Photo Quiz

Young Man with Acute Discoloration of the Left Eye

 

Am Fam Physician. 2018 Feb 15;97(4):271-272.

A 25-year-old man presented with malaise, fatigue, headache, and redness in his left eye. He was treated with oseltamivir (Tamiflu) for presumed influenza. The next day, his headaches became worse, and he developed blurry vision and eye pain with discharge. He went to the emergency department, where he was found to have dyspnea and hypotension. He had worsening hypoxic respiratory failure, and was intubated and admitted to the intensive care unit. His medical history was significant for intravenous heroin use.

On physical examination, his left eye was opaque, with scleral redness and edema. There was a prominent gray ring on the perimeter of the iris with purulent drainage (Figure 1). A retinal examination was not possible because of the hazy discoloration. Janeway lesions were noted on both hands. Because of lethargy, a lumbar puncture was performed. Cultures from blood, cerebral spinal fluid, urine, and sputum all showed methicillin-sensitive Staphylococcus aureus. A transesophageal echocardiogram revealed multiple mobile echogenicities on the mitral valve and severe mitral regurgitation.

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FIGURE 1


FIGURE 1

Question

Based on the patient's history and physical examination findings, which one of the following is the most appropriate treatment option to salvage ocular function?

A. Ceftazidime and vancomycin eye drops.

B. Intravenous ceftriaxone and vancomycin.

C. Intravenous piperacillin/tazobactam (Zosyn) and vancomycin.

D. Intravitreal ceftazidime and vancomycin.

Discussion

The answer is D: intravitreal ceftazidime and vancomycin. This patient presented with the clinical features of bacterial endocarditis with complication of endogenous endophthalmitis. Bacterial endocarditis initially should be treated empirically with intravenous vancomycin and an aminoglycoside or a third-generation cephalosporin, but the use of intravenous antibiotics alone is insufficient for endogenous endophthalmitis. To salvage ocular function, concurrent therapy with intravitreal antibiotics is recommended, often with an emergent vitrectomy. The decision to use intravitreal antibiotics or vitrectomy depends on the patient's vision at the time of diagnosis and overall hemodynamic condition.1

The clinical signs of endogenous endophthalmitis are eyelid edema, conjunctival injection, circumcorneal congestion, pain, photophobia, and the presence of floaters.2 Patients often have hypopyon or leukocytic exudate

Address correspondence to Farrakh Khawaja, MD, at Farrakh.Khawaja@memorialhermann.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Cunningham C, Widder J, Raiji V. Endophthalmitis. Dis Mon. 2017;63(2):45–48....

2. Sadiq M, Hassan M, Agarwal A, et al. Endogenous endophthalmitis: diagnosis, management, and prognosis. J Ophthalmic Inflamm Infect. 2015;5(1):1–11.

3. Sahin O. Ocular complications of endocarditis. In: Breijo-Márquez FR, ed. Endocarditis. 2012. http://intechopen.com/books/endocarditis/ocular-complications-of-endocarditis. Accessed January 20, 2017.

4. Ashley E, Niebauer J. Infective endocarditis. In: Cardiology Explained. London, United Kingdom: Chapman and Hall; 1997.

5. Arcieri ES, Jorge EF, Ferreira L, et al. Bilateral endogenous endophthalmitis associated with infective endocarditis: case report. Braz J Infect Dis. 2001;5(6):356–359.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

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