Successful antibiotic management of Staphylococcus epidermidis endophthalmitis without ICL explantation or vitrectomy.

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Ke Zheng, Xiaohong Zheng, Dekang Gan, Xingtao Zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2648102/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Oct, 2023 Read the published version in BMC Ophthalmology → Version 1 posted 8 You are reading this latest preprint version Abstract Purpose : We report a case of successful medical management of subacute endophthalmitis post implantable collamer lens (ICL) culture-positive of Staphylococcus epidermidis. Observations : A 18-year-old female presented with decreased visual acuity in the left eye 20 days after ICL implantation. A diagnosis of postoperative endophthalmitis was made based on examination and ultrasonography. A vitreous tap was taken, and intravitreal antibiotics (vancomycin 1mg/0.1ml and ceftazidime 2 mg/0.1 mL) were administered twice (q72h), and para bulbar injection of triamcinolone acetonide on day 8. The vitreous culture was confirmed for Staphylococcus epidermidis. The endophthalmitis was resolved, and BCVA improved from 6/20 to 12/20 on day 7 and 22/20 on day 38. This is the first successful medical resolution of Staphylococcus epidermidis endophthalmitis without ICL explantation and vitrectomy in the V4c model. Conclusions and importance : In antibiotic therapy, the excellent compliance and close follow-up of this endophthalmitis patient enabled careful postoperative surveillance on the effect of antibiotic therapy, avoiding the removal of the ICL or the loss of the integrity of the eye. The risk of potential infectious endophthalmitis post-ICL surgery should be fully emphasized during preoperative counseling. Postoperative endophthalmitis Staphylococcus epidermidis Implantable collamer lens Antibiotic therapy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Posterior chamber phakic implantable collamer lens (ICL) implantation was effective and safe for the correction of myopia1. Infectious endophthalmitis after intraocular surgery is a rare vision-threatening complication. The categories of postoperative endophthalmitis can be divided into acute, subacute, and chronic. The vitreous tap of most subacute cases is confirmed to be Staphylococcus epidermidis and fungi2. Post-ICL endophthalmitis has been reported previously 3. However, we reported the first successful medical treatment of Staphylococcus epidermidis endophthalmitis without ICL explantation and vitrectomy in the V4c model. Case Report A complete vaccination covid-19 test negative 18-year-old female with high myopia and astigmatism and no medical problems came to our clinic to evaluate refractive surgery. The cycloplegic refraction was − 11.25/-2.50x175 OD and − 9.5/-2.00x170 OS. The corrected distance visual acuity (CDVA) was 20/20 in both eyes. The endothelial cell density was 3245 cells/mm 2 OD and 3190 cells/mm 2 OS. The white-to-white diameter was 12.1mm and 12.3 mm, and the anterior chamber depth (from endothelium) was 3.38mm and 3.49mm, respectively. Informed consent was obtained after explaining the potential risks of surgery. V4c TICL (VTICMO13.7–15.0/+2.5x113 OD VTICMO13.7–13.0/+2.5x113 OS) (Visian, STAAR Surgical Co, California, USA) were implanted, the surgery was uneventful. Topical Levofloxacin 0.5% four times a day and prednisolone acetate 1% four times a day were started immediately after the surgery. The uncorrected distance visual acuity (UDVA) was 20/20 in both eyes on the first postoperative day; there was no corneal edema, and 1 + cells were present in the anterior chamber (AC). The ICLs were in situ with a vault of 660µm OD and 550 µm OS on pentacam. The patient presented with blurred vision and redness of the left eye 20 days following bilateral ICL surgery. She was noted to have participated in an intensive bicycle racing competition hosted in Shanghai 3 days ago. Visual acuity (VA)was 20/20OD and 10/20 OS with intraocular pressure (IOP) of 21.8 mmHg and 15.9 mmHg, respectively. Slit lamp exam showed clinical manifestations, including mild conjunctival and ciliary congestion, white round keratic precipitates, 3 + anterior chamber flare, and cells, with fibrin exudate, 1mm hypopyon in the anterior chamber, vitreous opacity OS; the right eye was unremarkable. The ICL was in a good position. Dilated fundus exam was invisible(Fig. 1 ). Treatment Considered for postoperative endophthalmitis OS, a vitreous tap and injection of vancomycin 1mg/0.1ml and ceftazidime 2 mg/0.1 mL was performed. The sample was sent for pathogen detection and drug sensitivity testing. The patient was also treated with systemic(cetrazidime1gIVq24h)and topical antibiotics(Tobramycin Dexamethasone Eye q15m 15mg:5mg/5ml, Levofloxacin 0.5% Eye Drop q2h), 1% prednisolone acetate eye drops three times a day and 0.5% tropicamide qd. The cultures were positive for Staphylococcus epidermidis, which was sensitive to all antibiotics. The patient was diagnosed with postoperative endophthalmitis. 