Age/Sex/Race
38 yo Caucasian Female
Chief Complaint
“I can’t see very well since I got off the ventilator. On my first day off of the ventilator, I saw complete black. Now, I’m able to make out outlines of big signs.”
Duration – since February
Location – OU (OD > OS)
Context – constant
Wears glasses but doesn’t help
Medical History
Type II Diabetes
February 2013: on ventilator for 11 days, stayed in the hospital until May 2013, diagnosed with urinary tract infection, kidney infection, double pneumonia and MRSA infection.
Ocular History
Has worn glasses for about 5 years
No history of any ocular diseases
Medications
Metformin and others
NKDA
Family History
Negative medical and ocular history
Applicable Testing & Results of Testing
Distance visual acuity (uncorrected)
OD: FC @ 3ft (PH: NI)
OS: 20/150+ (PH: 20/40)
Aided VAs: single vision glasses 2-3 yrs old
OD: -0.75-0.25X100; 20/800
OS: -1.00-0.50X059; 20/30
Cover test: Ortho at distance and near
Confrontation fields: FTFC OU
Extraocular muscles: Full OU
Pupils: PERRLA, (-) APD OU
Refraction:
OD: -2.00-0.25X070; 20/800
OS: -1.75-0.25X080, 20/20–
Slit lamp examination:
Normal lids & conjunctiva OU
Cornea: clear OU
No anterior chamber reaction
IOP: 16 mm Hg OU
Dilated Fundus Exam
OD – Vitreous cells 1+
– C/D: 0.30/0.30, healthy neural rim tissue
– Macular scar about 0.5DD
OS – Vitreous cells trace
– C/D: 0.45/0.45, healthy neural rim tissue
– + FLR, flat and evenly pigmented
– Bergmeister’s papillae
Differential Diagnosis:
– Endogenous bacterial endophthalmitis
– Endogenous fungal endophthalmitis
– Noninfectious posterior uveitis
Assessment and Plan
The patient was diagnosed with toxoplasmosis retinitis OD > OS. She had blurred vision in the right eye with white-yellow retinal lesion over the macula and vitritis over the macula. She was referred to an Ophthalmologist, who diagnosed it as a bacterial endogenous endophthalmitis. She wasn’t given any treatment at this visit and was scheduled to return to clinic in 3 months for evaluation.
The reason why she was diagnosed with bacterial endogenous endophthalmitis was due to her systemic health and hospital stay. It is caused by organisms that enter the eye through the blood-eye barrier from the blood stream. People with diabetes, cardiac disease, pneumonia, abdominal surgery, urinary tract infection and IV drug use are at risk of having bacterial endogenous endophthalmitis. It is often misdiagnosed as uveitis, conjunctivitis or acute glaucoma. Patients present with pain, blurry vision, floaters, headache, fever and rigors. Some of the signs include proptosis, chemosis, swollen lids, corneal edema, anterior uveitis, white or yellow retinal infiltrates and vitreous haze or abscess. In order to treat this, patients are given broad spectrum antibiotics and steroid. The choice of treatment is intravitreal Vancomycin or oral ciprofloxacin.
References:
Kanski, J. Clinical Ophthalmology A Systematic Approach. Elsevier, 6th edition, 2011.
Friedman, N.J., Kaiser, P.K., & Pineda, R. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. Elsevier, 3rd edition, 2009.
Ehlers, J.P. and Shah, C.P. The Willis Eye Manual. Lippincott, Williams & Wilkins, 5th edition, 2008.
Handbook of ocular disease management. http://cms.revoptom.com/handbook/oct02_sec5_4.htm
