SUBACUTE (WEEKS TO MONTHS AFTER SURGERY)
Variable. Insidious decreased vision, increasing redness, and pain.
AC and vitreous inflammation, lens capsular plaque, hypopyon; clumps of fibrinous exudate in the AC, on the iris surface, or along the pupillary border; vitreous abscesses; and vitritis.
Variable conjunctival injection, KP, corneal edema, and blebitis.
S. epidermidis or other common bacteria (e.g., streptococci with a filtering bleb). Cutibacterium acnes (formerly Propionibacterium acnes), or other rare, indolent bacteria: Recurrent, anterior uveitis, may have a hypopyon and granulomatous KP, but with minimal conjunctival injection and pain. A white plaque or opacities on the lens capsule may be evident (see Figure 12.15.1). Only a transient response to steroids.
Fungi (Aspergillus, Candida, Cephalosporium, Penicillium species, and others).
Lens-particle uveitis: Perform gonioscopy and dilated examination to look for retained lens fragment(s) in angle or vitreous.
UGH syndrome (iris chafing): Look for iris transillumination and IOL decentration. Most common with one-piece acrylic IOL (thick, square-edge haptics) in the sulcus and with any lens that impinges on the iris or ciliary body. See 9.15, Postoperative Glaucoma.
Aspiration of vitreous for smears (Gram, Giemsa, and methenamine–silver) and cultures (blood, chocolate, Sabouraud, thioglycolate, and a solid medium for anaerobic culture).
See Appendix 11, Intravitreal Tap and Inject. Intravitreal antibiotics are given as described previously. See Appendix 12, Intravitreal Antibiotics.
 NOTEC. acnes will be missed unless proper anaerobic cultures are obtained and held for extended culture (14 days). |
Initially treat as acute postoperative endophthalmitis, as described previously, but do not start steroids.
Immediate pars plana vitrectomy is beneficial if visual acuity on presentation is light perception within 6 weeks after cataract surgery. Prompt vitrectomy for endophthalmitis due to other procedures has not been studied in a large, randomized trial.
If a fungal infection is suspected, administer intravitreal amphotericin B (5 to 10 µg/0.1 mL) or intravitreal voriconazole (100 µg/0.1 mL).
Removal of the intraocular lens and capsular remnants may be required for diagnosis and treatment of C. acnes endophthalmitis, which may be sensitive to intravitreal penicillin, cefoxitin, clindamycin, or vancomycin.
If S. epidermidis is isolated, intraocular vancomycin (including irrigation of the capsular bag) alone may be sufficient.
Antimicrobial therapy should be modified in accordance with culture results, sensitivity testing, clinical course, and tolerance of therapeutic agents.
A vitrectomy with limited capsulectomy of the capsular plaque may be considered if vitreous aspiration cultures are negative or if the clinical response is incomplete. In cases with an incomplete response, removal of the entire capsule and IOL, along with intravitreal antibiotics, should be considered.
CHRONIC (>6 WEEKS AFTER SURGERY)
Routine postoperative inflammation is typically mild, responds promptly to steroids, and usually resolves within 6 weeks. Consider the following etiologies when postoperative inflammation persists beyond 6 weeks.
Severe intraocular inflammation in the early postoperative course:
Infectious endophthalmitis: Deteriorating vision, pain, fibrin, or hypopyon in the AC, vitritis. See 12.14, Acute Postoperative Endophthalmitis.
Retained lens material: A severe granulomatous inflammation with mutton-fat KP, resulting from a hypersensitivity reaction to lens protein exposed during surgery and may result in elevated IOP. See 9.11, 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 AC 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):
PUPPI: A small percentage of patients with well-positioned posterior chamber IOLs may develop a persistent, low-grade, steroid-responsive anterior uveitis that recurs when low-dose topical steroids are tapered off.
Lens-induced uveitis: Perform gonioscopy and dilated examination to look for retained lens fragment(s) in the angle or vitreous.
UGH syndrome: Irritation of the iris or ciliary body by an IOL. Increased IOP and red blood cells in the AC accompany the anterior segment inflammation. See 9.15, Postoperative Glaucoma.
Retinal detachment: Often produces a low-grade AC reaction. See 11.3, Retinal Detachment.
Subacute 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. Iris may appear flattened with loss of detail because of the spread of the membrane across the AC angle onto the iris. Large cells may be seen in the AC. 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 AC tap may also reveal many epithelial cells. See 4.30, Epithelial Downgrowth.
Pre-existing chronic uveitis: See 12.1, Anterior Uveitis (Iritis/Iridocyclitis).
Sympathetic ophthalmia: Diffuse granulomatous inflammation in both eyes, after penetrating trauma or surgery. See 12.4, Panuveitis.
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?
Complete ocular examination of both eyes, including a slit lamp assessment of the AC reaction, a determination of whether vitreous or residual lens material is present in the AC 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).
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.
Consider diagnostic medium-power argon laser treatment to areas of iris with suspected epithelial downgrowth. See 4.30, Epithelial Downgrowth.
When concerned for subacute postoperative endophthalmitis: A vitreous tap should be performed (see Appendix 11, Intravitreal Tap and Inject) for cultures, using both solid media and broth to isolate atypical organisms such as C. acnes (routine cultures also are obtained; see 12.14, Acute 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).
Consider an AC paracentesis for diagnostic smears and cultures. See Appendix 13, Anterior Chamber Paracentesis.
In the setting of a capsular plaque, transient improvement in inflammation with steroids, and a negative workup, a diagnostic vitrectomy 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 (along with intravitreal antibiotics) if there is an incomplete response as it usually successfully eradicates the infection.
See 12.1, Anterior Uveitis (Iritis/Iridocyclitis); 12.3, Posterior Uveitis; 12.14, Acute Postoperative Endophthalmitis; and 12.4, Panuveitis for more specific information on diagnosis and treatment.