24h after intravitreal injection, the BCVA was 6/20, with the resolution of hypopyon. (Fig. 2 ). Systematic antibiotic treatment was continued (intravenous administration of Ceftazidime) over the subsequent three days. Given persistent inferior keratic precipitates, anterior chamber flare and cells, and vitreous opacity, vision remained 6/20, fibrin exudation in the pupil area and the vitreous body was much less (Fig. 3 ), intravitreal injection of vancomycin 1mg/0.1ml and ceftazidime 2 mg/0.1 mL was performed 72hours again later. As the AC inflammation and IOL deposits were minimal, we did not remove the ICL nor AC washout, and a close follow-up was arranged to monitor the progress of endophthalmitis. After four days of the second intravitreal injection, the vision was 12/20, anterior chamber flare and cells (+), and Para bulbar injection of triamcinolone acetonide was administered. Outcome And Follow Up Outcome and follow up The topical treatment was tapered gradually over one month. There was a notable improvement in AC reaction, complete resolution of exudates, and gradual resolution of the vitreous opacity, BCVA improved to 22/20 on day 38 post the antibiotic Therapy with inactive vitreous opacities(Fig. 4 ). The uncorrected distance visual acuity of 20/20 was achieved three months following the antibiotic therapy, the manifest refraction was − 0.25/-0.50x65 = 1.0, the anterior chamber was unremarkable, persistent vitreous opacities were resolved, fundus photograph of the left eye was clear (Fig. 5 ). Discussion ICLs are ciliary sulcus placed anterior to the natural lens to treat myopia, correcting refractive error ranging from − 0.5D to -18D. It is an alternative, especially for patients with abnormal corneal topography and high myopia, and can provide better postoperative visual quality in patients with high myopia in the early postoperative period4. Infectious endophthalmitis is one of the most vision-threatening complications post-ICL surgery. The rate of endophthalmitis post-ICL patients was approximately 1 in 6000(0.017%~0.036%)5. Cases of endophthalmitis caused by Pseudomonas aeruginosa6, Cutibacterium acnes 7, and Staphylococcus epidermidis3 postoperative have been reported, which required removal of the ICL during the treatment and replanted. Staphylococcus epidermidis endophthalmitis commonly presents as subacute Inflammation ranging from two to six weeks post-operation. Our patient developed endophthalmitis 20 days after the implantation. Virulence of the pathogens is considered a critical factor in the prognosis. In some cases, patients will require a partial capsulectomy 8 . Poor prognosis cases mostly require intraocular lens removal, radical vitrectomy with hyaloid peeling, base dissection, and silicone oil 6 , 8 , 9 . Host factors that lower resistance to infection, such as chronic immunosuppressive therapy and diabetes mellitus, have also been reported to be significant risk factors for postoperative endophthalmitis 10 . The early postoperative recovery was uneventful. In our case, the cause of the infection remains uncertain, and the patient’s intensive physical exercise (riding race) may increase the risk of endophthalmitis, contaminated by the sweat flowing into the eye. In addition, the temporal precise unsutured corneal incision may increase the probability of the entry of the organisms leading to the formation of endophthalmitis. There is another case report of culture-positive coagulase-negative Staphylococcus epidermidis 11 . The model of ICL, in this case, is V4b without a central hole, which may be like a barrier against the invasion of the organism. In the V4c model with a central hole and two additional holes facilitating the aqueous outflow, it has not been reported whether it will increase the prevalence of endophthalmitis. Our case is the first successful antibiotic treatment of Staphylococcus epidermidis endophthalmitis without ICL explantation or vitrectomy in model V4c. To test the virulence and antibiotic susceptibilities and resistance traits of Staphylococcus epidermidis strains to cause postoperative endophthalmitis may offer more helpful information in the treatment selection and prognostic evaluation in a clinical setting12.To our knowledge, S. epidermidis isolates were sensitive to vancomycin 9 . ICL explantation would be required in cases of methicillin-resistant Staphylococcus epidermidis3.In our case, the Staphylococcus epidermidis is not antibiotic resistant. The endophthalmitis responded well to intravitreal antibiotics alone, contributing to antibiotic therapy's success in avoiding the vitrectomy. Slit lamp evaluation is critical in diagnosing, predicting