Sir,

Controversy exists as to whether routine first-day post-cataract surgery reviews (FDRs) are required especially for uncomplicated cases. Some reports suggest that FDRs are unnecessary1, 2 or that same-day examination is a satisfactory alternative.3 It has also been suggested that post-operative pressure spikes may require early intervention.4, 5 We describe an unusual case of presumed post-operative infective endophthalmitis detected at FDR.

Case report

A 77-year-old man with a history of right herpes zoster ophthalmicus was admitted for day-case right cataract surgery. Visual acuity was count fingers; there were localised inferior posterior synechiae and corneal stromal scarring and thinning related to an anaesthetic cornea and previous infective keratitis. A superior scleral tunnel was therefore used by an experienced anterior-segment surgeon. The synechiae were easily broken and uncomplicated surgery was completed within 20 minutes.

Precautions to reduce the risk of infective endophthalmitis included iodine scrub of the lids before peri-bulbar block and surgery. Sterile instrumentation and aseptic protocols were adopted throughout. At the end of surgery, 1 mg of intracameral cefuroxime in 0.1 ml was used.

The surgeon requested FDR. The patient stated that his sight had improved and his eye was comfortable and only slightly red. Visual acuity was 6/36, the bulbar conjunctiva was very injected, and marked fibrinous uveitis with an organised 0.8 mm hypopyon was present. (Figure 1). No clear vitreous or retinal view was possible, but there was a uniform red reflex.

Figure 1
figure 1

Fibrinous uveitis and hypopyon 1 day after cataract surgery.

Full size image

This was treated as post-operative infective endophthalmitis. An aqueous tap and vitreous biopsy were taken with subsequent intravitreal vancomycin 1 mg, intravitreal amikacin 0.4 mg, and intracameral vancomycin 1 mg (each in 0.1 ml). Topical and systemic antibiotics and steroids followed with resolution of the signs of infection and improvement of vision to 6/12 after 3 days .

Aqueous gram stain was clear, but mixed Gram-positive cocci and bacilli were present in the vitreous, some of which were intracellular in pus cells. No pathogens grew on culture.

Comment

This was uncomplicated surgery using evidence-based methods for preventing infective endophthalmitis. 6, 7 FDR resulted in the early detection and treatment with excellent outcome of a potentially devastating complication. The authors believe that this case demonstrates the need to be able to offer FDR in selected cases and be able to immediately deal with complications. All purchasers of cataract services need to take this into account in making informed decisions about quality service provision.