Case Study 4
CC: Left eye pain and fuzzy vision 2 days after eye surgery
The patient is a 69 year-old diabetic male, retired chemist, who awoke with severe eye pain and decreased vision in the L eye and presented to the ED a few hours later. His eye had been feeling well after undergoing cataract extraction surgery in that eye 2 days prior, until this morning. Pain is described as deep within the eye and 8/10. Bright lights seem to make the pain worse and the vision seems very foggy with lots of floaters. The patient denies any fevers or chills. No complaints with the right eye. No hx diabetic eye disease. No witnessed trauma to that eye.
Past Ocular History:
Myopia and presbyopia, corrected. Hx bilateral cataracts s/p uncomplicated R cataract surgery (phaco/PC-IOL) 2 months ago, uncomplicated L cataract surgery (phaco/PC-IOL) 2 days ago.
Prednisolone acetate 1% 4x/day L eye
Polytrim 4x/day L eye
Past Medical History:
Type 2 diabetes mellitus – on oral medication. Last HgA1c of 7. No neuropathy or nephropathy.
Hypertension – mild. On single oral medication.
Past Family Ocular History:
Negative for macular degeneration, glaucoma or other blinding diseases.
No smoking or significant alcohol use.
Denies recent illness or any new CNS, heart, lung, GI, skin or joint symptoms.
Visual Acuity (cc):
OS: 20/80 (20/25 post-operative day #1- 2days ago)
OD: 18 mmHg
OS: 15 mmHg
Equal, round and reactive R, L eye sluggish to react; no APD OU.
Full OU. No nystagmus.
Confrontational Visual Fields:
Full to finger counting OU
Normal appearing orbital structures, both sides.
Lids and Lashes
|Conjunctiva/Sclera||Clear OD, 2+ hyperemia OS|
|Cornea||Clear OD, OS with microcystic edema throughout the cornea, small keratic precipitates are noted in the inferior cornea, fibrin strands to the incision temporally, no wound leak|
|Anterior Chamber||Deep and quiet OD, 3+ cells and flare, +hypopyon approx. 1mm OS|
|Iris||Normal OD, hazy view OS but no obvious abnormalities|
|Anterior Vitreous||Clear OD, hazy view OS|
Dilated Fundus Examination:
|OD||Clear view, CDR 0.4, sharp optic disc margins, macula flat, normal foveal light reflex, normal vessels and peripheral retina.|
|OS||Very hazy view, CDR 0.4. Poor view of macula. Retina appeared attached 360 degrees.|
This patient most likely has postoperative endophthalmitis. Other differential diagnoses to consider include endogenous endophthalmitis (hematogenous spread of infection from a remote primary source), sterile endophthalmitis (inflammatory ocular response without an identifiable infectious agent), panuveitis of another cause (inflammation of intraocular structures, often of autoimmune etiology), or retained lens fragment from cataract surgery.
Endophthalmitis is inflammation of the internal structures of the eye, most likely as a response to ocular infection. Post-surgical endophthalmitis can be divided into acute (<6 weeks post-op) or delayed (>6 weeks post-op). Acute post-surgical endophthalmitis can be caused by Staph. epidermidis, Staph. aureus, or Streptococcus species. Delayed post-surgical endophthalmitis is more likely to be caused by Staph. epidermidis, corynebacterium, candida, or propionibacterium acnes. Causative agents of endogenous endophthalmitis include Streptococcus sp., S. aureus, enteric bacteria, candida, and aspergillus. Sterile endophthalmitis is often related to retained lens material or a reaction to intravitreal medications.
Typical symptoms of endophthalmitis at presentation include pain, conjunctival injection and loss of visual acuity. A full ocular examination is key in order to initiate treatment as soon as possible. Patients could present with mild to severe findings depending on the progression of the infection, to include: eyelid edema, conjunctival redness and swelling, corneal edema, anterior chamber cell and flare, hypopyon (layering of inflammatory cells and exudates in the inferior portion of the anterior chamber), and vitreous infiltrates. The retina is initially unaffected but its view limited by the amount of anterior segment involvement (cell and flare, ex.).
Work-up and treatment for endophthalmitis includes getting intravitreal and/or aqueous cultures and treatment with broad-spectrum antibiotics. Ultrasound can be performed if fundus is not well visualized. If the vision is better than light perception, initial treatment of endophthalmitis usually consists of a “tap and inject”- a vitreous and/or aqueous sample is taken for culture (the tap) and then broad spectrum antibiotics are then given by intravitreal injection (the inject). If the presenting vision is light perception or worse, it is sometimes preferred to immediately proceed to a pars plana vitrectomy surgery. Cultures of the vitreous are taken, a vitrectomy is done, and intravitreal antibiotics are delivered. Further treatment is directed based on treatment response, culture results, and antibiotic sensitivity studies.
Because endophthalmitis can cause devastating damage to the eye, it is one of the true ophthalmology emergencies. Starting treatment as soon as possible is extremely important. Any delay may result in worse visual outcomes.
- What would be the best treatment for a patient presenting two days after cataract surgery with signs and symptoms of endophthalmitis and vision of 20/80?
- Close observation. The ocular inflammation may be due to the recent surgery and may resolve on its own.
- Arrange for the patient to go immediately to the operating room for a pars plana vitrectomy with vitreous cultures and placement of intravitreal broad spectrum antibiotics.
- Proceed with a “tap and inject” – Take a vitreous and/or aqueous sample for culture and inject intravitreal broad spectrum antibiotics.
- Give the patient a more broad spectrum antibiotic topical drop to be used every 2 hours and see the patient the next day to see if there is any improvement.
- Which of the following is not commonly an exam finding with post-operative endophthalmitis?
- “cell and flare” in the anterior chamber of the eye
- vitreous haze or debris
- conjunctival injection and hyperemia
1. What would be the best treatment for a patient presenting two days after cataract surgery with signs and symptoms of endophthalmitis and vision of 20/80?
c. Proceed with a “tap and inject” – Take a vitreous and/or aqueous sample for culture and inject intravitreal broad spectrum antibiotics
Due to the visual acuity one would follow the protocol of “tap and inject”.
2. Which of the following is not commonly an exam finding with post-operative endophthalmitis?
Blood in the anterior chamber is not frequently seen in patients with post-operative endophthalmitis ; although post-operative bleeding could have occurred in the case of a complicated surgery.
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