the causative organisms, and guiding the therapeutic decisions before the microbiologic confirmation. In our case, the treatment started with intravitreal injection and system administration of antibiotics accompanied by intensive topical steroids and antibiotics before the culture confirmation. An ultrasonography B-scan assists in the diagnosis. The close follow-up of this endophthalmitis patient enables strict postoperative surveillance on the effect of medication treatment, avoiding the removal of the ICL or phacoemulsification and insertion of an intraocular lens (IOL), combined with pars plana vitrectomy. Conclusion To conclude, Staphylococcus epidermidis endophthalmitis is manageable and can be recovered without loss of vision when diagnosed and treated in time and correctly. Good patient compliance plays an essential role in successfully managing Staphylococcus epidermidis endophthalmitis without ICL explantation and vitrectomy, avoiding the loss of the eye's integrity. The risk for endophthalmitis is rare but should be fully emphasized during preoperative counseling. Declarations Authors’ Contributions K. Z. and X.H.Z. contributed equally to this work and should be considered as equal first authors. Drafting the work and substantively revision (K.Z. and X.H.Z.); Design of the work (X.T.Z.); acquisition, analysis, interpretation of data (D.K.G.). All the authors read and approved the final manuscript. Ethics approval and consent to participate This case study followed the tenets of the Declaration of Helsinki and was approved by the ethics committee of the Eye and ENT Hospital of Fudan University (NO. ky2021018). Informed consent was obtained. All methods were carried out in accordance with relevant guidelines and regulations. Consent for publication Written consent for the publication of clinical/personal information and images was obtained from the patient of the current case report. Authors information 1 Department of Ophthalmology, Eye and ENT Hospital, Fudan University, Shanghai, China; 2 NHC Key Laboratory of Myopia (Fudan University), Shanghai, China; 3 Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China 4 Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China, Funding None. Availability of data and materials Available upon request from Dr. Ke Zheng Conflicts of interest statement The authors declare no conflict of interest. References Packer KT, Vlasov A, Greenburg DL, Coggin A, Weightman JW, Beltran T, et al. U.S. military implantable collamer lens surgical outcomes: an 11-year retrospective review. J Cataract Refract Surg. 2022;48(6):649–56. Chinese Vitreo-Retina Society of Chinese Medical Association; Chinese Cataract and Refractive Surgery Society; China Ocular Trauma Society, Glaucoma Group of Ophthalmology Branch of Chinese Medical Association. [Chinese expert consensus on the diagnosis and management of infectious endophthalmitis after ophthalmic surgery (2022)]. Zhonghua Yan Ke Za Zhi. 2022 Jul 11;58(7):487–499. Chinese. Kaur M, Titiyal JS, Sharma N, Chawla R. Successful re-implantation of implantable collamer lens after management of post-ICL methicillin-resistant Staphylococcus epidermidis endophthalmitis. BMJ Case Rep 2015; 2015: bcr2015212708. Chen D, Zhao X, Chou Y, Luo Y. Comparison of Visual Outcomes and Optical Quality of Femtosecond Laser-Assisted SMILE and Visian Implantable Collamer Lens (ICL V4c) Implantation for Moderate to High Myopia: A Meta-analysis. J Refract Surg. 2022;38(6):332–8. Allan BD, Argeles-Sabate I, Mamalis N. Endophthalmitis rates after implantation of the intraocular Collamer lens: survey of users between 1998 and 2006. J Cataract Refract Surg. 2009;35(4):766–9. Oum BS, Lee JS, Choi HY, Lee JE, Kim SJ, Lee JE. Endophthalmitis caused by Pseudomonas aeruginosa after phakic posterior chamber intraocular lens implantation to correct high myopia. Acta Ophthalmol. 2011;89(2):e209–210. Wilkinson S, Etheridge T, Monson BK, Larochelle MB. Chronic postoperative Cutibacterium acnes endophthalmitis with implantable collamer lens. Am J Ophthalmol Case Rep. 2022;26:101500. Verma L, Chakravarti A. Prevention and management of postoperative endophthalmitis: A case-based approach. Indian J Ophthalmol. 2017;65(12):1396–402. Yannuzzi NA, Patel NA, Relhan N, Tran KD, Si N, Albini TA, et al. Clinical Features, Antibiotic Susceptibilities, and Treatment Outcomes of Endophthalmitis Caused by Staphylococcus epidermidis. Ophthalmol Retina. 2018;2(5):396–400. Verma L, Agarwal A, Dave VP, Honavar SG, Majji AB, Lall A, et al. All India Ophthalmological Society (AIOS) Task Force guidelines to prevent intraocular infections and cluster outbreaks after cataract surgery. Indian J Ophthalmol. 