Unilateral endophthalmitis after immediate sequential bilateral cataract surgery in a cognitively impaired patient: diagnosis and treatment

Abstract

Introduction: Immediate sequential bilateral cataract surgery (ISBCS) is a reasonable approach for cataract surgery in patients needing general anesthesia, such as those with cognitive impairment. To our knowledge, this is the first reported case of unilateral acute-onset postoperative endophthalmitis in a patient with cognitive impairment after ISBCS, with emphasis on diagnostic and treatment challenges. Patient and Clinical Findings: A 64-year-old woman with a history of cognitive impairment, seizure disorder, and no prior ocular surgery presented with dense visually significant cataracts and visual acuity of fix and follows in both eyes. Diagnosis, Intervention, and Outcomes: Patient underwent ISBCS under general anesthesia and without intracameral antibiotics or corneal sutures. The patient returned with unilateral acute-onset endophthalmitis 2 weeks postoperatively. Because of the patient's limited ability to comply with treatment, and lack of emergency general anesthesia needed for vitreous cultures, intravitreal vancomycin injection (1 mg/0.1 mL) was empirically given, with clinical resolution of the infection and visual acuity of fix and follows. Conclusions: Acute-onset postoperative endophthalmitis in the setting of cognitive impairment is challenging because emergency general anesthesia may not be available, and the patient can tolerate only limited interventions. In this patient, empiric intravitreal vancomycin injection without cultures led to a satisfactory clinical outcome.