Iris abscess as an unusual presentation of endogenous endophthalmitis in a patient with bacterial endocarditis

An Atypical Case of Exogeneous Endophthalmitis after Intravitreal Injection Presenting with Roth Spots

PURPOSE

To report an atypical case of exogeneous endophthalmitis presenting with Roth spots.

CASE

A 67-year-old man presented with decreased vision, mild pain, and discomfort in his left eye 12 days after an intravitreal aflibercept injection. Best-corrected visual acuity was 20/200, and there were +3 anterior chamber cells. On fundus examination, multiple intraretinal hemorrhages with a central white core resembling a Roth spot were observed. Intravitreal antibiotic injections were performed, and a vitreous sample was taken. Although post-intravitreal injection history was available, full systemic screening was planned to rule out endogenous endophthalmitis because of the presence of these Roth spots. Vitrectomy was performed and methicillin-sensitive coagulase-negative Staphylococcus was detected on culture.

CONCLUSION

Although the presence of Roth spots is an unexpected finding in post-injection endophthalmitis, it was nevertheless demonstrated in our case. For this reason, it should be kept in mind that Roth spots can be encountered in bacterial endophthalmitis.

Iris abscess a rare presentation of intravenous drug abuse associated Candida endophthalmitis

Purpose

To describe an unusual case of intravenous drug abuse associated endogenous endophthalmitis presenting with an iris abscess.

Observations

A 30-year old female with history of intravenous drug use presented with a two-week history of redness and blurry vision in the right eye. An initial diagnosis of anterior uveitis was made. However, she worsened on topical steroids and mydriatics. She was found to have a hypopyon and an iris abscess. She received broad spectrum antibiotic and antifungal treatment with voriconazole, this lead to significant clinical improvement. She was discharged on oral fluconazole and lost to follow up. The patient was noncompliant with the antifungal treatment. The hypopyon and iris abscess recurred, and she required a vitrectomy with iridectomy, along with intravitreal and systemic antifungal treatment. The vitreous cultures and surgical specimen of iris issue were positive for Candida albicans, and she received voriconazole. This led to resolution of the condition with a final visual acuity of 20/20 at six month follow up.

Conclusions and importance

An iris abscess is a rare clinical presentation of intravenous drug use-associated endogenous endophthalmitis and as a result may present a diagnostic challenge as it requires a high level of clinical suspicion and a detailed social history to elicit the drug abuse. Early diagnosis and aggressive therapy is the key to better visual outcomes in these patients.

Endogenous Endophthalmitis: A 10-Year Retrospective Study at a Tertiary Hospital in South India

PURPOSE

The aim of this study was to review the clinical profile including predisposing systemic conditions, microorganisms responsible, clinical presentation, and outcomes of endogenous endophthalmitis (EE) in South India.

DESIGN

This study is a retrospective, noncomparative case series.

METHODS

This study presents a retrospective analysis of records of patients with EE in a 10-year period.

RESULTS

A total of 61 eyes of 58 patients were included in the study. Preceding systemic illness or surgery was noted in 31 patients (53.4%). No predisposing condition was found in 27 patients (46.5%). All eyes had severe diffuse EE. Culture positivity was seen in 34 of 58 patients (58.6%). Gram-positive organisms were isolated in 9 cases (15.5%), and Gram-negative organisms were isolated in 20 cases (34.5%). Pseudomonas aeruginosa (13.8%) was the most common isolate. Eleven eyes (18%) were managed medically with intravenous and intravitreal antibiotics, and 38 eyes (62.3%) also underwent vitrectomy. Eight eyes (13.1%) required repeat vitrectomy, and 12 eyes (19.7%) were eviscerated. The mean follow-up was 16.2 ± 13.9 months. Final visual acuity of 20/200 or better was seen in 29.5% eyes. A favorable outcome was noted in culture-positive patients (P = 0.03) and in patients with no predisposing causes.

CONCLUSIONS

This study provides information about the clinical and microbiologic profile of EE. Aggressive medical and surgical treatment can result in favorable outcomes.

