A DIAGNOSTIC DILEMMA: A COMPLEX CASE OF SUBACUTE POST OPERATIVE ENDOPHTHALMITIS FOLLOWING CATARACT SURGERY ON A PATIENT WITH CHRONIC PANUVEITIS

To report a case of subacute post operative endophthalmitis 3 months after an uncomplicated phacoemulcification and intraocular lens implantation surgery in a patient with history of chronic panuveitis episodes on a background of autoimmune diseases, i.e. psoriasic arthritis, Sjogrens and fibromyalgia.

Day assessment unit, Surgical treatment centre and urgent eye clinic at East and North Hertfordshire NHS Trust.

A 55-year-old female presented to urgent eye clinic with nonpainful blurry vision in the left eye 2  months after an uncomplicated phacoemulsification cataract surgery with in-the-bag implantation of a hydrophobic acrylic intraocular lens.

Examination of the affected eye revealed visual acuity of counting fingers, same as preoperatively, intraocular pressure of 13 mmHg, few cells in anterior chamber (1+), no hypopyon or hyphaema but old keratic precipitates, previously documented in the notes as she had recurrent episodes of panuveitis with chronic residual vitritis. She had a B scan and which showed similar findings to previous scans, mild chronic vitritis. She had been on topical steroids for 2 months preoperatively as a prophylaxis. She was treated as possible post operative uveitis flare up and was started on intensive dose of topical steroids.

During a course of a week from initial presentation, she presented again to urgent care with exactly the same symptoms and was advised to continue with the topical steroids. At one of her visits she was offered to have an intraocular steroid implant (ozurdex) or to start oral steroids, she was not keen on these treatments as she had previous adverse reaction among oral steroids and her other medication. Two weeks later she presented with painful left eye with visual acuity of light perception, a pressure of 25mm Hg, corneal oedema, anterior chamber cells (3+), vitreous haze (3+), and hypopyon. A diagnosis of postoperative endophthalmitis was made and she underwent diagnostic vitreous tap as well as intraocular antibiotics of Vancomycin , Ceftazidime and Voriconazole. She had cultures which were positive for Pseudomonas aeruginosa.

Ocular pain was relieved with treatment however the patient’s vision was not improved. She underwent vitrectomy at a later stage and lensectomy, she had an Artisan lens insertion with poor vision outcome however no sings of active inflammation one month post operatively.

Delayed-onset postoperative endophthalmitis can be confused with uveitis, prompting steroid treatment to be started, especially on patients with chronic panuveitis. The main challenge is to diagnose endophthalmitis and to differentiate chronic from new inflammation and possible infection sings. Majority of these cases is caused by Propionibacterium species, however there are reports of Pseudomonas species, causing late-onset endophthalmitis, as in our case. Overall we emphasize the necessity of proactive diagnostic approach and aggressive surgical treatment in similar postoperative endophthalmitis cases.