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A 70-year-old woman presents to you with worsening vision in the left eye.  She states that her vision was “perfect” after cataract surgery 6 weeks ago.

(Data acquisition - Description of abnormalities)

This is an OCT of the patient’s macula, presumably of the left eye.  My attention is immediately drawn to the intraretinal, honeycomb-like cystoid spaces mainly involving the inner nuclear and outer plexiform layers.  There also appears to be some subretinal fluid accumulation.

(Data acquisition - History to obtain)

I would ask the patient whether she has any associated eye pain or photophobia.  I would ask her whether she has diabetes or hypertension; whether there were any complications during her cataract surgery; whether she takes any eyedrops including prostaglandin analogues; and whether she has other ocular diseases such as retinitis pigmentosa or uveitis.

(Data acquisition - Exam data to seek out)

I would perform a comprehensive exam of both eyes.  In particular, I would perform a slit-lamp exam looking for any anterior chamber inflammation; transillumination defects or other signs of iris trauma; or problems with the intraocular lens.  I would perform a dilated fundus exam looking for optic disc edema; exudates; retinal hemorrhages; bone spicules; and signs of retinal vasculitis.

(Diagnosis -- Focused differential diagnosis)

The differential diagnosis for this intraretinal edema is:

• Cystoid macular edema following ocular surgery (also known as Irvine-Gass syndrome)
  
  
• Diabetic macular edema
  
  
• Macular edema associated with a vein occlusion
  
  
• And macular edema that could be caused by a history of uveitis, retinitis pigmentosa, topical eyedrops, and retinal vasculitis or telangeictasias.

Since this cystoid macular edema has occurred 6 weeks after cataract surgery, the most likely diagnosis is Irvine-Gass syndrome.

What other tests would you want to order?

I would obtain a fluorescein angiogram to confirm my diagnosis of Irvine-Gass syndrome.

This is an early-phase fluorescein angiogram that shows leakage of the perifoveal capillaries in a petalloid pattern.  There may be some early optic head leakage of dye as well.  These findings are consistent with a diagnosis of Irvine-Gass syndrome.

(Management -- appropriate plan for medical or surgical management of condition)

If there were secondary causes of the CME; for example, iris incarceration in the wound or a one-piece IOL in the sulcus, then I would correct the underlying cause.  In any case, I would start topical prednisolone acetate 1% qid and a topical NSAID such as nepafenac once daily.  I would re-examine the patient 2-3 weeks later and also repeat an OCT of the macula.  If there was improvement, then I would continue the patient on this topical therapy for at least a few more weeks until there was resolution of the edema.  However, if there was no improvement and/or worsening of the CME, then I would consider subTenon triamcinolone.  If subTenon triamcinolone did not improve the CME, then I would consider either intravitreal triamcinolone or intravitreal anti-VEGF such as bevacizumab. 

(Management -- prognosis and/or therapeutic complications)

I would counsel the patient that the visual prognosis for cystoid macular edema and especially Irvine-Gass syndrome is quite good with the majority of cases resolving even without treatment over 6 months.  However, I would advise her that any secondary causes of cystoid macular edema would need to be addressed as well to optimize her recovery.  Lastly, I would inform her of the potential side effects of her treatment including elevated intraocular pressure from the corticosteroids and corneal toxicity from the topical NSAIDs.