Ultrasound Biomicroscopy Pars Plana Foci in Postoperative Endophthalmitis

Author: Erika Jean Salvame (Philippines)

Co-authors: Jocelyn Sy, Kristine Pormida, Ramon Henry Dickson

Purpose

To describe a case of post operative endophthalmitis in an uncontrolled diabetic with fungal foci documented at the pars plana using ultrasound biomicroscopy, same foci was also seen intraoperatively using endoscopic vitrectomy

Setting/Venue

Single Center Tertiary Hospital in the Philippines

Methods

Case Report

Results

A 55 year-old male diabetic who underwent complicated phacoemulsification, and secondary pars plana vitrectomy with phacofragmentation and sulcus intraocular lens implantation. There was postoperative improvement to a visual acuity (VA) of 20/80 post surgery. 1 week postop, VA decreased to hand movement with hypopyon and vitritis on b-scan. There was no improvement on intravitreal injection of antibiotics and patient underwent immediate pars plana vitrectomy, with intravitreal injection of antibiotics. Systemic workup revealed urinary tract infection on top of uncontrolled blood sugar. Intravitreal injection continued with oral and topical antibiotics with steady improvement of vision to VA 20/80 but by 1 month post-operation, VA again decreased to hand movement,. B scan revealed vitritis and retinal detachment. Pre operative ultrasound biomicroscopy revealed a hyperechoic nodule at the pars plana extending to the adjacent detached retina. Patient underwent intraocular lens explantation, and retinal detachment surgery with silicone oil. Intra-operative endoscopic evaluation also revealed cream feathery twin-like mounds deposited at the pars plana and allowed better access to the lesions for sampling. Microbiological workup revealed spores and hyphae suspicious of candida species. Intravitreal voriconazole and systemic anti-fungal treatment was initiated.

Conlusions

Fungal endophthalmitis is a potentially devastating postoperative complication. Its clinical course is nonspecific and be confounded by initial improvement and low grade prolonged inflammation. This case highlights the importance of multimodal platforms of imaging in identifying foci of infections. Adjunct intraoperative visualization platforms may also aid in better yield of samples for diagnostic evaluation.

Financial Disclosure

Department of Health Eye Center, East Avenue Medical Center, Philippines: Ongoing Vitreo Retina Fellowship