A Dickens

BH Doft

CW Eifrig

D Papaconstantinou

Dimitris Papaconstantinou

G Picht

Gerasimos Georgopoulos

GL Skuta

Ilias Georgalas

Ioannis Ladas

JC Mwanza

JP Cannon

Konstantinos Droutsas

LJ Katz

P Sternberg Jr

S Cillino

Themis Karmiris

TM Kuang

WC Hsu

Journal of Medical Case Reports

English

PubMed

Springer - Publisher Connector

JOURNAL OF MEDICAL
CASE REPORTS
Papaconstantinou et al. Journal of Medical Case Reports 2010, 4:203
http://www.jmedicalcasereports.com/content/4/1/203
Open AccessC A S E  R E P O R TCase reportAcute onset lactobacillus endophthalmitis after 
trabeculectomy: a case report
Dimitris Papaconstantinou, Ilias Georgalas*, Themis Karmiris, Ioannis Ladas, Konstantinos Droutsas and 
Gerasimos Georgopoulos
Abstract
Introduction: We report a case of early lactobacillus endophthalmitis which occurred ten days after trabeculectomy.
Case presentation: A 76-year-old Caucasian diabetic woman underwent uncomplicated trabeculectomy with a 
collagen implant as an adjunct, in her left phakic eye, for the treatment of uncontrolled open-angle glaucoma. Ten 
days post-operatively, our patient complained of left phakic eye discharge pain and visual acuity decreased to "light-
perception". The anterior chamber had 3+ cells and flare, and there was also 2 mm layered hypopyon. Vitreous 
involvement was present obscuring visualization of the fundus. On the same day our patient underwent vitrectomy 
surgery and intra-vitreal and systemic antibiotics were administered. Vitreous cultures grew Lactobacillus brevis. Our 
patient responded well to treatment and 30 days after vitrectomy visual acuity improved to 1/10. Six months later our 
patient underwent cataract surgery. Eight months after initial surgery visual acuity was 2/10 and intra-ocular pressure 
was 14 mmHg without any anti-glaucoma medication.
Conclusions: This is the first report of acute lactobacillus endophthalmitis in the phakic eye of a diabetic patient after 
trabeculectomy. Glaucoma surgeons should be aware of the potential for acute post-operative endophthalmitis due to 
rare microorganisms, such as lactobacillus, in glaucoma filtration surgery, especially in diabetic patients. The literature 
shows an increased risk of endophthalmitis when anti-metabolites are used in conjunction with trabeculectomy. 
Perhaps, any type of wound healing modulation, such as collagen or mitomycin-C may increase this risk. However, it is 
unclear at this time and more studies need to be done. In this single case, vitrectomy combined with intra-vitreal and 
systemic antibiotics were efficient in limiting the devastating sequels of this complication.
Introduction
Trabeculectomy is the most common operation for the
treatment of glaucoma worldwide. However, bleb failure
may be eventually induced, by wound healing processes
and scar formation [1,2]; many adjunctive procedures
such as the use of anti-metabolites [3], bleb needling and
implants have been proposed to enhance and maintain
the hypotensive effect of trabeculectomy [4,5]. Ologen™ is
a bioengineered, biodegradable soaked, three-dimen-
sional, porous, collagen-glycosaminglycan implant which
may be used in trabeculectomy, providing controlled
resistance between the anterior chamber and the subcon-
junctival space [4,6]. In a recent study trabeculectomy
with Ologen has not been proven to offer any significant
advantages when compared with trabeculectomy alone
[6]. Additionally, one of the studied eyes developed
endophthalmitis but this was not clearly associated with
the Ologen use [6].
Lactobacillus is a gram-positive microorganism that is
generally considered non-pathogenic and it is used for
enhancement of flavor in dairy products. We report a
case of early endophthalmitis due to Lactobacillus brevis
after trabeculectomy, which, to the best of our knowl-
edge, has never been reported before as a cause for post-
surgical endophthalmitis, and describe its course after
vitrectomy surgery.
Case presentation
A 76-year-old Caucasian woman was admitted for a trab-
eculectomy in the left phakic eye (LE) for uncontrolled
open-angle glaucoma. Visual acuity (VA) was 4/10. The
* Correspondence: igeorgalas@yahoo.com
1 Department of Ophthalmology, "G. Gennimatas" Hospital, University of 
Athens, Greece
Full list of author information is available at the end of the article© 2010 Papaconstantinou et al; 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 repro-
duction in any medium, provided the original work is properly cited.
