Actinomycosis in Ophthalmology

Updated: Mar 15, 2016
  • Author: Manolette R Roque, MD, MBA, FPAO; Chief Editor: Hampton Roy, Sr, MD  more...
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Overview

Background

The bacterial order Actinomycetales comprises 3 families: Actinomycetaceae, Mycobacteriaceae, and Streptomycetaceae. The genus Actinomyces, a member of the family Actinomycetaceae, grows as a fragile branching filament that tends to fragment into bacillary and coccoid forms producing chains of either conidia or arthrospores (see the image below). [1, 2]

Actinomyces israelii. (The image is labeled.) Actinomyces israelii. (The image is labeled.)

Actinomyces israelii species is a gram-positive, cast-forming, non–acid-fast, non–spore-forming anaerobic bacillus that is difficult to isolate and identify; this is shown in the image below.

Actinomyces israelii (non–spore-forming, gram-posi Actinomyces israelii (non–spore-forming, gram-positive bacilli). Courtesy of Medical Education Information Center, Department of Pathology and Laboratory Medicine, The University of Texas-Houston Medical School.

Its filamentous growth and mycelialike colonies have a striking resemblance to fungi. They are soil organisms, often found in decaying organic matter (eg, wet hay, straw). It is primarily a commensal microbe found in normal oral cavities, in tonsillar crypts, in dental plaques, and in carious teeth. [3, 4, 5, 6]

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Pathophysiology

Keratitis

Most reported cases of Actinomyces keratitis (keratoactinomycosis) are caused by A israelii. It is characterized by a dry ulceration with central necrosis, surrounded by a gutter of demarcation, usually accompanied by iritis and hypopyon. In severe cases, descemetocele and perforation may occur.

A primary corneal ulcer attributable to Actinomyces species is rare and usually follows corneal trauma. [7] A rare case of keratoactinomycosis developing in the absence of any known ocular trauma was reported in Kuala Lumpur.

Canaliculitis

Primary chronic canaliculitis is an uncommon problem caused by A israelii (Streptothrix).

McKellar presented a 10-year-old girl with a 6-month history of intermittent conjunctivitis and discharge from her pouted left lower punctum. Topical treatment with chloramphenicol/polymyxin sulphate failed despite a diagnosis of probable A israelii infection confirmed by microbiology. Surgical exploration revealed a canalicular diverticulum and 3 canaliculiths demonstrating solid casts of Actinomycetes on histologic examination. A therapeutic triad of punctoplasty, cast removal, and adjunctive topical cefazolin resulted in resolution. [8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20]

Other ocular involvement

Actinomycetes have been described as causative organisms in conjunctivitis, blepharitis, carunculitis, dacryocystitis, lacrimal gland ductulitis, crystalline keratopathy, postsurgical endophthalmitis, and infected porous orbital implant. Cervicofacial actinomycosis has also been reported. [21, 22, 23]

Postoperative endophthalmitis

Acute postoperative endophthalmitis caused by Actinomyces neuii after uncomplicated phacoemulsification with posterior chamber intraocular lens implant in a 58-year-old male has been reported. On postoperative day 6, he presented with pain, redness, and decreased visual acuity. Chronic endophthalmitis by Actinomyces neuii subspecies anitratus after uneventful phacoemulsification with implantation of a foldable posterior chamber intraocular lens in a 75-year-old man has been reported as well. Four weeks after surgery, anterior chamber and vitreous cellular debris developed in this eye. [24]

Endophthalmitis, attributable to Actinomyces viscosus, developed in a 78-year-old man after cataract surgery. Postoperative endophthalmitis with this organism is a rare occurrence. Inflammation was characterized by anterior segment and vitreous cellular debris in cases of chronic postoperative endophthalmitis associated with Actinomyces species. [25]

Endogenous endophthalmitis has been reported with Actinomyces israelii. [26]

Orbital actinomycosis

Painful ophthalmoplegia resulting from orbital actinomycosis has been reported. [27, 28, 29, 30, 31, 32]

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Epidemiology

Frequency

United States

Primary chronic canaliculitis is an uncommon problem that can be overlooked; however, it may account for approximately 2% of all tearing problems. Actinomycosis may form in up to 2% of all lacrimal disease. Its occurrence is probably much less in other areas.

International

Actinomycosis occurs worldwide, with a likelihood for higher prevalence rates in areas with low socioeconomic status.

In a literature review of lacrimal canaliculitis presented by Freedman et al in 2011, the prevalence of Actinomyces species infection was 30.3%. [20]

Race

No racial predilection exists.

Sex

No sexual predisposition exists.

Age

Actinomycosis can affect people of all ages. No age predisposition exists.

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