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A Young Patient With Floaters

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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.

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Exogenous fungal endophthalmitis

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.

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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
1.
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.
3.
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
4.
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
5.
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
6.
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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