UOTW #104

A 35 year old male with a history of hepatitis C and IV drug use presents with 2 days of left eye erythema, edema, and vision loss of the left eye. On physical exam, the patient is overall ill appearing and somnolent. He states that he last used heroin 3 days prior to presentation, but denies injecting drugs or other trauma to the left eye. He has chemosis to left eye, pain with extraocular eye movements, but is not entrapped.  Visual acuity testing was performed, patient is 20/40 in the right eye, no visual acuity in the left eye.  Patient’s WBC was 17.09 with a neutrophil predominance. CTA of the head and neck demonstrated normal vasculature with only left periorbital soft tissue swelling and possibly slight thickening of the sclera. US of the left eye was subsequently performed.

 

What does the clip show? What is the diagnosis? (Click the button for the answer!)

Answer

Endophthalmitis

Ophthalmology was consulted and on their ophthalmologic exam, left eye was found to have vitreous haze and they were unable to view structures. The patient was ultimately diagnosed with endogenous endophthalmitis likely secondary to endocarditis.

  • Endophtlamitis is an infection of the vitreous and/or aqueous humor caused by bacteria or fungi
  • Presenting symptoms include eye pain and progressive vision loss
  • On physical exam, patients usually have normal appearance of the external eye, but may have chemosis or hypopyon
  • Endothalmitis is usually secondary to trauma or ocular surgery (exogenous), or less commonly from bloodstream infection (endogenous)
  • In exogenous spread, the aqueous humor is usually infected first prior to extending into the vitreous humor whereas in endogenous spread the choroid plexus is seeded before spreading into the vitreous humor
  • This is an ophthalmologic emergency requiring admission due to potential for permanent vision loss
  • Treatment options includes vitreous aspiration, vitrectomy, intraocular antibiotics, systemic antibiotics, and steroids

 

Authors: Diana Labrada, MD
Peer Reviewer: Jacob Avila, MD

References

  1. Go, S. (2017). Eye Emergencies: Endophthalmitis. In TinTinalli’s Emergency Medicine Manual (pp. 818-819). New York, NY: McGraw-Hill Education.
  2. Durand ML. Endophthalmitis. Clin Microbiol Infect. 2013 Mar;19(3):227-34. doi: 10.1111/1469-0691.12118. PMID: 23438028; PMCID: PMC3638360.
  3. Durand, M. L., MD. (2020, February 21). Bacterial Endophthalmitis. Retrieved October 20, 2020, from https://www.uptodate.com/contents/bacterial-endophthalmitis?search=endophthalmitis


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