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Decreased Vision and Eye Pain 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 with advanced primary open-angle glaucoma presented with 1 day of decreased vision and eye pain. He had undergone trabeculectomy and 5-fluorouracil injection 1 month prior. On initial examination, his visual acuity was 20/25. He had diffuse conjunctival hyperemia without bleb purulence or leakage and more than 50 cells per high-power field of a 1 × 1-mm area of light on slitlamp biomicroscopy. He was treated for blebitis with topical fortified antibiotics but subsequently developed vitritis. He underwent vitreous tap and injection of vancomycin and amikacin followed by pars plana vitrectomy with bleb revision. Separate vitreous samples from each procedure were sent for Gram stain and bacterial and fungal culture on chocolate and Sabouraud agar with no growth. His eye pain worsened significantly, and ultrasound biomicroscopy showed scleral thickening (Figure 1A). Lab workup for autoimmune scleritis including tests for rheumatoid factor, antinuclear antibodies, and antineutrophil cytoplasmic antibodies was negative. He was admitted to the hospital and started intravenous vancomycin and piperacillin-tazobactam treatment. His vision continued to decline to counting fingers because of the development of a dense cataract with retrolenticular plaque (Figure 1B).

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Aspergillus fumigatus endophthalmitis and scleritis

C. Repeat aqueous or vitreous sampling

Patients with postoperative intraocular inflammation require thorough evaluation for infectious causes. Until absence of infection has been established, steroids (choice A) should be used cautiously. Lack of improvement while receiving sufficiently broad antibiotic therapy suggests alternative etiologies rather than inadequate coverage (choice B). When the diagnosis is unclear and vision loss progresses, intraocular fluid testing for atypical organisms, including mycobacteria and fungi, and masquerade syndromes such as lymphoma should be considered (choice C) over continued observation (choice D).

An aqueous sample was sent for broad-range bacterial, mycobacterial, and fungal polymerase chain reaction, which returned positive for Aspergillus fumigatus. The patient started oral voriconazole and high-dose indomethacin treatment and received intravitreal and subconjunctival voriconazole injections. He underwent pars plana vitrectomy with lensectomy and additional intravitreal voriconazole (Figure 2). A dense retrolenticular plaque and multiple vitreous fungal “snowballs” were found intraoperatively; there was no vasculitis or chorioretinitis.

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Article Information

Corresponding Author: Merina Thomas, MD, Casey Eye Institute, Oregon Health and Science University, 515 SW Campus Dr, Portland, OR 97239 (thomamer@ohsu.edu).

Published Online: January 20, 2022. doi:10.1001/jamaophthalmol.2021.4447

Conflict of Interest Disclosures: Dr Yee reported a core grant from the National Institutes of Health National Eye Institute (P30EY010572) and an unrestricted grant from Research to Prevent Blindness. No other disclosures were reported.

Meeting Presentation: Portions of this article were presented at the Women in Ophthalmology Summer Symposium; August 28, 2021; Amelia Island, Florida.

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

References
1.
Wolner  B , Liebmann  JM , Sassani  JW , Ritch  R , Speaker  M , Marmor  M .  Late bleb-related endophthalmitis after trabeculectomy with adjunctive 5-fluorouracil.   Ophthalmology. 1991;98(7):1053-1060. doi:10.1016/S0161-6420(91)32177-8PubMedGoogle ScholarCrossref
2.
Rao  NA , Hidayat  AA .  Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis.   Am J Ophthalmol. 2001;132(2):244-251. doi:10.1016/S0002-9394(01)00968-0PubMedGoogle ScholarCrossref
3.
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. doi:10.1016/j.ophtha.2008.02.027PubMedGoogle ScholarCrossref
4.
Krzystolik  MG , Ciulla  TA , Topping  TM , Baker  AS .  Exogenous Aspergillus niger endophthalmitis in a patient with a filtering bleb.   Retina. 1997;17(5):461-462. doi:10.1097/00006982-199717050-00021PubMedGoogle ScholarCrossref
5.
Fincher  T , Fulcher  SFA .  Diagnostic and therapeutic challenge of Aspergillus flavus scleritis.   Cornea. 2007;26(5):618-620. doi:10.1097/ICO.0b013e318033de67PubMedGoogle ScholarCrossref
6.
Bernauer  W , Allan  BDS , Dart  JKG .  Successful management of Aspergillus scleritis by medical and surgical treatment.   Eye (Lond). 1998;12(Pt 2):311-316. doi:10.1038/eye.1998.71PubMedGoogle Scholar
7.
Hong  BK , Lee  CS , Van Gelder  RN , Garg  SJ .  Emerging techniques for pathogen discovery in endophthalmitis.   Curr Opin Ophthalmol. 2015;26(3):221-225. doi:10.1097/ICU.0000000000000145PubMedGoogle ScholarCrossref
8.
Hariprasad  SM , Mieler  WF , Holz  ER ,  et al.  Determination of vitreous, aqueous, and plasma concentration of orally administered voriconazole in humans.   Arch Ophthalmol. 2004;122(1):42-47. doi:10.1001/archopht.122.1.42PubMedGoogle ScholarCrossref
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