2022;70(2):362–8. Davis MJ, Epstein RJ, Dennis RF, Cohen JA. Culture-positive endophthalmitis after implantation of intraocular Collamer lens. J Cataract Refract Surg. 2009;35(10):1826–8. Chiquet C, Musson C, Aptel F, Boisset S, Maurin M. Genetic and Phenotypic Traits of Staphylococcus Epidermidis Strains Causing Postcataract Endophthalmitis Compared to Commensal Conjunctival Flora. Am J Ophthalmol. 2018;191:76–82. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Oct, 2023 Read the published version in BMC Ophthalmology → Version 1 posted Editorial decision: Major revision 21 May, 2023 Reviews received at journal 25 Apr, 2023 Reviewers agreed at journal 25 Apr, 2023 Reviewers invited by journal 22 Apr, 2023 Editor assigned by journal 22 Apr, 2023 Editor invited by journal 22 Mar, 2023 Submission checks completed at journal 22 Mar, 2023 First submitted to journal 02 Mar, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2648102","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":185738014,"identity":"06f878f4-d30d-4f59-9806-86c597647677","order_by":0,"name":"Ke Zheng","email":"","orcid":"","institution":"Eye and ENT Hospital, Fudan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ke","middleName":"","lastName":"Zheng","suffix":""},{"id":185738016,"identity":"a64407fb-be69-451a-bb03-3c43a5aa5d4a","order_by":1,"name":"Xiaohong Zheng","email":"","orcid":"","institution":"Eye and ENT Hospital, Fudan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaohong","middleName":"","lastName":"Zheng","suffix":""},{"id":185738019,"identity":"d7ec1869-3031-4527-a68e-c0acdc1db6db","order_by":2,"name":"Dekang Gan","email":"","orcid":"","institution":"Eye and ENT Hospital, Fudan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dekang","middleName":"","lastName":"Gan","suffix":""},{"id":185738020,"identity":"b8a892f0-12ac-4fe5-9ef7-8288f8158fea","order_by":3,"name":"Xingtao Zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYDCCA0DM2AAkmCF8OTb29gOEtDA2wLUA1Rrz8ZxJIFIL1MrEeRIOBnh18B1vfv7w5w6bxA3H2a89/lBjk94mwZDA8KNiG04tkmeOGTZInklLnNnMU25w4Fhabpt04wHGnjO3cWoxuJHD2GDYdjixn5knTeIA2+HcNpkDCcyMbQS0JAK1tIG1/DucziaRYEBYy0GwLezHJICMBIJaQH6Z2diWZgz0C5vE2b40wzZgIB/E5xdgiD34+LPNRnbD+ePPJCq+2cjLt7cffPCjArcWJMCDiI4DxKgHAvYHRCocBaNgFIyCkQYAjmpgUO9R3bkAAAAASUVORK5CYII=","orcid":"","institution":"Eye and ENT Hospital, Fudan University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Xingtao","middleName":"","lastName":"Zhou","suffix":""}],"badges":[],"createdAt":"2023-03-02 15:29:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2648102/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2648102/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12886-023-03127-5","type":"published","date":"2023-10-12T15:02:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":34780487,"identity":"d5bcc4d0-d258-4fbe-9273-066302ad3d96","added_by":"auto","created_at":"2023-03-24 15:09:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":772120,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A-C) An anterior segment examination on postoperative 20 days showed mild redness,1mm hypopyon, keratic precipitates, anterior chamber flare, and cells3+. (D) Longitudinal B-scan showing the presence of multiple mild to moderate amplitude echoes in the vitreous cavity suggestive of vitreous exudates. (E) The OCT exam was invisible\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-2648102/v1/09df819220d29ce0411af41b.png"},{"id":34779786,"identity":"99cb38b9-44bd-49e9-93da-2dadf8ee86dc","added_by":"auto","created_at":"2023-03-24 15:01:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":794358,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A-C) 24 hours after the first intravitreal injection slit lamp examination showing fibrin exudate, 0.5mm hypopyon in the anterior chamber. (D) Longitudinal B-scan shows the presence of multiple mild to moderate amplitude echoes in the vitreous cavity. (E) Fundus photograph of the left eye showing moderate vitreous haze.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-2648102/v1/6923a2c6db82202ba6ce19c3.png"},{"id":34779782,"identity":"8ad82740-13d4-4e26-8f67-bd3f970936e5","added_by":"auto","created_at":"2023-03-24 15:01:40","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":413539,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A) 72 hours after the first intravitreal injection, anterior segment examination showed inferior keratic precipitates, 2+anterior chamber flare, and cells, hypopyon was invisible. (B)The ICL was well-centered in aimed position. Red retro illumination showing mild anterior vitreous cells behind the ICL. (C) Longitudinal B-scan showing the presence of multiple mild to moderate amplitude echoes in the vitreous cavity\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-2648102/v1/421caff96841181c171f3f98.png"},{"id":34779785,"identity":"271100cc-f588-4f86-895b-6d26d4dfc9ae","added_by":"auto","created_at":"2023-03-24 15:01:40","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":461283,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A) Complete resolution of Inflammation in the anterior chamber 38 days post-antibiotic Therapy. (B) Optical coherence tomography (OCT) of the macula revealed mild vitreous cell (C)Longitudinal B-scan showing the presence of multiple mild to moderate amplitude echoes in the vitreous cavity.