Papaconstantinou et al. Journal of Medical Case Reports 2010, 4:203
http://www.jmedicalcasereports.com/content/4/1/203
Page 2 of 3patient denied a history of systemic illness apart from
type II diabetes mellitus.
Uncomplicated trabeculectomy was performed during
which an Ologen implant was placed on top of the scleral
flap under the conjunctiva before the final suturing. On
the first post-operative day, there was a diffuse superior
bleb. The anterior chamber (AC) was half normal depth
and contained a minimal reaction of 1+ cells and flare
(Figure 1). One week post-operatively the situation was
unchanged. Ten days post-operatively, our patient com-
plained of LE discharge pain and VA decreased to "light-
perception". Anterior chamber had 3+ cells and flare, and
there was also 2 mm layered hypopyon with plastic fibrin
across the pupillary margin (Figure 2). Vitreous involve-
ment was present obscuring visualization of the fundus.
On the same day the patient underwent vitrectomy,
during which the vitreous cutter was placed in the mid
vitreous and before turning on the infusion, 0.5 mL vitre-
ous sample was aspirated. Subsequently the infusion was
turned on and the cortical vitreous was excised. An intra-
vitreal injection of vancomycin and amikacin was admin-
istered. The Ologen implant was not removed from the
trabeculectomy since there were no signs of severe blebi-
tis. Vitrectomy cassette and samples were sent to the lab-
oratory. Ologen implants from the same batch, with the
one used, were sent for culture; additionally, blood sam-
ples and samples from our patient's conjunctiva were
send for culture. Avelox tablets 400 mg (moxifloxacin-
hydrochloride) twice a day, ofloxacin and dexamethasone
drops four times a day and atropine drops twice a day,
were administered post-operatively.
Our patient responded well to treatment and infection
started resolving from the first post-operative day. Cul-
tures from both undiluted vitreous and cassette grew
Lactobacillus brevis, blood and cultures from the con-
junctival samples and the collagen implants (from the
same batch) were negative for any microorganism. One
week later fundus reflex was visible in slit-lamp biomi-
croscopy (Figure 3), and 30 days later VA was 1/10 and
intra-ocular pressure 14 mmHg. Six months later our
patient underwent uncomplicated phacoemulsification
and intra-ocular lens implantation. Eight months after
initial surgery VA is 2/10 and intra-ocular pressure is 14
mmHg without any anti-glaucoma medication.
Discussion
Bacterial endophthalmitis, after trabeculectomy, usually
develops months to years after surgery. Acute post-oper-
ative endophthalmitis has been rarely reported in phakic
eyes after trabeculectomy [7]. Eifrig et al. in a review of
the medical records of 35,916 patients that underwent
intra-ocular surgery, found only four patients who devel-
oped acute endophthalmitis after trabeculectomy, in
three of whom mitomycin-C (MMC) had been used as an
Figure 1 First day after trabeculectomy with Ologen, the anterior 
chamber is well formed and the Ologen implant in situ.
Figure 2 Ten days after trabeculectomy, there is hypopyon with 
plastic fibrin across the papillary margin.
Figure 3 After vitrectomy hypopyon has completely subsided.
Papaconstantinou et al. Journal of Medical Case Reports 2010, 4:203
http://www.jmedicalcasereports.com/content/4/1/203
Page 3 of 3adjunct [8]. Kuang et al. [9] in a retrospective study
reported only one case, out of 988 trabeculectomies, with
early post-operative endophthalmitis due to Morganella
morganii. Host flora is usually responsible for early cases
of endophthalmitis and Staphylococcus epidermitis is the
most common organism. Gram-negative organisms such
as H. influenzae are isolated most frequently from late
onset endophthalmitis [7,8]. Most literature suggests that
patients with diabetes are at increased risk of developing
endophthalmitis after intraocular surgery [10].
Lactobacillus is a gram-positive bacterium and is a
common inhabitant of the human mouth, gastrointestinal
tract, and female genital tract. Only 200 cases of lactoba-
cillus-associated infections have been reported in the lit-
erature [11] and only one case of endophthalmitis due to
lactobacillus has been reported which concerned and
injured eye [11,12]. In our case no anti-metabolite was
used, but an Ologen implant was placed on top of the
scleral flap under the conjunctiva, before the final sutur-
