey

2Department of Ophthalmology, Gulhane Education and Research Hospital, Ankara 06010, Turkey

Dear Editor,

We want to present the first reportedPropionobacterium acnes(P.acnes) endophthalmitis case after sutureless fixation of posterior chamber intraocular lens (IOL) to the sclera for the traetment of aphakia to the best of our knowledge.A 69-year-old man with aphakia due to complicated cataract surgery underwent sutureless intrascleral fixation of threepiece posterior chamber intraocular lens (PCIOL) with Yamane technique. What makes this case surprising and intreresting was the occurrence of this endophthalmitis in an eye in which the anterior vitreous was completely cleared by anterior vitrectomy after complicated cataract surgery and almost no capsules/zonules. As is known, the hallmark ofP. acnesinfection is the involvement of the posterior capsule or the presence of a white plaque on the IOL.

Intrascleral sutureless fixation of PCIOL has become more popular, since Yamaneet al[1]first described the technique at 2014 with less risks of damaging the cornea, iris and iridocorneal angle when compared to the other choices such as anterior chamber IOL or iris-fixated IOL. Previously described intraoperative and early postoperative complications were hyphema, cystoid macular edema, corneal edema and IOL dislocation[1-4]. However, late postoperative complications such as vitreous haemorrage, retinal detachment or endophthalmitis have not been reported before in the literature.

Ethical ApprovalThis study complied with the tenets of the Declaration of Helsinki. Written informed consent was obtained from the patient for publication.

CASE REPORT

The patient was a 69 year-old male with aphakia due to complicated cataract surgery in July 2019. Sutureless intrascleral fixation of three-piece PCIOL (Sensar AR40e,Johnson&Johnson Vision, USA) with Yamane technique was performed, and the haptics were placed to 180° apart to each other at 2 mm from the limbus. Peroperative anterior vitrectomy was performed. His vision improved to 20/25 one week later with good centralization of the IOL. However, his vision decreased to 20/4000 (hand motion) at postoperative 3rdmonth follow-up without pain and ciliary flush. Mild corneal edema, 4+ anterior chamber cells, and +3 vitreous haze were determined at the examination. The flanges were observed under the intact conjunctival tissue. Retina could not be seen due to vitritis (Figure 1A). Pars plana vitrectomy (PPV) and intravitreal vancomycine (Vancomycine Hcl DBL 500 mg,Wasserburger Arzneimittel GmbH, Germany) and ceftazidime(Fortum 1 g, GlaxoSmithKline SpA, Italy) injection was performed immediately. Aqueous humour and vitreous samples were taken for microbiological analysis. Retinal haemorrhages and whitish bacterial aggregates at pars plana were observed during surgery (Figure 1B, 1C).P. acneswas reported at the microbiological analysis of vitreus specimen. The vision was 20/32 at the follow-up examination sixth month after the surgery (Figure 2).

DISCUSSION

Here, we present aP. acnesendophthalmitis seen after secondary IOL implantation with Yamane technique. What makes this case surprising and intreresting was the occurrence of this endophthalmitis in an eye in which the vitreous was completely cleared by anterior vitrectomy after complicated cataract surgery and almost no capsules/zonules. As is known,the hallmark ofP. acnesinfection is the involvement of the posterior capsule or the presence of a white plaque on the IOL[5].

The major indications for sutureless intrascleral fixation of IOLs were complications that developed during phacoemulsification,such as capsular defects and IOL decentralisation or subluxation[6]. It is first described by Yamaneet al[1]in 35 eyes

Figure 1 Preoperative photos of anterior and posterior segment of the eye A: Mild corneal edema and anterior chamber cells.Flanges of IOL can be seen at 12 and 6 o’clock position. B-C: Whitish bacterial plaques (arrow-B) and retinal haemorrhages (arrow-C) was observed during PPV.

of 34 patients at 2014 with postoperative complications as iris capture of the IOL in 3 eyes, transient ocular hypertension in 2 eyes, and cystoid macular edema in 1 eye. Retinal detachment,endophthalmitis, IOL dislocation, or vitreous hemorrhage were not detected during the follow-up period[1]. There are several occasions of complications such as endophthalmitis were described with especially scleral-sutured fixation methods,therefore the prominent feature that makes this technique favorable is having less of risks of complications when compared with conventional scleral-sutured IOL implantation methods[7]. Todorichet al[8]reported 122 transconjunctival sutureless intrascleral PCIOL implantation cases and one culture negative endopthalmitis. This was the only endophthalmitis case reported after sutureless intrascleral IOL fixation.

P. acnesis an anaerobic, gram-positive, pleomorphic, bacillus causing low grade endophthalmitis, and typical clinical feature is the presence of whitish intracapsular plaque in the periphery.Conjunctival injection, keratic precipitates, and vitritis may be seen, but hypopyon occurs infrequently[9]. In this case without any capsular support, plaques were seen at the vitreous base near ora serrata. Corneal incisions of phacoemulcification surgery and scleral tunnels of Yamane technique are potential entry sites for the bug. Immediate vitrectomy is suggested in patients with endophthalmitis according to the vision at presentation[10]. Postoperative vision after vitrectomy surgery was 0.63 without any inflammation in the anterior chamber and the vitreous.

Figure 2 Photos of anterior segment and posterior segment of eye after PPV.

Intrascleral sutureless fixation of PCIOL is a compelling choice for the treatment of aphakia with insufficient capsular support or IOL decentralization, but annoyingly late onset complications such as endophthalmitis have to be kept in mind.

ACKNOWLEDGEMENTS

Authors’ contributions:Collection of data (Karaca U,Kucukevcilioglu M, Ozge G, Durukan AH), preparation of the manuscript (Karaca U, Kucukevcilioglu M), and supervision(Ozge G, Durukan AH). All the authors have read and approved the final manuscript.

Conflicts of Interest:Karaca U,None;Kucukevcilioglu M,None;Ozge G,None;Durukan AH,None.