Thread: Endophthalmitis: 82 year-old male status post phacoemulsification in the left eye with acute decreas

Endophthalmitis:

82 year-old male status post phacoemulsification in the left eye with acute decrease in vision.

HPI: This patient has a history of macular degeneration in both eyes. His left eye had been his better-seeing eye, but vision had gradually become hazy and dim, with reduced visual acuity due to progressive cataract. Six days prior to this presentation, the patient underwent uncomplicated phacoemulsification and intra-ocular lens (IOL) placement with a local ophthalmologist. In the day prior to this presentation, the patient become to notice ocular redness, discomfort, and dramatically decreased vision in the post-operative eye. The following morning, the patient was referred to the University of Iowa Hospitals and Clinics. That examination and findings are here presented.

Past Eye History: Known history of macular degeneration with geographic atrophy greater in the right eye (OD) than the left (OS). Baseline best-corrected visual acuity prior to this examination had been 20/400 and 20/80-2 in the right and left eyes, respectively, on pre-operative evaluation before cataract surgery. Prior history of phacoemulsification cataract removal, OD, several years prior.

Past Medical History: Unremarkable.

Medications: Supplements as recommended by the Age-Related Eye Disease.

Family and Social History: Noncontributory

EXAM, OCULAR:

•Visual Acuity: OD-- 20/400; OS-- Light perception with projection
•Intra-ocular pressure: 10 mmHg, OS; Not measured, OD
•Pupil was not visualized in the left eye
•External and anterior segment examination:
◦OD, Normal with PCIOL; OS: Profound conjunctival injection, corneal edema, and hypopyon (see Figure 1)
•Dilated fundus exam (DFE): OD--Normal; OS--No view
◦Echography, OS-- Diffuse, highly mobile vitreous opacities. No retinal detachment.

Course:

The presence of decreased vision, a red, injected eye, with intraocular inflammation and hypopyon six days after cataract extraction is a classic example of postoperative endophthalmitis. This case illustrates the rapid progression of postoperative endophthalmitis.

A vitrectomy was indicated to treat this severe infection because of his light perception only vision (Endophthalmitis Vitrectomy Study Group, 1995). An infusion cannula and sclerotomy sites were placed over the pars plana, 3mm posterior to the limbus. A vitreous tap using suction and the vitrectomy probe was performed first. The vitrectomy probe was used to create a small opening in the posterior capsule to gain access to the anterior chamber after which the dense fibrin white cells were removed. Pupil hooks were used to dilate the pupil. The opaque vitrous was then removed posteriorly. The retina was attached but had scattered hemorrhages throughout. The sclerotomy sites were closed followed by intravitreal injections of vancomycin (1mg) and ceftazidime (2mg). Kenalog (10mg) was injected subconjunctivally in the inferior nasal quadrant.

Post-operatively, the patient was given levofloxacin, 1% prednisolone, and 0.25% scopolamine eye drops. Microbiology later reported growth of a coagulase negative staphylococcus.

At one week follow-up, the patient's vision had improved to 20/400. There was a small amount (+1) of residual cell in the anterior chamber and a few remaning intra-retinal hemorrhages. The antibiotic drops were stopped and the prednisolone and scopalamine drops were slowly tapered. Ten weeks after vitrectomy, the eye was quiet and the vision had recovered to 20/100+, within one line of his preoperative state. Fundus examination revealed atrophy from macular degeneration and a new occult choroidal neovascularization (see Figure 2) that was confirmed by fluorescein angiogram. Avastin® (1.25mg) was injected into the left eye. The patient will follow-up in one month.

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