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JAMA Ophthalmology Clinical Challenge
June 2018

A Young Patient With Floaters

Author Affiliations
  • 1Department of Ophthalmology, University of Florida College of Medicine, Gainesville
JAMA Ophthalmol. 2018;136(6):712-713. doi:10.1001/jamaophthalmol.2017.5485
Case

A 26-year-old man presented to the emergency department with blurry vision and new floaters in his right eye. He stated his symptoms had been progressively worsening in the past week, during which he performed yard work uneventfully except for a foreign-body sensation and tearing while using a weed trimmer. He denied any significant medical or ocular history. On ophthalmoscopic examination, his visual acuity was 20/40−2 OD and 20/20−2 OS. His anterior segment examination findings were remarkable for 1+ diffuse conjunctival injection and 1+ anterior chamber cell in the affected eye. Posterior segment evaluation revealed a midvitreous opacity (Figure, A) and a 1-disc-diameter intraretinal white lesion in the posterior pole (Figure, B). Thorough examination of the peripheral retina with scleral depression did not reveal any peripheral pathologic findings. High-resolution computed tomography (CT) of the orbits was also unrevealing.

Figure.
A, Photograph of the right eye demonstrating vitreous opacities and a 1-disc-diameter intraretinal white lesion temporal to the fovea. B, Spectral domain optical coherence tomography image through the macular lesion with overlying vitreous debris.

A, Photograph of the right eye demonstrating vitreous opacities and a 1-disc-diameter intraretinal white lesion temporal to the fovea. B, Spectral domain optical coherence tomography image through the macular lesion with overlying vitreous debris.

Box Section Ref ID

What Would You Do Next?

  1. Order pyrimethamine, sulfadiazine, folinic acid, and prednisone

  2. Order topical and periocular steroids

  3. Order intravitreal and systemic antifungals

  4. Order lumbar puncture and oral doxycycline

Discussion
Diagnosis

Exogenous fungal endophthalmitis

What to Do Next

C. Order intravitreal and systemic antifungals

The patient was a healthy young man who presented to the emergency department with floaters and mild blurring of vision after yard work a week earlier. This history, with examination findings of midvitreous opacity and a retinal surface lesion, led to a clinical concern for exogenous fungal endophthalmitis. However, no external penetration site could be found on examination. In addition, a thorough intraocular examination and CT did not reveal any intraocular foreign body. The decision was made to treat conservatively with intravitreal and systemic voriconazole. Close follow-up revealed worsening intraocular inflammation, and vitrectomy was performed within 72 hours. During surgery, the macular lesion was clinically identified as a fungal ball with an associated retinal hole. A small linear opacity in the far peripheral vitreous, suspected to be the inciting foreign body, was removed with the vitrector. Cultures from vitreous tap at presentation revealed Candida albicans, which was sensitive to voriconazole. The patient recovered well, achieving a visual acuity of 20/20 in the affected eye 1 month postoperatively.

Although toxoplasmosis-associated chorioretinitis was initially considered and could be treated with triple or quadruple therapy of pyrimethamine, sulfadiazine, and folinic acid with or without prednisone,1 the string-of-pearls appearance of the vitritis was more consistent with fungal endophthalmitis, and treatment with antifungal therapy was more appropriate. Vitreous snowbanks are classic findings of intermediate uveitis, but treatment with long-acting corticosteroids, such as periocular injections, should not be initiated until infectious causes have been ruled out or treated.2,3 Primary intraocular lymphoma and other infections, such as Lyme or syphilis, may manifest as uveitis and central nervous system involvement warranting a lumbar puncture; however, the vitreous biopsy confirmed the diagnosis in this case, and further invasive testing was unnecessary. Doxycycline is effective against Lyme borreliosis4 but not appropriate for fungal infections.

Exogenous fungal endophthalmitis has been reported with variable final outcomes with regard to visual acuity and is caused by a variety of pathogens.5,6 Most causative fungal organisms have been reported as molds (most commonly Fusarium and Aspergillus species), whereas Candida species is less frequently identified.5,6 In penetrating globe injuries, such as this one, fungal endophthalmitis may be severe and lead to enucleation in unsalvageable cases.5 This morbidity stresses the importance of timely treatment.

In this case, history was important because a history of probable trauma was elicited despite no external evidence of ocular penetration. Imaging may not be adequate; CT has reduced sensitivity for less radiodense or even small metallic foreign bodies.7 Close monitoring is important to confirm the continued clinical improvement or, as in this case, to alter management if necessary.

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Article Information

Corresponding Author: Siva S. R. Iyer, MD, Department of Ophthalmology, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610 (ssr@ufl.edu).

Published Online: March 22, 2018. doi:10.1001/jamaophthalmol.2017.5485

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Centers for Disease Control and Prevention. Parasites—Toxoplasmosis (Toxoplasma Infection). https://www.cdc.gov/parasites/toxoplasmosis/health_professionals/index.html. Accessed June 17, 2017.
2.
Foster  CS, Vitale  AT, eds. Diagnosis & Treatment of Uveitis. New Delhi, India: Jaypee Brothers Medical Publishers; 2013:131-191, 194-214, 736-749.
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Mushtaq  B, Gupta  R, Elsherbiny  S, Murray  PI.  Ocular syphilis unmasked following intravitreal triamcinolone injection.  Ocul Immunol Inflamm. 2009;17(3):213-215.PubMedGoogle ScholarCrossref
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Wormser  GP, Dattwyler  RJ, Shapiro  ED,  et al.  The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America.  Clin Infect Dis. 2006;43(9):1089-1134.PubMedGoogle ScholarCrossref
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Wykoff  CC, Flynn  HW  Jr, Miller  D, Scott  IU, Alfonso  EC.  Exogenous fungal endophthalmitis: microbiology and clinical outcomes.  Ophthalmology. 2008;115(9):1501-1507, 1507.e1-1507.e2.PubMedGoogle ScholarCrossref
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Silva  RA, Sridhar  J, Miller  D, Wykoff  CC, Flynn  HW  Jr.  Exogenous fungal endophthalmitis: an analysis of isolates and susceptibilities to antifungal agents over a 20-year period (1990-2010).  Am J Ophthalmol. 2015;159(2):257-64.e1.PubMedGoogle ScholarCrossref
7.
Sychev  YV, Verner-Cole  EA, Suhler  EB, Stout  JT, Vemulakonda  GA.  Occult nonmetallic intraocular foreign bodies presenting as fulminant uveitis: a case series and review of the literature.  Clin Ophthalmol. 2013;7:1747-1751.PubMedGoogle Scholar
8.
Sagoo  MS, Mehta  H, Swampillai  AJ,  et al.  Primary intraocular lymphoma.  Surv Ophthalmol. 2014;59(5):503-516.PubMedGoogle ScholarCrossref
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