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A 48-year-old woman with redness, photophobia, and eye discomfort
Digital Journal of Ophthalmology 2013
Volume 19, Number 2
May 1, 2013
DOI: 10.5693/djo.03.2013.01.003
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Benjamin Erickson, MD | Bascom Palmer Eye Institute, Miami, Florida
Aleksandra Rachitskaya, MD | Bascom Palmer Eye Institute, Miami, Florida
Thomas Shane, MD | Bascom Palmer Eye Institute, Miami, Florida
Differential Diagnosis
The differential diagnosis for our patient included inflammatory causes such as granulomatous anterior uveitis (either exacerbated by surgical intervention or coincidental to it), anterior segment ischemia from a tight scleral buckle, or protracted postoperative inflammation. The last two conditions, however, would not be expected to produce typical mutton fat keratic precipitates. As a health care worker, she had PPDs placed annually and had always been nonreactive. Based on her ethnicity, the patient was at low risk for sarcoid. Lyme disease is rare in Miami, and she did not have a history of recent travel to endemic areas. She did not practice high-risk sexual behavior or report any stigmata of syphilis. Likewise, she did not have any respiratory or genitourinary symptoms consistent with Wegener’s granulomatosis. Toxoplasmosis was also considered unlikely because her B-scan ultrasound did not reveal evidence of significant posterior uveitis.

Consideration of infectious endophthalmitis from an indolent organism such as Propionibacterium acnes, Staphylococcus epidermidis, or Candida parapsilosis was also warranted because, while such infections do not usually produce granulomatous inflammation, the consequences of missing the diagnosis can be severe. Such infections can initially appear to respond to steroids, so the patient’s clinical improvement did not entirely rule them out. Again, however, the patient’s clinical presentation and B-scan findings were not typical, and the rates of endophthalmitis after pars plana vitrectomy are quite low with an incidence of approximately 0.02% in a retrospective study by the Pan American Collaborative Retina Study Group.(1)

Given the presence of an intumescent cataract, lens-related etiologies were also carefully considered. Phacomorphic glaucoma was ruled out by confirming that the anterior chamber angle was open on gonioscopy. Phacolytic glaucoma, which involves the leakage of soluble lens proteins through an intact capsular bag in the setting of a mature cataract and usually results in nongranulomatous anterior segment inflammation, was thought less likely than phacoantigenic endophthalmitis, a classically granulomatous autoimmune response to lens proteins. The rapid postoperative development of cataract in our patient might have been due to occult lens capsule trauma during the pars plana vitrectomy.