• Severe intraocular inflammation in the early postoperative course:
  • Infectious endophthalmitis: Deteriorating vision, pain, fibrin, or hypopyon in the anterior chamber, vitritis. See 12.13, POSTOPERATIVE ENDOPHTHALMITIS.
  • Retained lens material: A severe granulomatous inflammation with mutton-fat KP, resulting from an hypersensitivity reaction to lens protein exposed during surgery and may result in elevated IOP. See 9.12, LENS-RELATED GLAUCOMA.
  • Aseptic (sterile) endophthalmitis: A severe noninfectious postoperative uveitis caused by intraoperative injections (e.g., triamcinolone acetonide) or excess tissue manipulation, especially of vitreous manipulation, during surgery. A hypopyon and a mild vitreous cellular reaction may develop. Usually not characterized by profound or progressive pain or visual loss. A fibrinoid reaction is typically absent. Eyelid swelling and chemosis are atypical. Conjunctival injection is often absent. Usually resolves with topical steroid therapy.
  • TASS: An acute, sterile inflammation following uneventful surgery that develops rapidly within 6 to 24 hours. Characterized by anterior chamber cell and flare, possibly with fibrin or hypopyon, and severe corneal edema in excess of what would be expected following surgery. IOP may be increased. May be caused by any material placed in the eye during surgery including irrigating or injected solutions (e.g., due to the presence of a preservative or incorrect pH or concentration of a solution) or improperly cleaned instruments.
  • Acute iridocyclitis flare: HLA-B27-associated and herpetic uveitis flares can be triggered by surgical trauma.
• Persistent postoperative inflammation (e.g., beyond 6 weeks):
  • Poor compliance with topical steroids.
  • Steroid drops tapered too rapidly.
  • Retained lens material.
  • Iris or vitreous incarceration in the wound.
  • UGH syndrome: Irritation of the iris or ciliary body by an IOL. Increased IOP and red blood cells in the anterior chamber accompany the anterior segment inflammation. See 9.16, POSTOPERATIVE GLAUCOMA.
  • Retinal detachment: Often produces a low-grade anterior chamber reaction. See 11.3, RETINAL DETACHMENT.
  • Sub-acute endophthalmitis (e.g., C. acnes and other indolent bacteria, fungal, or partially treated bacterial endophthalmitis).
  • Epithelial downgrowth: Corneal or conjunctival epithelium grows into the eye through a corneal wound and may be seen on the posterior corneal surface and iris. The iris may appear flattened with loss of detail because of the spread of the membrane across the anterior chamber angle onto the iris. Large cells may be seen in the anterior chamber, and glaucoma may be present. The diagnosis of epithelial downgrowth can be confirmed by observing the immediate appearance of white spots after medium-power argon laser treatment to the areas of iris covered by the membrane. An anterior chamber tap may also reveal many epithelial cells.
  • Preexisting chronic uveitis: See 12.1, ANTERIOR UVEITIS (IRITIS/IRIDOCYCLITIS).
  • Sympathetic ophthalmia: Diffuse granulomatous inflammation in both eyes, after penetrating trauma or surgery. See 12.18, SYMPATHETIC OPHTHALMIA.

Workup and Treatment

1. History: Is the patient taking the steroid drops properly? Did the patient stop the steroid drops abruptly? Was there a postoperative wound leak allowing epithelial downgrowth? Previous history of uveitis?
2. Complete ocular examination of both eyes, including a slit lamp assessment of the anterior chamber reaction, a determination of whether vitreous or residual lens material is present in the anterior chamber, and an inspection of the lens capsule looking for capsular opacities (e.g., C. acnes capsular plaque). Perform gonioscopy (to evaluate for iris or vitreous to the wound or small retained lens fragments), an IOP measurement, vitreous evaluation for inflammatory cells, and a dilated posterior and peripheral fundus examination (to rule out retained lens material in the inferior pars plana, retinal detachment, or signs of chorioretinitis).
3. Obtain B-scan US when the fundus view is obscured. Consider UBM to assess the IOL position, for iris-IOL contact, and to evaluate for retained lens material.
4. When concerned for subacute postoperative endophthalmitis: A vitreous tap should be performed (see Appendix 11, INTRAVITREAL TAP AND INJECT) with anaerobic cultures, using both solid media and broth to isolate atypical organisms such as C. acnes (routine cultures also are obtained; see 12.13, POSTOPERATIVE ENDOPHTHALMITIS). The anaerobic cultures should be incubated in an anaerobic environment as rapidly as possible and held for an extended incubation period (14 days).
5. Consider an anterior chamber paracentesis for diagnostic smears and cultures. See Appendix 13, ANTERIOR CHAMBER PARACENTESIS.
6. Consider diagnostic medium-power argon laser treatment to areas of iris with suspected epithelial downgrowth.

In the setting of a capsular plaque, transient improvement in inflammation with steroids, and a negative work up, surgery may be required to diagnose and treat subacute endophthalmitis such as C. acnes. Initially, a vitrectomy with limited capsulectomy of the capsular plaque and injection of intravitreal antibiotics should be considered. Removal of the entire capsule and IOL may be required if there is an incomplete response as it usually successfully eradicates the infection.

See 12.1, ANTERIOR UVEITIS (IRITIS/IRIDOCYCLITIS);12.3, POSTERIOR UVEITIS; 12.13, POSTOPERATIVE ENDOPHTHALMITIS; and 12.18, SYMPATHETIC OPHTHALMIA for more specific information on diagnosis and treatment.

Routine postoperative inflammation is typically mild, responds promptly to steroids, and usually resolves within 6 weeks. Consider the following etiologies when postoperative inflammation is atypical.