OPHTHALMoLoGY CASES

Traumatic Cataract: 11 year-old boy with glass injury to the right eye
Jeffrey L. Maassen, MD, Thomas A. Oetting, MD, and A. Tim Johnson, MD, PhD Chief Complaint: 11 year-old male seen for evaluation of an open globe and traumatic cataract. History of Present Illness: An 11 year-old male was referred to the University of Iowa Hospitals and Clinics for evaluation of a possible open globe. One day prior, while hammering on a taillight of an old automobile a glass shard flew into his right eye. The boy complained of pain and a foreign body sensation and was taken to the local emergency treatment center for evaluation. A slit lamp examination failed to reveal a foreign body. Early the next morning he awoke with worsening pain and decreased vision. A local ophthalmologist noted a corneal laceration and cataract, but could not rule out the presence of an intraocular foreign body and referred him to the UIHC. Upon arrival, he continued to complain of pain and decreased vision in his right eye. Past Ocular History: No prior ocular injury, surgery, or illness. Past Medical History: Non-contributory Medications: Gatifloxacin (Zymar) ophthalmic drops, 4x/day, in the right eye. Family and Social History: Noncontributory Exam, Ocular:

Visual Acuity, without correction: right eye (OD)--20/70; left eye (OS)--20/20 Motility: Normal; no restrictions Confrontation visual fields: Full, both eyes (OU) Intra-ocular pressure: OD -- 15; OS not attempted due to risk of open globe Pupils: No relative afferent pupillary defect (RAPD) Slit lamp examination, OD: (see Figure 1) o 2.5 mm diameter full- thickness stellate corneal laceration (Seidel negative) o Anterior chamber - deep with 1+ cell and flare o Anterior capsular tear - from 11:00 to 4:00 position and extending to the zonules o Cortical lens material protruding through the tear

Dilated fundus exam (DFE): Noforeign body. No vitreous hemorrhage or vitritis. Normal macula, vessels, and periphery, OU

Figure 1 Traumatic cataract and anterior capsular tear (arrows).

Other examination: No IOFB detected by maxillofacial CT or ocular echography. The posterior lens capsule appeared to be intact with b-scan echography. Discussion: This case presents the interesting challenge of dealing with a traumatic cataract with anterior capsular rupture. When considering our surgical approach to this case, the most important consideration was identifying the anterior capsule. The anterior capsule appeared to be torn in a linear fashion from the 11:00 to the 4:00 position; however, protruding cortical lens material obscured the defect making it difficult to see the extent and position of the tear. Poor visualization of the anterior capsular edges hampers initiating a capsulorhexis. Even if an adequate capsulorhexis opening were achieved, aspiration of the lens material would be difficult due to poor visualization and possible aspiration of the remaining anterior capsule. To aid in identifying the capsule, we elected to use a capsular stain.

Indocyanine green (ICG) was initially described for use as a capsular stain in mature cataracts by Horiguchi, et al (Horiguchi, et al 1998). After comparing the results of ten mature cataracts operations assisted by ICG stain they concluded it was safe and effective. Trypan blue was described by Melles, et al (Melles, et al 1999) as a safe and an effective anterior capsular stain in mature cataracts. A recent study by Chung, et al (Chung, et al 2005) further established that ICG 0.5% and trypan blue 1% were safe in regards to endothelial cell count, corneal clarity, intraocular inflammation, and postoperative intraocular pressure. The use of ICG in traumatic cataract was initially described in a case report by Newsom and Oetting (2000). In their case they demonstrated that ICG showed preferential staining of the capsule over the lens material. Identification of ICG stained lens capsule and facilitated completion of the capsulorhexis. Trypan stained anterior capsule visualization in traumatic cataract was subsequently reported by Baykara, et al (Baykara, et al 2002). Description of Operative Procedure and Patient Course: Two days after the injury, cataract extraction was performed. A single paracentesis port was placed at the ten oclock position. A bubble of filtered air was injected through the paracentesis until the anterior chamber was full. A commercial preparation of 1% trypan blue was injected under the bubble by injection of Viscoat and evacuation of air and trypan blue from anterior chamber. (Figure 2). The anterior capsule stained blue, but the anterior cortical material did not stain. A 2.7 mm incision into the anterior chamber followed by a cystotome to create a nick in the temporal portion of the anterior capsule. A continuous curvilinear capsulorhexis was performed with Utrata forceps. The cortical and nuclear portions of the lens were removed by irrigation/aspiration. A foldable acrylic lens was injected into the intact capsular bag and the remaining viscoelastic was aspirated. The corneal laceration was sutured with two 10-0 nylon sutures. The wound was closed with 10-0 Vicryl suture.

