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Retinal Artery Occlusion After a Dog Bite in a 55-Year-Old Man

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

A 55-year-old man was referred to the eye clinic for unilateral uveitis and 2 days of sudden vision loss in his right eye. He reported experiencing light sensitivity and mild eye pain. He was in otherwise good health without any chronic medical problems. He reported receiving anticoagulation therapy in the past for a mitral valve problem. His visual acuity was 20/200 OD and 20/20 OS. The examination of the left eye was unremarkable. Slitlamp examination of his right eye revealed 3+ anterior chamber inflammation with vitreous cells. An examination of the dilated fundus showed optic nerve edema with an overlying white infiltrate. In addition, there was inferior retinal whitening consistent with an artery occlusion (Figure 1A). The whitening was attributable to inner retina ischemia, with sparing in the distribution of the cilioretinal artery. An inferior hemicentral retinal artery occlusion was confirmed on intravenous fluorescein angiography (Figure 1B). No embolus was noted at any retinal artery branch points. Notably, a dog bit the patient’s hand 2 months before presentation. Since that time, the patient developed a persistent cough, night sweats, and low-grade fevers that were treated unsuccessfully with 2 courses of oral antibiotics.

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Hemicentral retinal artery occlusion secondary to septic embolus

C. Obtain blood cultures and an echocardiogram

This patient experienced a hemicentral retinal artery occlusion with early endogenous endophthalmitis secondary to a septic embolus in the setting of bacterial endocarditis with bacteremia from Streptococcus viridans. This retinal artery occlusion was presumptively related to the recent dog bite and an underlying diagnosis of mitral valve prolapse. Endogenous bacterial endophthalmitis is an uncommon subset of endophthalmitis, accounting for approximately 2% to 8% of all endophthalmitis cases.1 A systematic review of endogenous bacterial endophthalmitis showed that most patients (77%) had an identifiable preexisting condition, 64% had an identifiable extraocular focus of infection, and 8% had endocarditis.2 As in this patient, 73% of patients in the review had systemic symptoms preceding ocular symptoms.2 Despite adequate treatment, visual prognosis remains poor for most patients with endogenous endophthalmitis.3

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Article Information

Corresponding Author: Shriji N. Patel, MD, Department of Ophthalmology, Vanderbilt University School of Medicine, 2311 Pierce Ave, Nashville, TN 37232 (shriji.patel@vumc.org).

Published Online: May 6, 2021. doi:10.1001/jamaophthalmol.2020.5282

Conflict of Interest Disclosures: Dr Patel reported receiving research grant support from Alcon outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Okada  AA , Johnson  RP , Liles  WC , D’Amico  DJ , Baker  AS .  Endogenous bacterial endophthalmitis: report of a ten-year retrospective study.   Ophthalmology. 1994;101(5):832-838. doi:10.1016/S0161-6420(13)31255-XPubMedGoogle ScholarCrossref
2.
Jackson  TL , Paraskevopoulos  T , Georgalas  I .  Systematic review of 342 cases of endogenous bacterial endophthalmitis.   Surv Ophthalmol. 2014;59(6):627-635. doi:10.1016/j.survophthal.2014.06.002PubMedGoogle ScholarCrossref
3.
Jenkins  TL , Talcott  KE , Matsunaga  DR ,  et al.  Endogenous bacterial endophthalmitis: a five-year retrospective review at a tertiary care academic center.   Ocul Immunol Inflamm. 2020;28(6):975-983. doi:10.1080/09273948.2019.1642497PubMedGoogle ScholarCrossref
4.
Esen  E , Sizmaz  S , Sariyeva  A , Demircan  N .  Bilateral central retinal artery occlusion in Behçet disease.   Ocul Immunol Inflamm. 2015;23(5):416-419. doi:10.3109/09273948.2014.896468PubMedGoogle ScholarCrossref
5.
Mac Grory  B , Lavin  P , Kirshner  H , Schrag  M .  Thrombolytic therapy for acute central retinal artery occlusion.   Stroke. 2020;51(2):687-695. doi:10.1161/STROKEAHA.119.027478PubMedGoogle ScholarCrossref
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