A complete vaccination covid-19 test negative 18-year-old female with high myopia and astigmatism and no medical problems came to our clinic to evaluate refractive surgery. The cycloplegic refraction was − 11.25/-2.50x175 OD and − 9.5/-2.00x170 OS. The corrected distance visual acuity (CDVA) was 20/20 in both eyes. The endothelial cell density was 3245 cells/mm2 OD and 3190 cells/mm2 OS. The white-to-white diameter was 12.1mm and 12.3 mm, and the anterior chamber depth (from endothelium) was 3.38mm and 3.49mm, respectively. Informed consent was obtained after explaining the potential risks of surgery. V4c TICL (VTICMO13.7–15.0/+2.5x113 OD VTICMO13.7–13.0/+2.5x113 OS) (Visian, STAAR Surgical Co, California, USA) were implanted, the surgery was uneventful. Topical Levofloxacin 0.5% four times a day and prednisolone acetate 1% four times a day were started immediately after the surgery. The uncorrected distance visual acuity (UDVA) was 20/20 in both eyes on the first postoperative day; there was no corneal edema, and 1 + cells were present in the anterior chamber (AC). The ICLs were in situ with a vault of 660µm OD and 550 µm OS on pentacam.
The patient presented with blurred vision and redness of the left eye 20 days following bilateral ICL surgery. She was noted to have participated in an intensive bicycle racing competition hosted in Shanghai 3 days ago. Visual acuity (VA)was 20/20OD and 10/20 OS with intraocular pressure (IOP) of 21.8 mmHg and 15.9 mmHg, respectively. Slit lamp exam showed clinical manifestations, including mild conjunctival and ciliary congestion, white round keratic precipitates, 3 + anterior chamber flare, and cells, with fibrin exudate, 1mm hypopyon in the anterior chamber, vitreous opacity OS; the right eye was unremarkable. The ICL was in a good position. Dilated fundus exam was invisible(Fig. 1).
Treatment
Considered for postoperative endophthalmitis OS, a vitreous tap and injection of vancomycin 1mg/0.1ml and ceftazidime 2 mg/0.1 mL was performed. The sample was sent for pathogen detection and drug sensitivity testing. The patient was also treated with systemic(cetrazidime1gIVq24h)and topical antibiotics(Tobramycin Dexamethasone Eye q15m 15mg:5mg/5ml, Levofloxacin 0.5% Eye Drop q2h), 1% prednisolone acetate eye drops three times a day and 0.5% tropicamide qd.
The cultures were positive for Staphylococcus epidermidis, which was sensitive to all antibiotics. The patient was diagnosed with postoperative endophthalmitis. 24h after intravitreal injection, the BCVA was 6/20, with the resolution of hypopyon. (Fig. 2). Systematic antibiotic treatment was continued (intravenous administration of Ceftazidime) over the subsequent three days.
Given persistent inferior keratic precipitates, anterior chamber flare and cells, and vitreous opacity, vision remained 6/20, fibrin exudation in the pupil area and the vitreous body was much less (Fig. 3), intravitreal injection of vancomycin 1mg/0.1ml and ceftazidime 2 mg/0.1 mL was performed 72hours again later. As the AC inflammation and IOL deposits were minimal, we did not remove the ICL nor AC washout, and a close follow-up was arranged to monitor the progress of endophthalmitis. After four days of the second intravitreal injection, the vision was 12/20, anterior chamber flare and cells (+), and Para bulbar injection of triamcinolone acetonide was administered.
Outcome And Follow Up
Outcome and follow up
The topical treatment was tapered gradually over one month. There was a notable improvement in AC reaction, complete resolution of exudates, and gradual resolution of the vitreous opacity, BCVA improved to 22/20 on day 38 post the antibiotic Therapy with inactive vitreous opacities(Fig. 4). The uncorrected distance visual acuity of 20/20 was achieved three months following the antibiotic therapy, the manifest refraction was − 0.25/-0.50x65 = 1.0, the anterior chamber was unremarkable, persistent vitreous opacities were resolved, fundus photograph of the left eye was clear (Fig. 5).