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-2648102/v1/ba1e6037f9d4006235929f19.png"},{"id":34779783,"identity":"338941e2-2839-4685-9e7c-8bb4c21ba725","added_by":"auto","created_at":"2023-03-24 15:01:40","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":458271,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A, B) The anterior chamber was unremarkable after three months post antibiotic therapy. (C)Longitudinal B-scan showing mild amplitude echoes in the vitreous cavity. (D）The Fundus photograph of the left eye is normal.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-2648102/v1/a6a13b99a5f0a0361efb9769.png"},{"id":44699984,"identity":"3e2ecd7a-5a74-49f9-903a-2b59044a7481","added_by":"auto","created_at":"2023-10-16 15:09:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3802813,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2648102/v1/0d5d3e48-bda7-4003-835c-c74238c97b81.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Successful antibiotic management of Staphylococcus epidermidis endophthalmitis without ICL explantation or vitrectomy.","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePosterior chamber phakic implantable collamer lens (ICL) implantation was effective and safe for the correction of myopia1. Infectious endophthalmitis after intraocular surgery is a rare vision-threatening complication. The categories of postoperative endophthalmitis can be divided into acute, subacute, and chronic. The vitreous tap of most subacute cases is confirmed to be Staphylococcus epidermidis and fungi2. Post-ICL endophthalmitis has been reported previously 3. However, we reported the first successful medical treatment of Staphylococcus epidermidis endophthalmitis without ICL explantation and vitrectomy in the V4c model.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA complete vaccination covid-19 test negative 18-year-old female with high myopia and astigmatism and no medical problems came to our clinic to evaluate refractive surgery. The cycloplegic refraction was \u0026minus;\u0026thinsp;11.25/-2.50x175 OD and \u0026minus;\u0026thinsp;9.5/-2.00x170 OS. The corrected distance visual acuity (CDVA) was 20/20 in both eyes. The endothelial cell density was 3245 cells/mm\u003csup\u003e2\u003c/sup\u003e OD and 3190 cells/mm\u003csup\u003e2\u003c/sup\u003e OS. The white-to-white diameter was 12.1mm and 12.3 mm, and the anterior chamber depth (from endothelium) was 3.38mm and 3.49mm, respectively. Informed consent was obtained after explaining the potential risks of surgery. V4c TICL (VTICMO13.7\u0026ndash;15.0/+2.5x113 OD VTICMO13.7\u0026ndash;13.0/+2.5x113 OS) (Visian, STAAR Surgical Co, California, USA) were implanted, the surgery was uneventful. Topical Levofloxacin 0.5% four times a day and prednisolone acetate 1% four times a day were started immediately after the surgery. The uncorrected distance visual acuity (UDVA) was 20/20 in both eyes on the first postoperative day; there was no corneal edema, and 1\u0026thinsp;+\u0026thinsp;cells were present in the anterior chamber (AC). The ICLs were in situ with a vault of 660\u0026micro;m OD and 550 \u0026micro;m OS on pentacam.\u003c/p\u003e \u003cp\u003eThe patient presented with blurred vision and redness of the left eye 20 days following bilateral ICL surgery. She was noted to have participated in an intensive bicycle racing competition hosted in Shanghai 3 days ago. Visual acuity (VA)was 20/20OD and 10/20 OS with intraocular pressure (IOP) of 21.8 mmHg and 15.9 mmHg, respectively. Slit lamp exam showed clinical manifestations, including mild conjunctival and ciliary congestion, white round keratic precipitates, 3\u0026thinsp;+\u0026thinsp;anterior chamber flare, and cells, with fibrin exudate, 1mm hypopyon in the anterior chamber, vitreous opacity OS; the right eye was unremarkable. The ICL was in a good position. Dilated fundus exam was invisible(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eTreatment\u003c/h3\u003e\n\u003cp\u003eConsidered for postoperative endophthalmitis OS, a vitreous tap and injection of vancomycin 1mg/0.1ml and ceftazidime 2 mg/0.1 mL was performed. The sample was sent for pathogen detection and drug sensitivity testing. The patient was also treated with systemic(cetrazidime1gIVq24h)and topical antibiotics(Tobramycin Dexamethasone Eye q15m 15mg:5mg/5ml, Levofloxacin 0.5% Eye Drop q2h), 1% prednisolone acetate eye drops three times a day and 0.5% tropicamide qd.\u003c/p\u003e \u003cp\u003eThe cultures were positive for Staphylococcus epidermidis, which was sensitive to all antibiotics. The patient was diagnosed with postoperative endophthalmitis. 