a 60-year - old gentleman presented to our institution with pain and dimness of vision in both eyes . on evaluation , his best corrected visual acuity ( bcva ) was 20/80 in right eye ( re ) and 20/120 in left eye ( le ) .
his cup - to - disc ratio was 0.6 re and 0.85 le with loss of the neural rim .
he was prescribed betoxolol 0.5% in both eyes ( be ) and recommended elective cataract extraction for the le .
keratometry measurements were 43.75 diopter ( d )  180 and 40.00  90 os with 3.75 d of against the rule astigmatism .
the calculated intraocular lens ( iol ) power was 23.50 d. the patient had used topical ofloxacin 3 mg / ml six times , 1 day prior to surgery , and thrice on the day of surgery at 1-hour intervals .
povidone iodine 5% was used half an hour before surgery and just before the commencement of surgery .
ocular adnexa was cleaned using 10% povidone iodine , the patient was draped and speculum was applied . a manual sutureless cataract extraction ( mscs ) with lri was planned for the le . through a 6-mm temporal sclerocorneal tunnel ,
a nasal 6-mm lri was performed using a 550-m steel knife prior to wound construction . on the first postoperative day ,
his bcva le was 20/60 , and the anterior segment was unremarkable except for mild iritis .
on the 15 postoperative day , he presented emergently with pain and redness in the operated eye . on examination ,
anterior segment examination revealed circumcorneal congestion , iris nodule , a 1.5-mm hypopyon , and a corneal exudate at the site of the prior lri [ fig . 1 ] .
b - scan ultrasonography revealed minimal vitreous exudates . on presentation at 15 post - op day with endothelial nodule at the site of limbal relaxing incision , hypopyon and iris nodule vitreous was aspirated and sent for analysis .
intravitreal vancomycin 1 mg / ml and amikacin 400 g/0.1ml were administered . based on the clinical picture of corneal exudate ,
iris nodules , and hypopyon with minimal posterior segment involvement , a clinical diagnosis of nocardial endophthalmitis was made .
the patient was treated with topical gatifloxacin and amikacin hourly , prednisolone acetate every 6 hours , and oral gatifloxacin .
the isolate was sensitive to amikacin , gatifloxacin , moxifloxacin , ciprofloxacin , ofloxacin , and chloramphenicol .
the inflammation worsened , exudates from the iris extended into the capsular bag and fresh exudates appeared at the sclerocorneal wound site .
a subsequent ultrasound revealed increased vitreous opacities . on the 18th postoperative day , the patient underwent core vitrectomy with anterior chamber washout and capsular bag removal with iol explantation .
his symptoms improved , iris and endothelial nodules resolved , hypopyon decreased and exudate at the lri site resolved [ fig . 2 ] .
he was discharged after a 1-week course on a regimen of oral gatifloxacin and topical amikacin , ciprofloxacin , and a cycloplegic .
four weeks later , the patient 's vision was 20/2000 and his examination revealed 2 + white blood cells ( wbcs ) in the anterior chamber , no hypopyon , and vitreous opacities .
lri preserves the perfect optical qualities of the cornea and is an excellent option for low - to - moderate degrees of astigmatism in a planned single bioptic procedure .
lri produces lesser effect than corneal relaxing incision ( cri ) , thus precise alignment of the axis is not as critical .
have shown that lri performed during phacoemulsification surgery is a safe , effective , and stable procedure to reduce pre - existing corneal astigmatism .
we are unaware of any prior report of a postoperative endophthalmitis associated with an lri performed at the time of cataract surgery . in this patient ,
as the lri was of partial thickness and cornea was not perforated , it appears that bacteria may be able to penetrate the cornea at the site of the lri .
this patient presented with iris nodules and hypopyon , a classic presentation of nocardial endophthalmitis .
the endothelial exudates were at the lri site while the wound was clear , thereby indicating the lri as the probable site of entry for the organism .
the rate of postoperative endophthalmitis after cataract surgery in this population is 0.064% and norcardial infections account for 16.4% of these cases .
norcardia endophthalmitis is more evident in emaciated and immunocompromised individuals and associated with poor prognosis .
mscs is practiced widely in india and constitutes about 62% of the total 69,479 cataract procedures done at our institute in 2008 .
the endophthalmitis rate with the mscs group was 0.03% and was lesser than the 0.05% infection rate with the phacoemulsification group ( unpublished data ) .
have proved that poorly constructed wounds with a short corneal valve have a higher risk of developing endophthalmitis . in this patient , the scleral and corneal valves were 2 mm and 1.5 mm , respectively . in spite of making a larger incision in the mscs group , the infection rates are probably comparable due to the wider sclerocorneal tunnel covered well with conjunctiva at the end of surgery .
lalitha et al . from the same population reported nil endophthalmitis in the 4275 cases who underwent mscs technique in the total group of 36,072 cataract procedures where the overall endophthalmitis rate was 0.05% . in our experience , the mscs technique per se has not been found to be a significant risk factor for endophthalmitis compared to phacoemulsification . in summary
 limbal relaxing incisions ( lris ) are considered a relatively safe procedure with rapid stabilization and absence of infectious complications . 
 do we need to readdress this last impression ? 
 we report a case of nocardia endophthalmitis associated with an exudate at the site of an lri in a patient who underwent routine cataract surgery . 
 this case , to the best of our knowledge , is the first report of its kind , stressing the need for a cautious approach to the adoption of this method of astigmatic correction . 
Case Report
Discussion