Figure 2 The anterior capsule is well delineated from the cortical material by the trypan blue staining.

Postoperative day #1 the patient was 20/70, the corneal laceration was Seidel negative, but there was a small piece of residual cortical material centered near the pupil. No residual corneal or capsular staining was noted. Postoperative day #2 his vision was 20/40 and the lens remnant was gone. Postoperative week #1 his vision was 20/30+. Conclusion: This case further supports the earlier finding of Newsom and Oetting (2000) that capsular stains have greater affinity for the anterior capsule than for lens material. In this setting, trypan blue offers several advantages for traumatic cataract removal. 1. Trypan blue aids in the initial assessment of the anterior capsule, 2. it improves the surgeons ability to successfully initiate and complete a continuous curvilinear capsulorhexis, and 3. it aids in aspiration of the lens material by distinguishing between remaining capsule and lens material. A recent letter to the Journal of Cataract and Refractive Surgery (Bishop, 2005) suggests that any type of capsule staining technique is contraindicated once the anterior capsule has been opened. We strongly disagree with this assertion. We propose the opposite and suggest that the preferred technique for initiating the capsulorhexis in cases of traumatic anterior capsular tear is the initial use of capsular stains such as ICG and trypan blue. Diagnosis: Self-sealing corneal laceration with traumatic cataract and anterior capsular rupture

References 1. Horiguchi M, Miyake K, Ohta I, Ito Y. Staining of the Lens Capsule for Circular Continuous Capsulorrhexis in Eyes With White Cataract. Arch Ophthalmol 1998; 116:535-537. 2. Melles GR, de Waard PW, Pameyer JH, Beekhuis WH. Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refract Surg 1999; 25:7-9. 3. Chung CF, Liang CC, Lai JS, Lo ES, Lam DS. Safety of trypan blue 1% and indocyanine green 0.5% in assisting visualization of anterior capsule during phacoemulsification in mature cataract. J Cataract Refract Surg 2005; 31:938-942. 4. Newsom TH, Oetting TA. Indocyanine green staining in traumatic cataract. J Cataract Refract Surg 2000. 26:1691-1693. 5. Baykara M, Dogru M, Ozcetin H, Erturk H. Primary repair and intraocular lens implantation after perforating eye injury. J Cataract Refract Surg 2002. 28:1832-1835. 6. Bishop RM. Letter: Contraindications to capsule staining. J Cataract Refract Surg 2005. 31:1272.

Endophthalmitis:
82 year-old male status post phacoemulsification in the left eye with acute decrease in vision

Jeffrey L. Maassen, MD and James C. Folk, MD December 6, 2005, Updated April 5, 2006 Chief Complaint: 82 year-old male with complaints of acute decreased vision, left eye. History of Present Illness: This patient has a history of macular degeneration in both eyes. His left eye had been his better-seeing eye, but vision had gradually become hazy and dim, with reduced visual acuity due to progressive cataract. Six days prior to this presentation, the patient underwent uncomplicated phacoemulsification and intra-ocular lens (IOL) placement with a local ophthalmologist. In the day prior to this presentation, the patient become to notice ocular redness, discomfort, and dramatically decreased vision in the post-operative eye. The following morning, the patient was referred to the University of Iowa Hospitals and Clinics. That examination and findings are here presented. Eye History: Known history of macular degeneration with geographic atrophy greater in the right eye (OD) than the left (OS). Baseline best-corrected visual acuity prior to this examination had been 20/400 and 20/80-2 in the right and left eyes, respectively, on pre-operative evaluation

before cataract surgery. Prior history of phacoemulsification cataract removal, OD, several years prior. Medical History: Unremarkable. Medications: Supplements as recommended by the Age-Related Eye Disease. Family and Social History: Noncontributory EXAM, OCULAR