24h after intravitreal injection, the BCVA was 6/20, with the resolution of hypopyon. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Systematic antibiotic treatment was continued (intravenous administration of Ceftazidime) over the subsequent three days.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eGiven persistent inferior keratic precipitates, anterior chamber flare and cells, and vitreous opacity, vision remained 6/20, fibrin exudation in the pupil area and the vitreous body was much less (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), intravitreal injection of vancomycin 1mg/0.1ml and ceftazidime 2 mg/0.1 mL was performed 72hours again later. As the AC inflammation and IOL deposits were minimal, we did not remove the ICL nor AC washout, and a close follow-up was arranged to monitor the progress of endophthalmitis. After four days of the second intravitreal injection, the vision was 12/20, anterior chamber flare and cells (+), and Para bulbar injection of triamcinolone acetonide was administered.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eOutcome And Follow Up\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eOutcome and follow up\u003c/div\u003e \u003cp\u003eThe topical treatment was tapered gradually over one month. There was a notable improvement in AC reaction, complete resolution of exudates, and gradual resolution of the vitreous opacity, BCVA improved to 22/20 on day 38 post the antibiotic Therapy with inactive vitreous opacities(Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The uncorrected distance visual acuity of 20/20 was achieved three months following the antibiotic therapy, the manifest refraction was \u0026minus;\u0026thinsp;0.25/-0.50x65\u0026thinsp;=\u0026thinsp;1.0, the anterior chamber was unremarkable, persistent vitreous opacities were resolved, fundus photograph of the left eye was clear (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eICLs are ciliary sulcus placed anterior to the natural lens to treat myopia, correcting refractive error ranging from \u0026minus;\u0026thinsp;0.5D to -18D. It is an alternative, especially for patients with abnormal corneal topography and high myopia, and can provide better postoperative visual quality in patients with high myopia in the early postoperative period4. Infectious endophthalmitis is one of the most vision-threatening complications post-ICL surgery. The rate of endophthalmitis post-ICL patients was approximately 1 in 6000(0.017%~0.036%)5. Cases of endophthalmitis caused by Pseudomonas aeruginosa6, Cutibacterium acnes 7, and Staphylococcus epidermidis3 postoperative have been reported, which required removal of the ICL during the treatment and replanted. Staphylococcus epidermidis endophthalmitis commonly presents as subacute Inflammation ranging from two to six weeks post-operation. Our patient developed endophthalmitis 20 days after the implantation.\u003c/p\u003e \u003cp\u003eVirulence of the pathogens is considered a critical factor in the prognosis. In some cases, patients will require a partial capsulectomy\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Poor prognosis cases mostly require intraocular lens removal, radical vitrectomy with hyaloid peeling, base dissection, and silicone oil\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Host factors that lower resistance to infection, such as chronic immunosuppressive therapy and diabetes mellitus, have also been reported to be significant risk factors for postoperative endophthalmitis\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The early postoperative recovery was uneventful. In our case, the cause of the infection remains uncertain, and the patient\u0026rsquo;s intensive physical exercise (riding race) may increase the risk of endophthalmitis, contaminated by the sweat flowing into the eye. In addition, the temporal precise unsutured corneal incision may increase the probability of the entry of the organisms leading to the formation of endophthalmitis. There is another case report of culture-positive coagulase-negative Staphylococcus epidermidis\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. The model of ICL, in this case, is V4b without a central hole, which may be like a barrier against the invasion of the organism. In the V4c model with a central hole and two additional holes facilitating the aqueous outflow, it has not been reported whether it will increase the prevalence of endophthalmitis. Our case is the first successful antibiotic treatment of Staphylococcus epidermidis endophthalmitis without ICL explantation or vitrectomy in model V4c.