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Numerous White Retinal Lesions Following Cataract Surgery

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 74-year-old woman was referred for evaluation of retinal lesions in her left eye. Her ocular history was notable for recent cataract surgery 5 weeks prior to presentation that was complicated by endophthalmitis. A normal funduscopic examination was documented prior to cataract surgery. At the time of initial presentation to her local retina specialist 1 week following her cataract surgery, the patient had severe pain and redness. Her visual acuity was light perception. An examination revealed a 2-mm hypopyon and dense vitreous haze with no view of the retina. She was treated for presumed endophthalmitis with a vitreous tap and intravitreal injections of vancomycin (1 mg/0.1 mL), ceftazidime (2.2 mg/0.1 mL), and dexamethasone (0.4 mg/0.1 mL). The vitreous sample obtained at the time of treatment grew Staphylococcus caprae susceptible to vancomycin.

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Vancomycin and ceftazidime deposits

C. Observation

This patient was referred for new retinal lesions after treatment for presumed bacterial endophthalmitis following cataract surgery. At the time of consultation, we opted to observe closely given the patient was improving clinically with decreased intraocular inflammation.

Repeat injection of intravitreal antibiotics (choice A) is not the preferred answer as the lesions developed following antibiotic treatment and she was improving clinically. Because the vitreous cultures provided a presumed diagnosis of S caprae endophthalmitis susceptible to vancomycin, injecting antifungals (choice D) would be unlikely to aid this patient.

Deposits similar to those seen in this case have been reported in 2 scenarios: (1) preretinal precipitates resulting from intravitreal injections and (2) epiretinal deposits in the setting of Cutibacterium acnes infection.1 Given her clinical improvement with resolving inflammation, an invasive procedure such as pars plana vitrectomy with vitreous biopsy (choice B) or capsular biopsy was not pursued and would be reserved for patients who may not otherwise be improving clinically, in whom a smoldering infection such as C acnes is suspected, or in whom the diagnosis remains uncertain. Our case differs from the epiretinal deposits seen with C acnes given the fulminant postcataract endophthalmitis that occurred, rather than the delayed-onset smoldering inflammation seen with C acnes. Additionally, this case lacked a posterior capsular plaque and there was notable improvement with eventual resolution of the deposits without further intervention.

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Article Information

Corresponding Author: Avni P. Finn, MD, MBA, Department of Ophthalmology, Vanderbilt University Medical Center, 2311 Pierce Ave, Nashville, TN 37212 (avni.finn@vumc.org).

Published Online: August 4, 2022. doi:10.1001/jamaophthalmol.2022.2152

Conflict of Interest Disclosures: Dr Finn reported being on the advisory board for Allergan and Genentech and being a consultant for Apellis Pharmaceuticals. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Rossin  EJ , Tieger  M , Rao  NA , O’Hearn  TM , Eliott  D , Wu  DM .  Two cases of Cutibacterium acnes (C acnes) endophthalmitis manifesting with unusual epiretinal deposits.   Ophthalmic Surg Lasers Imaging Retina. 2022;53(3):164-167. doi:10.3928/23258160-20220215-01PubMedGoogle ScholarCrossref
2.
Lim  JI , Campochiaro  PA .  Successful treatment of gram-negative endophthalmitis with intravitreous ceftazidime.   Arch Ophthalmol. 1992;110(12):1686. doi:10.1001/archopht.1992.01080240024015PubMedGoogle ScholarCrossref
3.
Campochiaro  PA .  Physical incompatibility of vancomycin and ceftazidime for intravitreal injection—reply.   Arch Ophthalmol. 1993;111(6). doi:10.1001/archopht.1993.01090060016002Google ScholarCrossref
4.
Lifshitz  T , Lapid-Gortzak  R , Finkelman  Y , Klemperer  I .  Vancomycin and ceftazidime incompatibility upon intravitreal injection.   Br J Ophthalmol. 2000;84(1):117-118. doi:10.1136/bjo.84.1.117aPubMedGoogle ScholarCrossref
5.
Valdes Lara  CA , Testi  I , Pavesio  C .  Ceftazidime and vancomycin deposits after intravitreal injection in a vitrectomized eye.   Ophthalmology. 2021;128(11):1591. doi:10.1016/j.ophtha.2021.04.010PubMedGoogle ScholarCrossref
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