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Janet Boschert
Muskogee, OK VA resident
Abstract:
A gentleman being treated for endocarditis had symptoms of bilateral decreased vision
and floaters. Based upon observed vitritis and retinal infiltrates, bilateral endogenous
endophthalmitis was diagnosed and treated leading to a favorable visual outcome.
1. Case History
a. Demographics: 51 y.o. white, male
b. Chief complaint: decreased vision and floaters OU (OS> OD)
c. Medical history: currently hospitalized for uncontrolled diabetes type II,
atrial fibrillation, native valve endocarditis, hx of hypertension and
hyperlipidemia
d. Ocular history: unremarkable
e. Medication: acetaminophen, amiodarone, aspirin, digoxin, enoxaparin,
furosemide, insulin, moxifloxacin, nitroglycerin, promethazine, ranitidine,
temazepam, warfarin, lisinopril, hydrocodone, and morphine
f. Other salient information:
i. blood cultures were positive for methacillin sensitive- S. aureus
(MSSA) and the patient was started on IV nafcillin to treat the
endocarditis
ii. IV drug abuser
2. Pertinent findings
a. Initial exam
i. VA: 20/60-2 OD PH NI and 20/400 PH 20/70 OS
ii. IOP: 8 mmHg OD and 5 mmHg OS
iii. cells in the vitreous OS>OD
iv. 2DD, yellow-white lesion / infiltrate slightly elevated with distinct
borders in temporal peripheral retina OD
v. similar, 5DD yellow-white lesion / infiltrate, slightly elevated with
distinct borders in inferior peripheral retina OS
vi. sent pt to Oklahoma City VA ophthalmology department
b. Oklahoma City VA
i. diagnosed bilateral endogenous endophthalmitis OS>OD
secondary to MSSA endocarditis
1. started Pred Forte q 2 hours OU
2. fortified vancomycin q 2 hours OU
3. fortified cefazolin q 2 hours OU
4. scopolamine BID OU
5. schedule for surgery
a. pars plana vitrectomy OD
b. vitreal taps OU
c. subconjunctival and intravitreal injections
i. vancomycin
ii. cefazolin
iii. dexamathasone
ii. prophylactic, pan retinal photocoagulation around infiltrates
c. Follow-up # 1 at our VA (Muskogee): 10 days after the initial exam
i. Cc: eyes hurt and feeling very tired
ii. VA: 20/30-1 OD PH NI and 20/100-1 PH NI OS
iii. Clear vitreous
iv. Severe SPK OS>OS
v. Smaller, 1 DD lesion OD
vi. Smaller, 1.5 DD lesion OS
1. change medication
a. Pred Forte q 4 hours OU
b. Add Vigamox QID OU
c. Discontinue fortified cefazolin and vancomycin
d. Pt had already stopped scopolamine in Oklahoma
City
d. Follow-up # 2: 1 week later
i. Cc: vision getting better and floaters have decreased in number and
equal in both eyes
ii. Reports never got any eye drops in his eyes since last exam
iii. VA: 20/25-2 OD and 20/70 PH 20/60-2 OS
iv. Refuses to be dilated
v. Plan:
1. start Ciloxan QID OU
2. RTC 1 week
e. Follow-up # 3: approximately 1 month since initial exam
i. Pt appeared much healthier and was able to walk with a cane
ii. Pt reports 1 more week of IV nafcillin and then stopping
iii. Cc: pt thinks he seeing more floaters but maybe thinks it was they
were more pronounced now that he could see better
iv. Pt reported blood sugar fluctuations and good compliance with
Ciloxan
v. VA: 20/20 OD and 20/40-2 OS PH NI
vi. Retinal infiltrates about the same size as previous (1DD) but flat
and stable
vii. >20 dot-blot hemorrhages and exudates in the posterior pole OU
viii. fundus pictures of the posterior pole, but the retinal infiltrates were
too far peripheral to be seen
ix. Plan:
1. RTC at Tulsa VA (pt moving) in 1 month
2. discontinue Ciloxan
f. Laboratory studies:
i. vitreal taps failed to have growth
ii. Pt tested negative for HIV
3. Differential diagnosis
a. Primary leading: bilateral endogenous endophthalmitis secondary to
MSSA endocarditis
b. Others: diseases with yellow-white retinal lesions and vitritis
i. ocular toxoplasmosis
ii. ocular toxocariasis
iii. acute retinal necrosis
iv. primary intraocular lymphoma
v. cytomegalovirus retinitis
vi. sarcoidosis
vii. progressive ocular retinal necrosis
viii. fungi endogenous endophthalmitis
ix. Retinoblastoma
4. Diagnosis and discussion
i. Endophthalmitis: definition, statistically information, classification
ii. Clinical findings and symptoms of endophthalmitis
iii. Pathophysiology of the disease
iv. Statistical information from the Endophthalmitis Vitrectomy Study
(EVS) vs. Endogenous Bacterial Endophthalmitis retrospective
study
v. Endogenous
1. high –risk factors / pre-disposing conditions
2. ocular circulatory system reviewed to explain metastatic
spread
vi. Endophthalmitis versus the other differentials
1. Pt not HIV positive
2. infiltrates responded to antibiotics and steroids
3. Pt already had positive blood cultures of bacteria
vii. Unique features:
1. endogenous
2. bilateral
3. IV drug abuser
4. visual results (most patients in the studies and other case
reports have much worse outcomes)
5. presence of retinal infiltrates
6. no observed anterior chamber inflammation
7. no reported pain
8. pt currently on IV antibiotic previous to initial exam
5. Treatment, Management
a. IV antibiotics
i. Vitreous and anterior chamber taps to culture cause of infection
ii. intravitreal and subconjuntival injections of steroids and antibiotics
b. vitrectomy versus no vitrectomy
c. EVS (Endophthalmitis Vitrectomy Study)
i. Study the benefit/risk of vitrectomy
ii. Only study participants had endophthalmitis following cataract
surgery – results not valid for endogenous type per study
iii. Our patient only had a vitrectomy in 1 eye (vitrectomy vs no
vitrectomy)
d. IV drug abuser: reports show much higher risk of Bacillus cereus
e. Expected visual outcomes
Bibliography
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6. Clinical Pearls
a. Systemic diseases can have ocular manifestations
i. Be aware of concurrent medical conditions
ii. Be aware of pt’s medication (no pain because pt already on pain
meds?)
b. Fortified antibiotics
i. What they are - define
ii. Why they are needed