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Patient Presentation: A 23-year-old obese female was diagnosed with idiopathic intracranial hypertension (IIH) and referred to neurosurgery for ventriculoperitoneal shunt. A baseline ocular examination was performed prior to the procedure.
On examination, vision was 20/200 in the right eye, and 20/40 in the left eye. There was a right relative afferent pupillary defect. Slit lamp examination was normal.
A dilated fundus examination was performed demonstrating the following:
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Uveitis
Case 14
Patient Presentation: A 35-year-old man presented to a tertiary care retina clinic with pain and redness in the left eye for 1 week. His distance visual acuity was 20/20 OD and 20/50 OS. IOP was 12 OD and 14 OS, and there was no RAPD. His past ocular history was unremarkable. However, the patient had a history of opioid dependence and was taking methadone. He denied intravenous drug use. Review of systems was negative.
Slit-lamp examination (SLE) revealed 3+ AC cells OS and 2+ vitreous cells. Dilated fundus examination OD was within normal limits. A widefield fundus photograph OS is below:
Question 1: Describe the findings in the fundus photograph above.
An OCT over the macular lesion in the left eye was conducted and is shown below:
Question 2: What is the main finding in the OCT image above?
The presence of a unilateral area of retinitis with associated inflammation was suspicious for an infectious etiology, and the patient was started on empiric treatment for toxoplasmosis with Trimethoprim/sulfamethoxazole (TMP/SMX) and oral Prednisone. However, his vision continued to decline. Four weeks after his symptoms began, visual acuity OS decreased to hand motions. Large, white round aggregations were seen in the anterior vitreous on SLE:
Question 3: Based on the patient history, exam and imaging, what condition would you be suspicious for?
The patient underwent a diagnostic pars plana vitrectomy and fungal cultures were positive for Candida dubliniesis.
Question 4: What treatment would you start this patient on?
The patient was started on a regimen of oral voriconazole and intravitreal voriconazole and amphotericin B injections. One week postoperatively, OCT OS showed the following:
Question 5: Describe the OCT findings.
One year after his initial presentation, the retinitis resolved and his vision improved to 20/20 OS. The patient required 68 intravitreal antifungal injections to achieve quiescence. Below is his disease course following vitrectomy. Note resolution of pillar-like growths by postoperative week 40.
Reference:
Murtaza F, Pereira A, Sen HN, Wiley HE, Christakis PG. Refractory Candida dubliniensis Retinitis in an Immunocompetent Patient [published online ahead of print, 2023 Mar 3]. Ocul Immunol Inflamm. 2023;1-4. doi:10.1080/09273948.2023.2185264
Learning Objectives:
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To identify OCT and fundus findings in fungal endophthalmitis
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To understand the treatment and management of fungal endophthalmitis
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