The patient was a 70-year-old man with blurred vision in the right eye for about two weeks. He was recently hospitalized for pneumonia and bacteremia and was intubated during part of his admission. He first noticed the visual change in the right eye upon awakening after being intubated. The visual acuity was 20/60 J3 OD and 20/60 J2 OS. The examination of the right eye was remarkable for 1+ vitreous cells and a whitish lesion with an adjacent deep hemorrhage in the temporal macula. What is the most likely diagnosis? What treatment would you recommend?
Photo OD 4/17
Photo OD 5/5
FA OD 0:18
FA OD 5:28
Answer:
The history and the initial clinical findings strongly suggested endogenous endophthalmitis. The fluorescein angiogram shows a circumscribed lesion with some leakage. There is also late disc leakage, which is commonly seen in infectious or inflammatory eye conditions. The patient was treated with intravitreal vancomycin, and by the next day the infection appeared to be sterilized. When seen on 5/5 there was no clinical evidence of infection. Cultures did not reveal any bacterial growth.
Endogenous endophthalmitis is often treated with intravenous antibiotics, but initial intravitreal antibiotics can have efficacy. Given the evident resolution of the infection on the first day after intravitreal vancomycin, we decided to defer on intravenous antibiotics and the patient subsequently did well.
References:
Michael E, Welch S, Niederer RL. Rapid treatment of endophthalmitis with intravitreal antibiotics is associated with better vision outcomes. Clin Exp Ophthalmol 2023;51:137-143.
Lim SW, Sung Y, Kwon HJ, Song WK. Endogenous Endophthalmitis Associated with Liver Abscess Successfully Treated with Vitrectomy and Intravitreal Empirical Antibiotics Injections. Case Reports in Ophthalmological Medicine 7/4/2020.
The history and the initial clinical findings strongly suggested endogenous endophthalmitis. The fluorescein angiogram shows a circumscribed lesion with some leakage. There is also late disc leakage, which is commonly seen in infectious or inflammatory eye conditions. The patient was treated with intravitreal vancomycin, and by the next day the infection appeared to be sterilized. When seen on 5/5 there was no clinical evidence of infection. Cultures did not reveal any bacterial growth.
Endogenous endophthalmitis is often treated with intravenous antibiotics, but initial intravitreal antibiotics can have efficacy. Given the evident resolution of the infection on the first day after intravitreal vancomycin, we decided to defer on intravenous antibiotics and the patient subsequently did well.
References:
Michael E, Welch S, Niederer RL. Rapid treatment of endophthalmitis with intravitreal antibiotics is associated with better vision outcomes. Clin Exp Ophthalmol 2023;51:137-143.
Lim SW, Sung Y, Kwon HJ, Song WK. Endogenous Endophthalmitis Associated with Liver Abscess Successfully Treated with Vitrectomy and Intravitreal Empirical Antibiotics Injections. Case Reports in Ophthalmological Medicine 7/4/2020.