\u003c/p\u003e \u003cp\u003eTo test the virulence and antibiotic susceptibilities and resistance traits of Staphylococcus epidermidis strains to cause postoperative endophthalmitis may offer more helpful information in the treatment selection and prognostic evaluation in a clinical setting12.To our knowledge, S. epidermidis isolates were sensitive to vancomycin\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. ICL explantation would be required in cases of methicillin-resistant Staphylococcus epidermidis3.In our case, the Staphylococcus epidermidis is not antibiotic resistant. The endophthalmitis responded well to intravitreal antibiotics alone, contributing to antibiotic therapy's success in avoiding the vitrectomy.\u003c/p\u003e \u003cp\u003eSlit lamp evaluation is critical in diagnosing, predicting the causative organisms, and guiding the therapeutic decisions before the microbiologic confirmation. In our case, the treatment started with intravitreal injection and system administration of antibiotics accompanied by intensive topical steroids and antibiotics before the culture confirmation. An ultrasonography B-scan assists in the diagnosis. The close follow-up of this endophthalmitis patient enables strict postoperative surveillance on the effect of medication treatment, avoiding the removal of the ICL or phacoemulsification and insertion of an intraocular lens (IOL), combined with pars plana vitrectomy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo conclude, Staphylococcus epidermidis endophthalmitis is manageable and can be recovered without loss of vision when diagnosed and treated in time and correctly. Good patient compliance plays an essential role in successfully managing Staphylococcus epidermidis endophthalmitis without ICL explantation and vitrectomy, avoiding the loss of the eye's integrity. The risk for endophthalmitis is rare but should be fully emphasized during preoperative counseling.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eK. Z. and X.H.Z. contributed equally to this work and should be considered as equal first authors. Drafting the work and substantively revision (K.Z. and X.H.Z.); Design of the work (X.T.Z.); acquisition, analysis, interpretation of data (D.K.G.). All the authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case study followed the tenets of the Declaration of Helsinki and was approved by the ethics committee of the Eye and ENT Hospital of Fudan University (NO. ky2021018). Informed consent was obtained. All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten consent for the publication of clinical/personal information and images was obtained from the patient of the current case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Department of Ophthalmology, Eye and ENT Hospital, Fudan University, Shanghai, China;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eNHC Key Laboratory of Myopia (Fudan University), Shanghai, China;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eLaboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China,\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAvailable upon request from Dr.\u0026nbsp;Ke Zheng\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePacker KT, Vlasov A, Greenburg DL, Coggin A, Weightman JW, Beltran T, et al. U.S. military implantable collamer lens surgical outcomes: an 11-year retrospective review. J Cataract Refract Surg. 2022;48(6):649\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChinese Vitreo-Retina Society of Chinese Medical Association; Chinese Cataract and Refractive Surgery Society; China Ocular Trauma Society, Glaucoma Group of Ophthalmology Branch of Chinese Medical Association. [Chinese expert consensus on the diagnosis and management of infectious endophthalmitis after ophthalmic surgery (2022)]. Zhonghua Yan Ke Za Zhi. 2022 Jul 11;58(7):487\u0026ndash;499. Chinese.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaur M, Titiyal JS, Sharma N, Chawla R. Successful re-implantation of implantable collamer lens after management of post-ICL methicillin-resistant Staphylococcus epidermidis endophthalmitis. BMJ Case Rep 2015; 2015: bcr2015212708.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen D, Zhao X, Chou Y, Luo Y. Comparison of Visual Outcomes and Optical Quality of Femtosecond Laser-Assisted SMILE and Visian Implantable Collamer Lens (ICL V4c) Implantation for Moderate to High Myopia: A Meta-analysis. J Refract Surg. 2022;38(6):332\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllan BD, Argeles-Sabate I, Mamalis N. Endophthalmitis rates after implantation of the intraocular Collamer lens: survey of users between 1998 and 2006. J Cataract Refract Surg. 2009;35(4):766\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOum BS, Lee JS, Choi HY, Lee JE, Kim SJ, Lee JE. Endophthalmitis caused by Pseudomonas aeruginosa after phakic posterior chamber intraocular lens implantation to correct high myopia. Acta Ophthalmol. 2011;89(2):e209\u0026ndash;210.