LAUSR

A 44-year-old Caucasian man presented with a three-month history of foreign body sensation in the left eye, progressing to ipsilateral retrobulbar ache and periorbital oedema for the past two days. Past ocular history was significant for vitrectomy and gas tamponade 12 years ago for a left traumatic retinal detachment, followed by cataract surgery eight years ago at another institution (operative details unavailable) with no significant improvement in vision. Past medical history was significant for tachycardia, ischaemic heart disease, asthma and depression, which were medically treated. On examination, visual acuity was R 6/6 and L light perception. A dense left relative afferent pupillary defect was elicited. The left eye was mildly proptosed with moderate surrounding periorbital oedema. Ocular motility was full despite pain on adduction. He was afebrile and systemically well. Slitlamp examination revealed a severely injected left eye, microcystic corneal oedema, grade 4 cells and flare but no hypopyon. Intraocular pressure was also raised (31 mmHg) on the left. View through the pupil was poor due to corneal oedema but the IOL could not be visualised (Figure 1A). B-scan ultrasonography showed mild vitritis and posterior scleritis (Figure 2A). Computed tomography imaging of the orbits showed preseptal lid oedema and an intraocular foreign body, likely a dislocated IOL, in the vitreous cavity (Figure 2B). Examination of the right eye was unremarkable. Blood tests and eye swabs were performed to exclude underlying systemic infective, autoimmune and rheumatological conditions, including Creactive protein (less than 2.0). Following investigations, he was treated with systemic oral prednisone 60 mg daily for panuveitis and diffuse scleritis, in addition to systemic oral valaciclovir prophylaxis 1 g three times a day as provisional diagnosis of viral herpetic keratouveitis was presumed in view of the corneal clinical picture. Significant clinical improvement was noted on subsequent review three days later. As the corneal oedema had improved at that time, one haptic of the IOL could be seen protruding through the pupil toward the endothelium (Figure 1B) but status of the posterior capsule and zonular complex still could not be delineated. Valaciclovir was stopped as viral polymerase chain reaction swab had returned negative for herpes simplex virus. Ocular inflammation had also improved so the patient was weaned off oral prednisone and started on Prednefrin Forte four times daily, atropine one per cent twice daily and timolol 0.5 per cent twice daily and scheduled for vitrectomy to remove the dislocated IOL and insertion of a secondary IOL.