ing of the conjunctiva. The endophthalmitis occurred 10
days after surgery and we decided to perform vitrectomy
first since endophthalmitis after trabeculectomy is usu-
ally severe and aggressive treatment, with vitrectomy and
systemic antibiotics is advocated [13]; and second in
order to yield enough undiluted vitreous for culture.
Conclusions
We report the first case of acute lactobacillus
endophthalmitis in the phakic eye of a diabetic patient
after trabeculectomy. Glaucoma surgeons should be
aware of the potential of acute post-operative
endophthalmitis due to rare microorganisms, such as lac-
tobacillus, in glaucoma filtration surgery, especially in
diabetic patients. The literature shows an increased risk
of endophthalmitis when anti-metabolites are used in
conjunction with trabeculectomy. Perhaps any type of
wound healing modulation, such as collagen or mitomy-
cin-C, may increase this risk; however, it is unclear at this
time and more studies needs to be done. In this case, vit-
rectomy combined with intra-vitreal and systemic antibi-
otics were efficient in limiting the devastating sequels of
this complication.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
DP, IG and IL were in charge of the medical care of the patient and performed
the different surgeries. KD, TK were responsible for the photographs and the lit-
erature review. DP, IG and KD wrote the manuscript. GG and IL reviewed it,
drafted it critically and provided helpful comments. All authors read and
approved the final manuscript.
Author Details
Department of Ophthalmology, "G. Gennimatas" Hospital, University of Athens, 
Greece
References
1. Skuta GL, Parrish RK: Wound healing in glaucoma filtering surgery.  Surv 
Ophthalmol 1987, 32(3):149-170.
2. Picht G, Grehn F: Classification of filtering blebs in trabeculectomy: 
biomicroscopy and functionality.  Curr Opin Ophthalmol 1998, 9(2):2-8.
3. Mwanza JC, Kabasele PM: Trabeculectomy with and without mitomycin-
C in a black African population.  Eur J Ophthalmol 2001, 11(3):261-263.
4. Cillino S, Zeppa L, Di Pace F, Casuccio A, Morreale D, Bocchetta F, Lodato 
G: E-PTFE (Gore-Tex) implant with or without low-dosage mitomycin-C 
as an adjuvant in penetrating glaucoma surgery: 2 year randomized 
clinical trial.  Acta Ophthalmol 2008, 86(3):314-321.
5. Hsu WC, Ritch R, Krupin T, Chen HS: Tissue bioengineering for surgical 
bleb defects: an animal study.  Graefes Arch Clin Exp Ophthalmol 2008, 
246(5):709-717.
6. Papaconstantinou D, Georgalas I, Karmiris E, Diagourtas A, Koutsandrea C, 
Ladas I, Apostolopoulos M, Georgopoulos G: Trabeculectomy with 
OloGen versus trabeculectomy for the treatment of glaucoma: a pilot 
study.  Acta Ophthalmol 2010, 88(1):80-85.
7. Katz LJ, Cantor LB, Spaeth GL: Complications of surgery in glaucoma. 
Early and late bacterial endophthalmitis following glaucoma filtering 
surgery.  Ophthalmology 1985, 92(7):959-963.
8. Eifrig CW, Flynn HW Jr, Scott IU, Newton J: Acute-onset postoperative 
endophthalmitis: review of incidence and visual outcomes (1995-
2001).  Ophthalmic Surg Lasers 2002, 33(5):373-378.
9. Kuang TM, Lin YC, Liu CJ, Hsu WM, Chou CK: Early and late 
endophthalmitis following trabeculectomy in a Chinese population.  
Eur J Ophthalmol 2008, 18(1):66-70.
10. Doft BH, Wisniewski SR, Kelsey SF, Fitzgerald SG: Diabetes and 
postoperative endophthalmitis in the endophthalmitis vitrectomy 
study.  Arch Ophthalmol 2001, 119(5):650-656.
11. Cannon JP, Lee TA, Bolanos JT, Danziger LH: Pathogenic relevance of 
Lactobacillus: a retrospective review of over 200 cases.  Eur J Clin 
Microbiol Infect Dis 2005, 24(1):31-40.
12. Dickens A, Greven CM: Posttraumatic endophthalmitis caused by 
Lactobacillus.  Arch Ophthalmol 1993, 111(9):1169.
13. Sternberg P Jr, Martin DF: Management of endophthalmitis in the post-
endophthalmitis vitrectomy study era.  Arch Ophthalmol 2001, 
119(5):754-755.
doi: 10.1186/1752-1947-4-203
Cite this article as: Papaconstantinou et al., Acute onset lactobacillus 
endophthalmitis after trabeculectomy: a case report Journal of Medical Case 
Reports 2010, 4:203
Received: 4 January 2010 Accepted: 30 June 2010 
Published: 30 June 2010
This article is available from: http://www.jmedicalcasereports.com/content/4/1/203© 2010 Papaconst ntinou et al; licensee BioMed Central Ltd. is an Open Access article distributed und r th  t ms of the Creativ  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 cited.Journal of Medic  Case Reports 2010, 4:203


