PUBLICATION EXCLUSIVE: Man presents with blurry vision and floaters after cataract surgery

A 73-year-old Caucasian man was referred to the uveitis service at Tufts Medical Center for persistent iritis of the right eye associated with cloudy vision and floaters. He underwent uncomplicated cataract surgery of the right eye approximately 10 months before his presentation. One month after surgery, he presented to his primary ophthalmologist with iritis and hypopyon of the operative eye. He was started on hourly prednisolone, fluorometholone ointment nightly and oral NSAIDs. The iritis reportedly resolved with steroid treatment but recurred after tapering steroids. He then had persistent iritis that did not improve despite restarting prednisolone drops.

The patient had a medical history of hypertension and deep vein thrombosis. His ocular history was significant for bilateral cataract surgery about 10 months before presentation. He reported smoking a half pack of cigarettes daily and using alcohol occasionally. He denied any drug use. His medication list included warfarin, hydrochlorothiazide, lisinopril, atenolol and amlodipine. On review of systems, he denied any history of cold sores or shingles, and he complained of some arthritis in one ankle. He denied any breathing issues, skin problems or rashes.

Figure 1. Slit lamp photograph of the right eye showing dense white intracapsular plaque temporally.

Images: Witkin D, Rifkin L

Figure 2. OCT of the macula of the right eye.

Examination

On presentation to the uveitis clinic, the patient’s best corrected visual acuity was 20/25-1 in the right eye and 20/20-3 in the left eye. Both pupils were equally round and briskly reactive, and there was no afferent pupillary defect. IOP was 19 mm Hg in the right eye and 15 mm Hg in the left eye. He had moderate blepharitis in both eyes. He had conjunctival cysts in both eyes without conjunctival granulomas. The right cornea had active endothelial pigment dusting, and there were 1+ cells in the right anterior chamber. There was a dense white intracapsular plaque temporally (Figure 1) in the right eye and trace posterior capsular haze in the left eye. The vitreous in the right eye had 1+ anterior cells, 1+ central haze and 2+ haze inferiorly. Cup-to-disc ratio was 0.3 in the right eye and 0.2 in the left eye. Neither eye had signs of retinitis, choroiditis or vasculitis. OCT of the macula of both eyes was within normal limits without intraretinal fluid or subretinal fluid. OCT signal of the right eye was attenuated by vitreous haze (Figure 2).

What is your diagnosis?

A 73-year-old Caucasian man was referred to the uveitis service at Tufts Medical Center for persistent iritis of the right eye associated with cloudy vision and floaters. He underwent uncomplicated cataract surgery of the right eye approximately 10 months before his presentation. One month after surgery, he presented to his primary ophthalmologist with iritis and hypopyon of the operative eye. He was started on hourly prednisolone, fluorometholone ointment nightly and oral NSAIDs. The iritis reportedly resolved with steroid treatment but recurred after tapering steroids. He then had persistent iritis that did not improve despite restarting prednisolone drops.

The patient had a medical history of hypertension and deep vein thrombosis. His ocular history was significant for bilateral cataract surgery about 10 months before presentation. He reported smoking a half pack of cigarettes daily and using alcohol occasionally. He denied any drug use. His medication list included warfarin, hydrochlorothiazide, lisinopril, atenolol and amlodipine. On review of systems, he denied any history of cold sores or shingles, and he complained of some arthritis in one ankle. He denied any breathing issues, skin problems or rashes.

Figure 1. Slit lamp photograph of the right eye showing dense white intracapsular plaque temporally.

Images: Witkin D, Rifkin L

Figure 2. OCT of the macula of the right eye.

Examination

On presentation to the uveitis clinic, the patient’s best corrected visual acuity was 20/25-1 in the right eye and 20/20-3 in the left eye. Both pupils were equally round and briskly reactive, and there was no afferent pupillary defect. IOP was 19 mm Hg in the right eye and 15 mm Hg in the left eye. He had moderate blepharitis in both eyes. He had conjunctival cysts in both eyes without conjunctival granulomas. The right cornea had active endothelial pigment dusting, and there were 1+ cells in the right anterior chamber. There was a dense white intracapsular plaque temporally (Figure 1) in the right eye and trace posterior capsular haze in the left eye. The vitreous in the right eye had 1+ anterior cells, 1+ central haze and 2+ haze inferiorly. Cup-to-disc ratio was 0.3 in the right eye and 0.2 in the left eye. Neither eye had signs of retinitis, choroiditis or vasculitis. OCT of the macula of both eyes was within normal limits without intraretinal fluid or subretinal fluid. OCT signal of the right eye was attenuated by vitreous haze (Figure 2).

What is your diagnosis?