A 69 year old white male underwent uncomplicated cataract surgery OU. His post-op acuities were 20/25-2 OD and 20/25-1 OS. About 3 months later he contracted low grade iritis OS, coinciding with acute PVD. That eye continued to have problems:
- 1 month later patient had a retinal detachment due to horseshoe tear
- RD was repaired with scleral buckle and gas exchange
- Normal post-op inflammation
- Patient developed persistent iritis and ocular hypertension
- Indolent endophthalmitis suspected
- 3 months after RD repair, patient underwent culture, vitrectomy and intravitreal antibiotics (cultures were negative)
- Vision improved to 20/30 but inflammation returned
- Inflammation became increasingly worse and CME developed
- BCVA dropped to 20/400
- After multiple exams, retina and uveitis specialists felt chronic iritis was due to multiple surgical procedures
- Because patient also suffered from severe uveitis, resulting in hypopyon, the specialists recommended IOL exchange with an anterior chamber lens
- During surgery a small nest of flocculent white material was discovered on the lens at the junction of the haptic that could not be seen with dilation or gonioscopy
- Aqueous humor was culture negative but capsule cultures were positive for Propionibacterium acnes
This challenging case demonstrates one of the more delayed types of endophthalmitis. Thankfully, these are rare. But involvement of specialists can be critical in the decision making process. Fortunately, this patient did very well throughout the post-op period with antibiotics and a slow taper of steroid and final visual acuity in the left eye was 20/30+2.
