December 7, 2013 | POSTED BY | Articles, Clinical Optometry
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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:

–       Toxoplasmosis

–        Toxocariasis

–        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