Question of the Week

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It’s a Saturday night, and you are the on-call resident. The rest of your department is currently on a plane that just left for a conference in Salt Lake City when you get a page from the ED. The patient is a 68-year-old man with a history of type II diabetes who underwent uncomplicated cataract surgery 5 days ago. He tells you that this morning he awoke with a red and painful right eye. Throughout the day, his vision worsened. On examination, his visual acuity is 20/100 OD. Intraocular pressure is 12 mmHg OD. Slit lamp exam revealed diffuse conjunctival injection, corneal edema, and a 1 mm hypopyon. There is a limited view of the fundus due to vitreous haze, and a B-scan showed some vitreous opacities without retinal detachment.

What is your next step?

A. Observe the patient and reassess vision in 24 hours

B. Start systemic corticosteroids and broad-spectrum antibiotics

C. Administer intravitreal vancomycin and ceftazidime

D. Inject moxifloxacin into the anterior chamber

E. Prepare for an emergent vitrectomy

The correct answer is C. This patient presents with classic acute postoperative endophthalmitis, which typically occurs within 1 week of cataract surgery. The presentation of a painful eye with decreased vision, corneal edema, a 1 mm hypopyon, and vitreous haze on B-scan strongly support the diagnosis. Type II diabetes is a known risk factor for postoperative endophthalmitis. The most likely causative organism is coagulase-negative Staphylococcus, which is the most frequent isolate in this setting. Management involves intravitreal injection of vancomycin and ceftazidime to cover both Gram-positive and Gram-negative organisms. A vitreous tap is often performed just before injection to obtain a specimen for Gram stain and culture, but empiric treatment should not be delayed. Observation without treatment risks rapid progression to irreversible vision loss (Choice A). Systemic antibiotics do not achieve therapeutic levels within the vitreous, and the use of systemic corticosteroids is controversial because it has not been shown to improve visual acuity (Choice B). It is too late for intracameral moxifloxacin, as this is used for prophylaxis at the time of surgery, not for treatment of established intraocular infection (Choice D). The Endophthalmitis Vitrectomy Study showed VA improvement for patients with light perception vision. However, in a case of 20/100 vision, emergency vitrectomy is likely not initially indicated (Choice E). It is reasonable to assess how the patient responds to the intravitreal therapy, and if there is worsening, then you might consider a vitrectomy. 

Source: Verma L, Chakravarti A. Prevention and management of postoperative endophthalmitis: A case-based approach. Indian J Ophthalmol. 2017 Dec;65(12):1396-1402. doi: 10.4103/ijo.IJO_1058_17. PMID: 29208820; PMCID: PMC5742968.