Day-3 hypopyon after cataract surgery, with a second case on the same list
A 72-year-old woman presents 3 days after uneventful phacoemulsification with in-the-bag IOL implantation in the right eye. She reports increasing pain and progressive blurring since the evening of surgery. Right VA is 6/60 with a 2 mm hypopyon, marked anterior chamber fibrin, 3+ cells, and dense vitreous haze that obscures fundal detail; IOP is 12 mmHg. There is no wound leak and the IOL is well centred. She received intracameral cefuroxime 1 mg/0.1 mL at the end of surgery and is using topical moxifloxacin and dexamethasone. Her left eye is quiet with VA 6/6. The same theatre list included six other cataract operations that morning, and the day-1 review of one other patient has been brought forward after that patient telephoned reporting a similar red, painful eye with a hypopyon. The vitreoretinal surgeon is 90 minutes away and the theatre has no on-site vitrectomy machine.
1. Toxic anterior segment syndrome or infectious endophthalmitis? Give the features that favour each in this patient and explain why the distinction changes what you do tonight.
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Features favouring infectious endophthalmitis:
- Onset on day 3 - TASS is typically 12–48 hours.
- Significant pain with progressive blurring.
- Dense vitreous haze obscuring fundal detail. TASS is overwhelmingly an anterior segment process; vitreous involvement points to infection.
- Hypopyon with fibrin.
Features favouring TASS:
- Two patients from the same morning list with an identical picture - clustering is the signature of a shared non-infectious insult (irrigating solution, instrument-cleaning residue, a drug dilution, viscoelastic).
- No documented wound leak or capsule break; both received intracameral cefuroxime, possibly from the same batch.
Why the distinction changes tonight: the treatments diverge. TASS is managed with aggressive topical steroids and often resolves over weeks; endophthalmitis needs immediate vitreous tap and intravitreal antibiotics, and steroid introduced too early can blunt the host response. But the overlap is real, and a TASS-like cluster can equally be a shared contaminated source rather than a sterile one.
Therefore tonight treat as endophthalmitis. Do not wait for the vitreous sample, do not delay for a vitrectomy opinion, and do not give intravitreal steroid at the time of the tap. A delay in treating a curable infection costs vision permanently; treating possible TASS with antibiotics as well costs almost nothing.
2. Outline your management over the next 4 hours, including what you do about the absence of on-site vitrectomy.
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- Examination and documentation: relative afferent pupillary defect, and a B-scan ultrasound to assess the posterior segment - no vitrectomy machine is needed to exclude retinal detachment or a choroidal elevation, only a probe.
- Vitreous tap: pars plana approach 3.5–4 mm posterior to the limbus in a pseudophakic eye, 25/23 G needle on a 1 mL syringe, aspirating 0.1–0.2 mL of vitreous for Gram stain, bacterial and fungal culture, and PCR if available. An anterior chamber tap is an adjunct with lower yield.
- Intravitreal antibiotics: ceftazidime 2.25 mg/0.1 mL and vancomycin 1 mg/0.1 mL, drawn up and injected separately - never mixed in one syringe.
- Topical: fortified vancomycin 5% and ceftazidime 5% hourly around the clock plus cycloplegia.
- Systemic antibiotics: the EVS did not show benefit from intravenous antibiotics and the evidence for oral moxifloxacin is not strong enough to make it mandatory; use it for a virulent organism, an immunocompromised host, or peribulbar/orbital extension.
- Vitrectomy is indicated for light-perception-only acuity (the EVS subgroup that benefits), progression after 48–72 hours, or severe vitreous opacification. Because the machine is 90 minutes away, pre-alert the vitreoretinal unit now so transfer is a decision rather than a scramble.
- Do not explant a well-positioned in-the-bag IOL at the first episode.
- Admit, review at 6–12 hours and then daily; add intravitreal dexamethasone only after 24–48 hours once cultures and the clinical course are known.
3. What system-level actions do you take, and how do you counsel the patient about a possible shared cause?
Read the worked answer
Tonight - contain it:
- Inform the theatre manager, infection prevention lead and on-call microbiology immediately. A cluster of post-operative inflammation is a patient-safety event.
- Quarantine shared items: the phaco machine and handpieces, irrigation/aspiration cassettes, the batch of balanced salt solution, viscoelastic, trypan blue and - a very common culprit - the intracameral cefuroxime dilution, which is often prepared on the unit and may be the wrong concentration or pH, or contaminated. Also review instrument cleaning and rinse-water quality, a classic cause of TASS.
- Contact all seven patients from that list today and examine them at the slit lamp; do not wait for them to telephone. Keep a single written log.
- Review that session's theatre records for deviations, shared instruments or a change of supplier.
Governance: report through the hospital incident system and the national reporting system, and complete a duty-of-candour discussion with this patient and with the others as soon as there is information to share.
Counselling this patient: explain that there are two possible explanations - an infection, which you are treating, and an inflammation caused by something used in surgery, which you are also treating - that treatment for both starts tonight, and that the eventual outlook depends on the organism and the response over 48–72 hours. Be explicit that vision may not return fully, that further surgery including vitrectomy may be needed, and that she should tell you at once if the pain or the vision worsens.