A 68-year-old man presents to the emergency department 3 weeks after uncomplicated phacoemulsification cataract surgery with acute-onset pain, photophobia, and blurred vision. Examination reveals conjunctival injection, corneal edema, and the structure marked **A** in the diagram — a yellowish-white horizontal fluid level in the lower anterior chamber. Which of the following is the MOST appropriate immediate management?

Explanation

## Why Intravitreal injection of vancomycin and ceftazidime after aqueous tap for culture, with same-day ophthalmology consultation is right The structure marked **A** — hypopyon (white inflammatory cells settling in the lower anterior chamber as a yellowish-white horizontal fluid level) — is a hallmark of severe intraocular inflammation and indicates **endophthalmitis until proven otherwise**. Post-surgical endophthalmitis (occurring within 6 weeks of cataract surgery, as in this case) is a sight-threatening emergency caused most commonly by coagulase-negative staphylococci, *Staphylococcus aureus*, and streptococci. Per AK Khurana Ophthalmology 7e and Harrison 21e, the standard of care is **same-day intravitreal antibiotic injection** (vancomycin 1 mg/0.1 mL + ceftazidime 2.25 mg/0.1 mL) after aqueous tap for culture and sensitivity. This is a true ophthalmologic emergency requiring immediate specialist intervention. ## Why each distractor is wrong - **Topical prednisolone acetate 1% hourly and oral ciprofloxacin for 2 weeks**: Topical antibiotics and steroids alone are insufficient for endophthalmitis; they do not achieve therapeutic intraocular concentrations. Delaying intravitreal antibiotics in post-surgical endophthalmitis risks irreversible vision loss within days. - **Observation with topical moxifloxacin and prednisolone acetate 1% four times daily for 1 week**: Observation is contraindicated in suspected endophthalmitis. Hypopyon indicates severe intraocular inflammation requiring urgent intervention, not watchful waiting. - **Pars plana vitrectomy followed by systemic antibiotics and oral corticosteroids**: While vitrectomy may be considered in severe cases with profound vision loss (per the Endophthalmitis Vitrectomy Study), it is not the first-line immediate step. Intravitreal antibiotics must be given emergently; vitrectomy is reserved for cases with severe vision loss or inadequate response. **High-Yield:** Hypopyon = endophthalmitis until proven otherwise; post-surgical endophthalmitis is a same-day intravitreal antibiotic emergency (vancomycin + ceftazidime) — do not delay with topical therapy alone. [cite: AK Khurana Ophthalmology 7e; Harrison 21e Ch 32]