Numerous White Retinal Lesions Following Cataract Surgery: JAMA Ophthalmology Clinical Challenge
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.
At time of examination in clinic 4 weeks following treatment, the patient was receiving topical steroid and cycloplegic drops. Her best-corrected visual acuity had improved to 20/70. Examination showed a deep and quiet anterior chamber with a well positioned intraocular lens without any plaques or deposits on the lens capsule. Dilated ophthalmoscopic examination demonstrated improvement in the vitreous debris with 1+ vitritis and numerous superficial, round, white lesions spread throughout the fundus in all 4 quadrants and in the macula. Optical coherence tomography verified the preretinal location of the lesions. It was diagnosed as Vancomycin and ceftazidime deposits.
This patient was referred for new retinal lesions after treatment for presumed bacterial endophthalmitis following cataract surgery. At the time of consultation, surgeos opted to observe closely given the patient was improving clinically with decreased intraocular inflammation.
Repeat injection of intravitreal antibiotics was 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 were 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. Given her clinical improvement with resolving inflammation, an invasive procedure such as pars plana vitrectomy with vitreous biopsy or capsular biopsy was not pursued and 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. This 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.
Intravitreal injections of vancomycin and ceftazidime are routinely used in combination for broad-spectrum coverage in the treatment of endophthalmitis. Studies have shown in vitro combination of ceftazidime (4 mg/0.1 mL) and vancomycin (1 mg/0.1 mL) results in precipitation of the antibiotic. As such, it has been recommended to avoid combining the 2 medications into a single syringe. It is hypothesized that the alkaline nature of vancomycin results in precipitation due to the sodium carbonate in ceftazidime; however, formulations without sodium carbonate have also resulted in precipitation. Prior reports describe vitreous precipitates in patients treated with intravitreal vancomycin (1 mg/0.1 mL) and ceftazidime (2.2 mg/0.1 mL). Increase in the pH and concentration of the antibiotics by the pharmacy or injector may result in increased precipitation of the medication
In this case, the development of preretinal lesions following intravitreal injections is most consistent with vancomycin and ceftazidime precipitates deposited on the retinal surface. Authors acknowledged the lack of histopathologic correlation to make this diagnosis with certainty.
Patient Outcome: The lesions improved in number and size and there was movement of the deposits from the retinal surface into the vitreous. Visual acuity improved to 20/40 over the course of 2 months, with eventual complete resolution of the preretinal white lesions without recurrence of inflammation
Source: Kurt Scavelli, MD; William B. Priester, MD; Avni P. Finn, MD, MBA doi:10.1001/jamaophthalmol.2022.2152
