Sir,

Acute post-operative bacterial endophthalmitis is one of the most devastating complications of cataract surgery. Typical symptoms and signs include pain, reduced visual acuity, pan-uveitis, and hypopyon formation. This case and the images illustrate a rarely seen presentation of post-operative endophthalmitis characterised by vascular sheathing and retinal infiltrates.

Case report

A 72-year-old woman underwent right phacoemulsification with in-the-bag lens implantation. Surgery was uncomplicated; she received subconjunctival gentamicin and dexamethasone at the end of the procedure and G Tobradex QDS post-operatively. The patient was in reasonable general health with a history of hypertension but no symptoms suggestive of connective tissue disease.

Four days later the patient noticed increased floaters in her right eye. Two days after this she attended the clinic as her vision had decreased. Visual acuity was 6/24 correcting to 6/12−3. There was mild limbal injection and a moderate (+3) anterior uveitis with no hypopyon. There was moderate vitreous (+2) activity with ‘snowballs’ inferiorly. The optic disc appeared swollen and there were multiple intra-retinal haemorrhages, many of which had a central white core and resembled Roth's spots (Figure 1). Vascular sheathing was also noted.

Figure 1
figure 1

Colour photography shows scattered haemorrhages and Roth's spots. Fluorescein angiography demonstrates disc leakage and staining and leakage of vessel walls.

Full size image

Fluorescein angiography revealed disc leakage with associated staining and late leakage of the vessel walls (Figure 1). The left eye appeared normal.

A diagnosis of post-operative endophthalmitis was considered most likely. Following vitreous and aqueous biopsy, the patient received 1 mg intravitreal vancomycin, 0.4 mg amikacin, and 4 mg subconjunctival dexamethasone. She was commenced on topical dexamethasone and cycloplegics, 40 mg prednisolone, and ciprofloxacin orally. The following day, the appearance conformed to a more typical post-operative endophthalmitis with marked vitritis. Vitreous biopsy subsequently revealed Gram-positive cocci on microscopy and culture grew Staphylococcus epidermidis sensitive to amikacin and vancomycin. Investigations including CXR, FBC, ESR, CRP, ACE, autoimmune and vasculitic markers were normal. On discharge, her visual acuity was 6/9−2 corrected and the fundal appearances had improved with resolution of the retinal haemorrhages and infiltrates.

Comment

Unlike the vast majority of cases of post-operative endophthalmitis, the presentation in this patient is unusual, with the main symptom being increased floaters and clinical signs of retinal infiltrates, mild vitritis, and vascular sheathing.

There is a paucity of literature referring to posterior segment appearances in bacterial endophthalmitis.1, 2, 3 Interestingly, animal models have shown that retinal periphlebitis often develops early in stimulated endophthalmitis, with histology providing evidence of inflammatory cell infiltration of retinal vasculature.4

In summary, post-operative bacterial endophthalmitis can present with atypical symptoms and unusual clinical appearance. Although these cases are rare, the authors believe it is advisable to treat with early intravitreal antibiotics rather than wait for evolution of clinical signs, considering the catastrophic outcome on visual prognosis in this condition.5