Visual Acuity: OD20/400; OSLight perception with projection Intra-ocular pressure: 10 mmHg, OS; Not measured, OD Pupil was not visualized in the left eye External and anterior segment examination: o OD, Normal with PCIOL; OS: Profound conjunctival injection, corneal edema, and hypopyon (see Figure 1) Dilated fundus exam (DFE): ODNormal; OSNo view o Echography, OSDiffuse, highly mobile vitreous opacities. No retinal detachment.

Figure 1: Left eye (OS) status post phacoemulsification and IOL placement 6 days prior. The eye now has profound injection, corneal edema, hypopyon, and fibrin strands in the anterior chamber.

Course The presence of decreased vision, a red, injected eye, with intraocular inflammation and hypopyon six days after cataract extraction is a classic example of postoperative endophthalmitis. This case illustrates the rapid progression of postoperative endophthalmitis. A vitrectomy was indicated to treat this severe infection because of his light perception only vision (Endophthalmitis Vitrectomy Study Group, 1995). An infusion cannula and sclerotomy sites were placed over the pars plana, 3mm posterior to the limbus. A vitreous tap using suction and the vitrectomy probe was performed first. The vitrectomy probe was used to create a small opening in the posterior capsule to gain access to the anterior chamber after which the dense fibrin white cells were removed. Pupil hooks were used to dilate the pupil. The opaque vitrous was then removed posteriorly. The retina was attached but had scattered hemorrhages throughout. The sclerotomy sites were closed followed by intravitreal injections of vancomycin (1mg) and ceftazidime (2mg). Kenalog (10mg) was injected subconjunctivally in the inferior nasal quadrant.

Post-operatively, the patient was given levofloxacin, 1% prednisolone, and 0.25% scopolamine eye drops. Microbiology later reported growth of a coagulase negative staphylococcus. At one week follow-up, the patient's vision had improved to 20/400. There was a small amount (+1) of residual cell in the anterior chamber and a few remaning intra-retinal hemorrhages. The antibiotic drops were stopped and the prednisolone and scopalamine drops were slowly tapered. Ten weeks after vitrectomy, the eye was quiet and the vision had recovered to 20/100+, within one line of his preoperative state. Fundus examination revealed atrophy from macular degeneration and a new occult choroidal neovascularization (see Figure 2) that was confirmed by fluorescein angiogram. Avastin (1.25mg) was injected into the left eye. The patient will follow-up in one month.
Figure 2 : Fundus and flurorescein images, OS, ten weeks after initial infection. The vitreous space is clear and retinal hemorrhages have resolved. The retina had atrophy and occult choroidal neovascularization.

Discussion of Epidemiology and Treatment: The incidence of post cataract surgery endophthalmitis has varied over the past century. Estimates are approximately 5-10% in late 1800s, 1.5% during the 1930s, 0.5% ~1950s, and 0.06% - 0.09% in the early 1990s. There is recent evidence that clear corneal incision may have greater risk of endophthalmitis than cataract surgery performed using a scleral tunnel incision. Colleaux et al (2000) reported an incidence of 0.129% with clear cornea incision vs. 0.05% for a scleral tunnel approach. However, most studies lack sufficient power to truly estimate whether difference is significant. A recent study by Taban et al reviewed 215 articles reporting cataract surgery associated endophthalmitis from 1963 through 2003. The pooled review encompassed a total of 3,140,650 cataract extractions. The overall pooled estimate (1964-2003) for endophthalmitis was 0.128%. The 1990s had an incidence 0.087% while more recently the incidence since 2000 was 0.265%. In this review, the incidence for clear cornea was 0.19% vs. 0.07% for scleral tunnel. It remains difficult to say whether there is a significant difference between the two approaches after considering the multiple other variables in cataract surgery.

