Transcript Folie 1 - Extras Springer

After Cataract Surgery…
Rowayda M. Amin, MD
Assist. Lecturer of Ophthalmology
Ihab Osman, MD, Islam Shereen, MD
Lecturer of Ophthalmology, Islam
Alexandria University
Ocular History
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57 year old female referred for chronic
post-operative inflammation following
uneventful cataract surgery 5 months
before
Diminished vision, minimal pain and
photophobia
No systemic disease
Hysterectomy 8 months prior
First Presentation
OD
 VA: 4/60
 2+ AC cell, mild flare
OS
 Unremarkable
 Pseudophakic
First Presentation - Right Fundus
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Moderate haze
Severe vitritis
Optic disc hyperemia
VA: 4/60
First Presentation - Right Fundus
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Whitish small flaky mass in the inferior vitreous
 Snowball?
 Retained lens
fragment?
First Presentation - Left Fundus
Normal disc
and vessels
 VA: 6/6
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Work-up
CXR
 PPD
 Blood work
 Meticulous review of systems
 All were negative
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Working hypothesis: lens-induced uveitis
Treatment
corticosteroids
 Oral Prednisolone 60 mg/day
 2 weeks later…no improvement
 periocular corticosteroids
 subtenon Triamcinolone (40mg)
 1 month later…no improvement
 Vitrectomy against lens-induced-uveitis
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48 hours after Vitrectomy
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Vitreous still hazy
2 whitish masses in the
vitreous cavity now
VA: 4/60
Reconsider Diagnosis
 infection?
 masquerade
 AC
tap
syndrome?
Candida Endophthalmitis
Right Fundus
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Whitish small flaky mass in the inferior vitreous seen
1.5 months prior was:
FUNGUS BALL
Treatment Options
Systemic antifungals
 Fluconazole (100-200 mg po) daily for
approximately 2 months.
 Voriconazole
 For moderate-to-severe inflammation
 PPV with intravitreal amphotericin B
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Treatment
Patient already had vitrectomy
 Systemic Fluconazole 200mg/d
 intravitreal Amphotericin B
 begin: 1.5 months after first presentation
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12 hours later…
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Severe haze and AC hypopion
No pain, mild injection
Endophthalmitis?
Sterile or infectious?
1/60
Endophthalmitis again?
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Differentiating between sterile and infectious
endophthalmitis can be difficult.
Sterile endophthalmitis typically has no pain, a quiet
conjunctiva, occurs within 24 hours of surgery and is
culture negative.
Infectious endophthalmitis is characterized by pain, later
onset, vitritis, culture positive and has more prevalent
lid swelling, chemosis, injection and discharge.
72 hours later…
 40
mg oral steroids
 hourly topical steroids
 daily follow up
 hypopion resolved
 media clear
4 weeks later…
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VA improved to 6/24
resolved vitritis
no vitreous haze
Conclusion
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Infectious endophthalmitis is an important cause of
inflammation following intraocular surgery.
However, not all cases are infectious .
Involvement of the posterior segment makes
differentiating sterile from infectious
endophthalmitis challenging.
Early recognition and prompt treatment are essential
to reduce long-term sequelae.