Acute onset lactobacillus endophthalmitis after trabeculectomy: a case report

Abstract
          
            Introduction
            We report a case of early lactobacillus endophthalmitis which occurred ten days after trabeculectomy.
          
          
            Case presentation
            A 76-year-old Caucasian diabetic woman underwent uncomplicated trabeculectomy with a collagen implant as an adjunct, in her left phakic eye, for the treatment of uncontrolled open-angle glaucoma. Ten days post-operatively, our patient complained of left phakic eye discharge pain and visual acuity decreased to "light-perception". The anterior chamber had 3+ cells and flare, and there was also 2 mm layered hypopyon. Vitreous involvement was present obscuring visualization of the fundus. On the same day our patient underwent vitrectomy surgery and intra-vitreal and systemic antibiotics were administered. Vitreous cultures grew Lactobacillus brevis. Our patient responded well to treatment and 30 days after vitrectomy visual acuity improved to 1/10. Six months later our patient underwent cataract surgery. Eight months after initial surgery visual acuity was 2/10 and intra-ocular pressure was 14 mmHg without any anti-glaucoma medication.
          
          
            Conclusions
            This is the first report of acute lactobacillus endophthalmitis in the phakic eye of a diabetic patient after trabeculectomy. Glaucoma surgeons should be aware of the potential for acute post-operative endophthalmitis due to rare microorganisms, such as lactobacillus, in glaucoma filtration surgery, especially in diabetic patients. The literature shows an increased risk of endophthalmitis when anti-metabolites are used in conjunction with trabeculectomy. Perhaps, any type of wound healing modulation, such as collagen or mitomycin-C may increase this risk. However, it is unclear at this time and more studies need to be done. In this single case, vitrectomy combined with intra-vitreal and systemic antibiotics were efficient in limiting the devastating sequels of this complication.
          </jats:sec

Crossref

Acute-onset postoperative endophthalmitis: review of incidence and visual outcomes (1995-2001). Ophthalmic Surg Lasers

CK: Early and late endophthalmitis following trabeculectomy in a Chinese population.

GL: Complications of surgery in glaucoma. Early and late bacterial endophthalmitis following glaucoma filtering surgery. Ophthalmology

Grehn F: Classification of filtering blebs in trabeculectomy: biomicroscopy and functionality. Curr Opin Ophthalmol

Greven CM: Posttraumatic endophthalmitis caused by Lactobacillus. Arch Ophthalmol

HS: Tissue bioengineering for surgical bleb defects: an animal study. Graefes Arch Clin Exp Ophthalmol

Kabasele PM: Trabeculectomy with and without mitomycinC in a black African population.

LH: Pathogenic relevance of Lactobacillus: a retrospective review of over 200 cases.

Lodato G: E-PTFE (Gore-Tex) implant with or without low-dosage mitomycin-C as an adjuvant in penetrating glaucoma surgery: 2 year randomized clinical trial. Acta Ophthalmol

Management of endophthalmitis in the postendophthalmitis vitrectomy study era. Arch Ophthalmol

Parrish RK: Wound healing in glaucoma filtering surgery. Surv Ophthalmol

SG: Diabetes and postoperative endophthalmitis in the endophthalmitis vitrectomy study. Arch Ophthalmol

Trabeculectomy with OloGen versus trabeculectomy for the treatment of glaucoma: a pilot study. Acta Ophthalmol

file:///data/remote/core/dit/data/Springer-OA/pdf/09d/aHR0cDovL2xpbmsuc3ByaW5nZXIuY29tLzEwLjExODYvMTc1Mi0xOTQ3LTQtMjAzLnBkZg==.pdf

Acute onset lactobacillus endophthalmitis after trabeculectomy: a case report

Abstract

Similar works

Full text

Available Versions

Springer - Publisher Connector

Springer - Publisher Connector

Crossref