19
QUESTION
WHEN SHOULD I SUSPECT ENDOPHTHALMITIS IN MY POSTOPERATIVE CATARACT PATIENT AND WHAT ARE THE TREATMENT OPTIONS?
Bernard H. Doft, MD
Post–cataract surgery endophthalmitis is one of the most dreaded complications of cataract surgery. The incidence may be rising in correspondence with increased use of clear corneal surgery, and it could be as high as 2 to 3/1000 operations. Recent data based on multicenter trials suggests that prophylactic intracameral antibiotics may markedly decrease the rate of post-cataract endophthalmitis. All cataract surgeons should become familiar with this data and make a decision whether or not to employ this approach. However, the topic of this review is not prophylaxis, but rather about diagnosis and treatment. Every ophthalmologist recognizes the typical case of a patient presenting a few days after surgery with a painful red eye, count fingers vision, a hypopyon, and a limited view posteriorly; however, there are much more subtle presentations, and early detection can result in better outcomes. Making an early diagnosis can sometimes be difficult. When should you suspect endophthalmitis? Once you suspect it, what do you do? To address these questions, let us look at a few patients presenting at various time points after cataract surgery.
Patient 1 comes in on the first postoperative day. He has a bit of discomfort. Vision is 20/60. At the slit-lamp, you see mild corneal edema and a definite hypopyon. When you look behind the intraocular lens (IOL), the vitreous is clear. Is this endophthalmitis? It can be hard to tell. If endophthalmitis is presenting this early, such as on the first postoperative day, it is likely due to a pretty virulent organism, yet the vitreous in this patient is clear. Does that make sense? What do you do? The answer is watch the patient for a few hours and have another look. Okay, so it doesn’t get worse in those few hours. What now? Well, it still could be endophthalmitis, but more likely you need to think about toxic anterior segment syndrome (TASS). Watch a bit longer, and look again in a few more hours. If the vitreous remains quiet, then it is probably TASS. This syndrome is not infectious endophthalmitis, and management is entirely different than for endophthalmitis.
Figure 19-1. Classic postoperative endophthalmitis with hypopyon. Fibrin strands are present.
Patient 2 comes in on the first postoperative day, just like Patient 1. You had performed clear corneal cataract extraction with posterior chamber IOL insertion. After the patient arrives, you wait a few hours and look again. The hypopyon is bigger, and there is fibrin in the anterior chamber (AC), and the vitreous is becoming cloudy. The patient became worse in those few hours. Now you have your diagnosis. Endophthalmitis that presents this early is probably due to a virulent organism, causing the rapid increase in inflammation. Emergency treatment is necessary.
Let us look at Patient 3. It is 5 to 6 days postoperatively. The patient comes in for a routine exam. She has no complaints but states, “My vision isn’t perfect, Doc.” On exam, vision is 20/50, the cornea is clear, the IOL is in good position, and with a careful exam, you see definite cells in the AC but no hypopyon. It is a bit more inflammation than you are used to seeing, and there are also some cells in the vitreous. “My surgery went well,” you say. “Why should there be a cellular reaction in the AC?” Keep asking yourself that question. Do not let the absence of pain or the absence of a hypopyon fool you. Perform gonioscopy. There are times that one can see a small layering of cells in the inferior angle with a gonioscopy lens when one cannot really appreciate it at the slit-lamp alone. Remember, you don’t have to have a hypopyon to diagnose endophthalmitis. This is another patient to watch carefully. See the patient several hours later. If things are getting worse when you see the patient later that day, there is a good chance it is endophthalmitis. It is probably better to err on the side of over diagnosis in this case, even if you are not yet positive that there is an infection.
Okay, now let’s look at Patient 4. It is 3 to 5 days after surgery. The patient says, “My eye aches.” Of course, your staff had the patient come right over. On exam, visual acuity is 20/800, and the eye is red. The AC shows a 1-mm layered hypopyon, cells, and fibrin strands (Figure 19-1). The vitreous is cloudy. With indirect ophthalmoscopy, you can just barely make out the retina. No mystery here! This is classic postoperative endophthalmitis.
Now, here’s a variant. Patient 5 presents just like Patient 4 except he is diabetic. Management might differ, so read on.
One more patient is Patient 6. He has the exact same presentation as Patient 4 except that vision on presentation is light perception (LP) only. He cannot appreciate hand motion. The diagnosis is obvious endophthalmitis as in Patients 4, 5, and 6, and the presentations are textbook. Treatment options vary depending on presentation, so read the following.
Here is our last patient, Patient 7. It is more than 6 weeks since his surgery, but it can even be a year or longer. The patient came in a month early for his checkup. He has mild complaints about blurred vision in the eye in question. Acuity is 20/40. The eye looks white. There is no hypopyon, but there is a mild AC reaction with a few keratic precipitates (Figure 19-2). You see some creamy opacification of the posterior capsule. (Things can get to the point that this capsular opacification is much worse, as shown in Figure 19-3). The vitreous has some inflammation that might look like a small string of pearls, but it is mild. The eye appears to have mild uveitis. Most likely, the diagnosis is chronic indolent endophthalmitis. Management is quite different than for patients who present with more acute endophthalmitis.
Figure 19-2. Keratic precipitates in an eye with chronic indolent endophthalmitis.
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