Game, Set, And Match? A Presumed Endophthalmitis Scare 14 Days After Flak And Flacs

To report a rare and severe late postoperative complication of bacterial keratitis mimicking endophthalmitis following femtosecond laser-assisted astigmatic keratotomy (FLAK) and cataract surgery (FLACS) triggered by playing tennis.

A private eye hospital

An 81-year-old male underwent uncomplicated bilateral FLACS, intrastromal FLAK (85% corneal depth, 1.0 mm from the limbus), and trifocal intraocular lens implantation. Follow-up on postoperative day 1 was unremarkable with stable wounds and minimal inflammation. On day 14, following vigorous tennis and suspected eye rubbing, the patient presented with sudden-onset pain, watering, and blurred vision in the left eye.Examination revealed an uncorrected VA of 6/12, intraocular pressure of 37mmHg, and an epithelial defect overlying the FLAK wound. A 1 mm hypopyon and dense fibrin were noted at the internal aspect of the keratotomy. Given the clinical severity, the case was managed as presumed endophthalmitis. Management included an urgent anterior chamber tap, a washout of hypopyon and fibrin and intracameral injection of Ceftazidime (2.25mg/0.1ml) and Vancomycin (1mg/0.1ml), supplemented by a subconjunctival injection of Vancomycin (2mg/0.2ml) near the AK site. Cultures were negative, though Gram stain showed significant white blood cells. Following intensive hourly Moxifloxacin and fortified Vancomycin, the infection and the inflammation resolved rapidly. Final unaided VA was 6/7.5, though total visual recovery required 6 weeks. The final clinical diagnosis was bacterial keratitis with severe reactive uveitis ("pseudo-endophthalmitis").

Intrastromal FLAK incisions, while initially sealed, remain vulnerable to mechanical disruption and infection during the early postoperative month. Physical exertion (e.g., tennis) and mechanical trauma (eye rubbing) can compromise the wound, leading to potentially sight-threatening complications, such as severe infectious keratitis mimicking endophthalmitis. Surgeons should consider stricter postoperative activity counselling for patients undergoing FLAK compared to standard FLACS.