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It is not clear from the records available as to why this patient shifted from Chennai to another major well-recognised institution at Pondicherry (and again later back to Sankara Nethralaya at Chennai). The patient was admitted to JIPMER, Pondicherry on 6th (or 8th) July 1997 where after duly confirming all the above findings and noting marked pigmentation of the right angle, extracapsular cataract extraction with PC IOL was done on 10.07.1997 after due preoperative and intraoperative precautions. In spite of these, the patient exhibited a severe postoperative reaction on day 1-2, which unfortunately is not an uncommon occurrence in such cases, either because of an acute inflammatory response of the eye, or, may be worse, a fulminant intraocular infection. (In such a situation it is considered safer to err on the side of the infection, and treat as such). On 11.07.1997 it was decided by the Professor-in-charge to treat the patient actively as endophthalmitis in view of severe uveitis and hypopyon. He was started on local antibiotics and steroids together with systemic intravenous antibiotics and subconjunctival gentamycin and steroids. On 12.07.1997, the visual acuity of the patient was PL positive but uncooperative for PR (noted later as inaccurate) with exudates present in anterior chamber intracameral antibiotics were administered (Vancomycin + Amikacin) and Gram staining was noted to be negative in the aqueous tap taken page 70 (not confirmatory of intraocular infection either way at this stage). Another note on page 5 (44) of the typed version of the Discharge Summary states: 13.07.1997- aqueous tap; coagulase negative staphylococci (coag. -ve always being of doubtful significance microbiologically, but in the circumstances should be and was given due importance and treated as such); 14.07.1997 aqueous and vitreous tap sterile; 19.07.1997 vitreous tap sterile. In the circumstances the surgical team in charge may have decided against the potential benefits of an intravitreal injection it is at least not recorded as such. Subconjunctival antibiotics (as Cefazolin) were also continued for next few days but, most unfortunately, with no real benefit to the eye. All standard preoperative, peroperative and postoperative medical protocols seem to have been rigorously followed. The patients visual acuity right eye was PL? absent on 23.07.1997 when he was discharged (22.07 or 23.07.1997) on medication. (The patient was issued a visual handicap certificate of 30% with a diagnosis of Phthisis Bulbi Right Eye on 12.11.1997).

Treatment:

Intravitreal vancomycin 1 mg + ceftazidime 2.25 mg + dexamethazone 0.4 mg Subconjunctival vancomycin 25 mg + ceftazidime 100 mg + dexamethazone 24 mg Topical vancomycin 50 mg/ ml every one hourly + ceftazidime 50 mg/ ml every one hourly + prednisolone acetate 1% every one hourly + atropine 1% once a day Systemic Injection vancomycin 1g intravenously 12 hourly + Injection ceftazidime 2g intravenously 8 hourly + Injection prednisolone 60 mg once a day.

8.   Vitrectomy is always required in fungal endophthalmitis, as the response is conservative treatment is poor owing to inadequate penetration of antifungal agents. In addition to 5 mg amphotericin B intravitreally, oral ketoconazole 200 mg 3 time daily and topical natamycin have been advocated to aspergilla endophthalmitis.

Prognosis Olson et al in a study of 40 cases reported a final visual acuity of 20/200 or better in 25 percent and loss of light perception in 35 percent. Endophthalmitis formed an important cause of the removal of the eye (29 out of 40) after IOL surgery in another study. Although the outcome of endophthalmitis has improved considerably, it is still one of the sight-threatening complications of cataract and IOL implantation surgery. Use of intravitreal antibiotics has greatly improved the prognosis but in many situations although the infection itself is eradicated, the patient is blind from the toxic effects of the antibiotic. This results in anatomical rather than functional success.

The recommendations are:

a. Antibiotics Intravitreal injection: amikacin or ceftazidime and vancomycin       Subconjunctival injection: vancomycin and ceftazidime or gentamicin and cefuroxime.

The injections are repeated daily for 5-7 days according to the response to therapy       Topical eye drops: Fortified gentamicin and vancomycin             It is specifically noted in all medical literature that though systemic antibiotics are routinely administered (as IV/IM injections or oral pills), they are of little value in treating endophthalmitis b. Steroids Are recommended for topical (betamethasone eye drops), subconjunctival (dexamethasone or betamethasone injection) as well as systemic (oral tablet prednisolone) administration     i. It was clearly a case of severe endophthalmitis in view of the signs and symptoms that presented on POD 1 itself, though not recorded in so many words ii. Aqueous tap was taken on 12.07.1997 result obtained on 13.07.1997 was recorded in the Discharge Summary as 13.07.1997 - coagulase negative staphylococcus. No record of sensitivity test Though there is no record in the treatment chart of both aqueous and vitreous aspiration being done on any date upto 14.07.1997, the Discharge Summary has an entry, 14.07.1997 - aqueous and vitreous tap sterile and also of 19.07.1997 vitreous tap sterile though the corresponding entry in the treatment chart of 19.07.1997 is of aqueous tap being taken, not vitreous                   No record any intravitreal (i.e., posterior chamber vitreous cavity of the eye) injection at all. Only one intracameral (i.e., anterior chamber) injection of vancomycin and amikacin given on 12.07.1997 Subconjunctival injection was of only cephazolin (a first-generation antibiotic of the cephalosporin group) first on 14.07.1997, second on 15.07 and last on 19.07.1997;