Standard treatment for postoperative endophthalmitis has been clarified in part by the Endophthalmitis Vitrectomy Study. This prospective study randomized 420 patients less than six weeks out from CE/IOL with clinical signs and symptoms of endophthalmitis. The patients were randomized to: groups receiving or not receiving systemic antibiotics; and to groups receiving pars plana vitrectomy versus tap and inject. Results of this study demonstrated: 1) Patients with light perception vision benefited from pars plana vitrectomy [3X greater chance of 20/40, 2X greater chance of 20/100, and risk of severe loss (<5/200)], 2) Patients with vision better than light perception had the same outcome whether early they underwent pars plana vitrectomy or tap and inject, 3) Patients receiving intravenous (IV) vancomycin and amikacin showed no statistical benefit compared to those who did not receive IV antibiotics. Diagnosis: Acute Post-Operative Endophthalmitis

EPIDEMIOLOGY

SIGNS

Variable incidence of post-cataract surgery endophthalmitis over the past century:

0.128% (summary review of 215 articles reporting cataract surgery associated endophthalmitis from 1963-2003; Taban, et al. 2005). Some studies have suggested that endophthalmitis rates may be increasing in recent years. o Some reviews indicate that an increased rate of post-operative endophthalmitis in clear cornea incision cataract surgery may be a cause (0.129% endophthalmitis for clear cornea incision cataract surgery vs. 0.05% for scleral tunnel [Colleaux et al, 2000])

Profoundly decreased vision Conjunctival injection Corneal edema Anterior chamber reaction Hypopyon Vitritis

SYMPTOMS

TREATMENT

Ocular Pain Decreased vision Irritation Headache Photophobia "Red eye" noted by patient or family

For VA that is "hand motions" or better:

Tap and inject. First tap the eye for samples: o Anterior chamber aqueous tap with 30g needle on a tuberculin syringe sent for cultures o Vitrous sample obtained through the pars plana with a 25 gauge, 1 inch needle directed toward the mid-vitreous cavity and then sent for cultures Inject the vitrous cavity with antibiotics (ie. Vancomycin and amikacin were used in the EVS. Ceftazidine is often used in clinical practice in the place of amikacin, primarily due to the risk of aminoglycoside toxicity with amikacin)

Tap and Inject Video (free. registration required)

For VA that is worse than "hand motions":

Pars plana vitrectomy. Send aqueous and vitrectomy cultures taken during surgery. Inject intravitreal antibiotics at the time of surgery

Follow cultures and adjust antibiotics accordingly, if necessary Differential Diagnoses for Post-Operative Endophthalmitis

Post-operative inflammation Retained lens Fragment Chronic (delayed-onset) Endophthalmitis (within 6 weeks of intraocular surgery--rare; organisms include Proprionibacterium acnes, coagulase-negative Staphylococcus, fungi) Endogenous endophthalmitis Anterior Uveitis Ulcerative keratitis

References 1. Endophthalmitis Vitrectomy Study Group. "Results of the Endophthalmitis Vitrectomy Study". Arch Ophthalmol 1995; 113(12):1479-1496. 2. Taban et al. "Acute Endophthalmitis Following Cataract Surgery". Arch Ophthalmol 2005 May;123(5):613-20. 3. Colleaux KM, Hamilton WK. "Effect of prophylactic antibiotics and incision type on the indicence of endophthalmitis after cataract surgery". Can J Ophthalmol. 2000;35(7):373-8. 4. Chapter 16. Vitrectomy. In: Flynn, Bressler, Brown, Meredith, Regillo, and Isernhagen. Section 12. Retina and Vitreous, 2004-2005 Basic and Clinical Science Course. San Francisco : American Academy of Ophthalmology; 2004; p. 296-300.