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Hypopyon and a dull reflex after cataract surgery
A 60-year-old man underwent right cataract surgery. On the first postoperative day, slit-lamp examination shows a hypopyon and there is a dull fundal glow.
Name the diagnosis.
- Suspected acute postoperative endophthalmitis.
List three other signs.
- Lid oedema.
- Conjunctival congestion or chemosis.
- Vitreous inflammatory exudate/haze (vitritis).
Name one investigation before treatment.
- Vitreous sampling for microscopy, Gram stain, culture and susceptibility, followed immediately by intravitreal antibiotics; an aqueous sample may also be obtained under the local protocol.
Choose. Understand. Revisit.
An older patient has a deep anterior chamber, iridodonesis and no crystalline lens seen in the pupillary area. What best explains the resulting high hypermetropia?
In a schematic eye, use a +3 D hypermetropic shift per 1 mm reduction in axial length. If refraction starts at +2 D and axial length changes from 22 to 20 mm, what is the estimated refraction?
Perform a pupil examination
Examine the patient’s pupils and present your findings.
Demonstrate the examination.
- Introduce yourself, confirm identity, explain and obtain consent.
- Ask the patient to look at a distant target; compare pupils in ambient and dim light.
- Assess size in millimetres, symmetry, shape and position.
- Bring the torch from the side; test direct and consensual responses in each eye.
- Perform a swinging-flashlight test for RAPD.
- Assess the near response when appropriate; thank the patient and report findings.
Which pupil features should you report?
- Size in millimetres, shape, position and symmetry in light and dark.
- Direct and consensual light responses, RAPD and near response.
What is a positive RAPD?
- When light moves from the better afferent eye to the affected eye, both pupils constrict less or appear to dilate.
- It suggests asymmetric afferent dysfunction, commonly optic-nerve or significant retinal disease.
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