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilkinson S, Etheridge T, Monson BK, Larochelle MB. Chronic postoperative Cutibacterium acnes endophthalmitis with implantable collamer lens. Am J Ophthalmol Case Rep. 2022;26:101500.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerma L, Chakravarti A. Prevention and management of postoperative endophthalmitis: A case-based approach. Indian J Ophthalmol. 2017;65(12):1396\u0026ndash;402.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYannuzzi NA, Patel NA, Relhan N, Tran KD, Si N, Albini TA, et al. Clinical Features, Antibiotic Susceptibilities, and Treatment Outcomes of Endophthalmitis Caused by Staphylococcus epidermidis. Ophthalmol Retina. 2018;2(5):396\u0026ndash;400.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerma L, Agarwal A, Dave VP, Honavar SG, Majji AB, Lall A, et al. All India Ophthalmological Society (AIOS) Task Force guidelines to prevent intraocular infections and cluster outbreaks after cataract surgery. Indian J Ophthalmol. 2022;70(2):362\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavis MJ, Epstein RJ, Dennis RF, Cohen JA. Culture-positive endophthalmitis after implantation of intraocular Collamer lens. J Cataract Refract Surg. 2009;35(10):1826\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiquet C, Musson C, Aptel F, Boisset S, Maurin M. Genetic and Phenotypic Traits of Staphylococcus Epidermidis Strains Causing Postcataract Endophthalmitis Compared to Commensal Conjunctival Flora. Am J Ophthalmol. 2018;191:76\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Postoperative endophthalmitis, Staphylococcus epidermidis, Implantable collamer lens, Antibiotic therapy","lastPublishedDoi":"10.21203/rs.3.rs-2648102/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2648102/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: We report a case of successful medical management of subacute endophthalmitis post implantable collamer lens (ICL) culture-positive of Staphylococcus epidermidis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObservations\u003c/strong\u003e: A 18-year-old female presented with decreased visual acuity in the left eye 20 days after ICL implantation. A diagnosis of postoperative endophthalmitis was made based on examination and ultrasonography. A vitreous tap was taken, and intravitreal antibiotics (vancomycin 1mg/0.1ml and ceftazidime 2 mg/0.1 mL) were administered twice (q72h), and para bulbar injection of triamcinolone acetonide on day 8. The vitreous culture was confirmed for Staphylococcus epidermidis. The endophthalmitis was resolved, and BCVA improved from 6/20 to 12/20 on day 7 and 22/20 on day 38. This is the first successful medical resolution of Staphylococcus epidermidis endophthalmitis without ICL explantation and vitrectomy in the V4c model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions and importance\u003c/strong\u003e: In antibiotic therapy, the excellent compliance and close follow-up of this endophthalmitis patient enabled careful postoperative surveillance on the effect of antibiotic therapy, avoiding the removal of the ICL or the loss of the integrity of the eye. The risk of potential infectious endophthalmitis post-ICL surgery should be fully emphasized during preoperative counseling.\u003c/p\u003e","manuscriptTitle":"Successful antibiotic management of Staphylococcus epidermidis endophthalmitis without ICL explantation or vitrectomy.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-03-24 15:01:35","doi":"10.21203/rs.3.rs-2648102/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-05-21T10:20:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-04-26T03:37:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"01b77b83-0c86-46cd-abcf-316016ce41dc","date":"2023-04-25T12:22:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-04-23T00:28:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-04-23T00:19:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-03-22T21:58:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-03-22T21:53:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2023-03-02T15:15:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8cdd57f6-10ea-4fa1-9cfd-34eaa2349cb1","owner":[],"postedDate":"March 24th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T15:06:36+00:00","versionOfRecord":{"articleIdentity":"rs-2648102","link":"https://doi.org/10.1186/s12886-023-03127-5","journal":{"identity":"bmc-ophthalmology","isVorOnly":false,"title":"BMC Ophthalmology"},"publishedOn":"2023-10-12 15:02:55","publishedOnDateReadable":"October 12th, 2023"},"versionCreatedAt":"2023-03-24 15:01:35","video":"","vorDoi":"10.1186/s12886-023-03127-5","vorDoiUrl":"https://doi.org/10.1186/s12886-023-03127-5","workflowStages":[]},"version":"v1","identity":"rs-2648102","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2648102","identity":"rs-2648102","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}