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 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 Moderate haze Severe vitritis Optic disc hyperemia VA: 4/60

First Presentation - Right Fundus Whitish small flaky mass in the inferior vitreous Snowball? Retained lens fragment?

First Presentation - Left Fundus Normal disc and vessels VA: 6/6

Work-up CXR PPD Blood work Meticulous review of systems All were negative 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

48 hours after Vitrectomy Vitreous still hazy 2 whitish masses in the vitreous cavity now VA: 4/60

Reconsider Diagnosis infection? masquerade syndrome? AC tap

Candida Endophthalmitis

Right Fundus 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

Treatment Patient already had vitrectomy Systemic Fluconazole 200mg/d intravitreal Amphotericin B begin: 1.5 months after first presentation

12 hours later… Severe haze and AC hypopion No pain, mild injection Endophthalmitis? Sterile or infectious? 1/60

Endophthalmitis again? 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… VA improved to 6/24 resolved vitritis no vitreous haze

Conclusion 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.