Systematic review of 342 cases of endogenous bacterial endophthalmitis

We review a total of 342 cases of endogenous bacterial endophthalmitis reported between 1986 and 2012. Predisposing conditions were present in 60%, most commonly diabetes, intravenous drug use, and malignancy. The most common sources of infection were liver, lung, endocardium, urinary tract, and meninges. Systemic features such as fever were present in 74%, hypopyon in 35%, and an absent fundal view in 40%. Diagnostic delay occurred in 26%. Blood cultures were positive in 56%, and at least one intraocular sample was positive in 58% (comprising 26% anterior chamber samples, 59% vitreous taps, and 41% vitrectomy specimens). Worldwide, Gram negative infections (55%) were more frequent than Gram positive (45%) infections, particularly in Asia. Over the last decade, 11% of eyes were treated with systemic antibiotics alone, 10% intravitreal antibiotics alone, 36% systemic plus intravitreal antibiotics, and 20% systemic plus intravitreal antibiotics plus pars plana vitrectomy. The most commonly used intravitreal antibiotics were vancomycin (for Gram positive infection) and ceftazidime (Gram negative). The median final visual acuity was 20/100, with 44% worse than 20/200. Among all cases, 24% required evisceration or enucleation, and mortality was 4%. Both intravitreal dexamethasone and vitrectomy were each associated with a significantly greater chance of retaining 20/200 or better and significantly fewer eviscerations or enucleations-these warrant further study. For most patients, treatment should include a thorough systemic evaluation and prompt intravitreal and systemic antibiotics.

Staphylococcal native valve endocarditis with iris abscess and intracranial hemorrhage in an adolescent girl

Native valve infective endocarditis by Staphylococcus aureus is a well-known entity. Metastatic eye abscess and intracranial hemorrhage are rare manifestations of infective endocarditis. We describe an adolescent girl who presented with staphylococcal native valve endocarditis with metastatic iris abscesses and after valve replacement surgery, succumbed to her illness as a result of an intracranial hemorrhage.

[Iris abscess after bacterial endocarditis in a patient with leukaemia. Differential diagnosis]

PURPOSE

To report a case of iris abscess due to bacterial endocarditis.

CASE REPORT

A 46-year-old male under diagnosis of promielocitic leukemia and endocarditis presented with decreased vision in left eye (OS). Ophthalmic exploration revealed iris abscess and hypopyon with fibrinous exudate in iris of the left eye and tyndall +1 in right eye (OD). Blood culture and anterior chamber paracentesis was positive for methicillin-sensitive Staphylococcus aureus and negative for blastic cells in citology. Treatment with systemic antibiotic was initiated with total resolution of inflammation.

CONCLUSION

Iris abscess is an unusual septic focus in bacterial endocarditis. It is crucial to rule out an extramedullary metastasis in a patient with leukemia due to the general prognosis.

Iris abscess as an unusual presentation of endogenous endophthalmitis after intramuscular injection

PURPOSE

To report a case of iris abscess due to endogenous endophthalmitis after an intramuscular injection complicated with gluteal abcess.

METHOD

A 65-year-old female presented with decreased vision and burning pain in her right eye, 2 weeks after an intramuscular injection.

RESULTS

Iris abscess and hypopyon with a fibrinous exudate was noted in the anterior chamber of the right eye. Blood culture and anterior chamber paracentesis was positive for methicillin-sensitive Staphylococcus aureus.

CONCLUSIONS

The authors believe this to be the first case of an iris abscess due to gluteal abscess after intramuscular injection.

Iris abscesses with and without intralenticular fungal invasion in the horse

OBJECTIVE

To describe clinical and histologic findings in horses with iris abscesses. Design Retrospective medical records study.

ANIMALS STUDIED

Medical records of horses that had iris abscesses at the University of Florida Veterinary Medical Center, Peterson & Smith Equine Hospital, and Veterinary Eye Specialists of London, Ontario, from 2005 to 2008 were reviewed.

PROCEDURE

Data collected from the medical records included signalment, clinical and histologic descriptions of ocular lesions, therapy, complications, and visual outcomes.

RESULTS

The medical records of two Quarterhorses, one pony, one warmblood, one Westphalian, and one Arab horse with unilateral iris abscesses were identified. Mild-to-severe clinical signs of iridocyclitis were present in all six eyes with iris abscesses. The eyes of two horses with iris abscesses were also associated with deep stromal abscesses and responded to medical therapy alone in one case, and medical therapy and corneal transplantation in the other. Iris abscesses in two horses were also associated with intralenticular invasion due to a Cladosporium and a Fusarium-type fungus respectively, and resulted in enucleations. Two horses with iris abscesses and no apparent lens involvement resolved with medical therapy in one case and surgical removal of the iris abscess and medical therapy in the other.

CONCLUSIONS

This is the first clinical report of iris abscesses in the horse, and the first histologic report of fungal invasion of the horse lens.