A 68-year-old man from Delhi presents with progressive vision loss in both eyes over 2 years. He has type 2 diabetes (HbA1c 8.2%) and hypertension. On examination, best-corrected visual acuity is 6/60 in the right eye and 6/36 in the left eye. Slit-lamp examination reveals dense nuclear sclerotic cataracts bilaterally. Fundus examination is clear. A-scan biometry shows axial length 23.5 mm (right eye). He undergoes phacoemulsification and IOL implantation in the right eye. Postoperatively, on day 5, he develops sudden onset pain, photophobia, and corneal edema with fibrin in the anterior chamber. Intraocular pressure is 32 mmHg. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Endophthalmitis ### Case Analysis The patient presents with classic signs of **acute bacterial endophthalmitis** occurring 5 days post-cataract surgery: - Sudden onset pain (severe intraocular inflammation) - Photophobia (ciliary body involvement) - Corneal edema (anterior chamber reaction) - Fibrin in anterior chamber (dense inflammatory exudate) - Elevated intraocular pressure (32 mmHg from inflammation) ### Key Point: **Endophthalmitis is a surgical emergency** requiring immediate vitreous sampling and intravitreal antibiotic injection. Delay in treatment leads to permanent vision loss. ### Pathophysiology Bacterial seeding of the vitreous cavity occurs through: 1. Incision contamination during surgery 2. Hematogenous spread (rare) 3. Conjunctival flora migration Common organisms: *Staphylococcus epidermidis* (most common), *Staphylococcus aureus*, *Bacillus* species, gram-negative rods. ### Clinical Pearl: **Timing is critical:** Endophthalmitis typically presents 3–7 days post-op (acute) or weeks to months later (chronic). The 5-day presentation here is classic for acute bacterial endophthalmitis. ### Differential Features | Feature | Endophthalmitis | TASS | Angle-Closure | Capsular Rupture | |---------|-----------------|------|---------------|------------------| | **Onset** | 3–7 days post-op | 24–48 hours | Acute, any time | Intraoperative | | **Pain** | Severe | Mild to moderate | Severe | Mild | | **Fibrin** | Yes, dense | Yes, mild | No | No | | **Vitreous haze** | Yes, prominent | No | No | Possible | | **Hypopyon** | Common | Rare | No | No | | **Culture positive** | Yes (60–70%) | No (sterile) | N/A | N/A | ### High-Yield: **TASS** (Toxic Anterior Segment Syndrome) is a sterile, chemical reaction to lens proteins, endotoxins, or surgical solutions—cultures are negative. It occurs within 24–48 hours and is self-limited with topical steroids. Endophthalmitis requires antibiotics. ### Management Algorithm ```mermaid flowchart TD A[Suspected endophthalmitis post-op]:::outcome --> B{Vitreous clarity?}:::decision B -->|Hazy/opaque| C[Vitreous tap + culture]:::action B -->|Clear| D[AC tap + culture]:::action C --> E[Intravitreal antibiotics<br/>Vancomycin + Ceftazidime<br/>+ Amikacin]:::urgent D --> E E --> F[Systemic antibiotics<br/>+ topical steroids]:::action F --> G[Vitrectomy if no<br/>improvement in 48 hrs]:::action G --> H{Visual recovery?}:::decision H -->|Yes| I[Continue antibiotics]:::outcome H -->|No| J[Poor prognosis]:::urgent ``` ### Key Point: **Immediate intravitreal injection** of vancomycin (1 mg/0.1 mL) + ceftazidime (2.25 mg/0.1 mL) ± amikacin (0.4 mg/0.1 mL) is the standard of care. Do not wait for culture results.