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Grand Rounds January 5, 2007

Jeffrey D. Colburn, M.D., PGY-2 Vanderbilt Eye Institute. Grand Rounds January 5, 2007. CC: New onset blurry vision (x2 days) HPI: 70 yo WF admitted 10 days prior for N/V/failure to thrive s/p Abd surgery Pain in OS transiently 2 days ago Like “looking through a dirty windshield”

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Grand Rounds January 5, 2007

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  1. Jeffrey D. Colburn, M.D., PGY-2 Vanderbilt Eye Institute Grand RoundsJanuary 5, 2007

  2. CC: New onset blurry vision (x2 days) HPI: 70 yo WF admitted 10 days prior for N/V/failure to thrive s/p Abd surgery Pain in OS transiently 2 days ago Like “looking through a dirty windshield” New floaters OU The Case…

  3. Past Ocular Hx Wears glasses CEIOL OD Past Med/Surg Hx Insulinoma, s/p pancreatic enucleation, 8/29/06 Ventral hernia, 8/06 CT guided drainage of fluid collection surrounding pancreas (9/21/06) Home TPN since 10/2/06 HTN CAD, s/p MI & CABG Depression Meds: ASA, Imdur, Cartia, Coreg, Lasix, HCTZ, KCl, Protonix, Pravachol, Naproxen, MVI, Nitro, Ca+D, Lopid, Prozac, Reglan, Vancomycin Allergies: Theodur, Demerol Family Hx Father – Colon CA Mother – CHF Son – DM Daughter – SLE Social Hx No Tobacco Occasional EtOH ROS + Nausea, Vomiting, Fatigue, chronic SOB History

  4. BCVA: 20/200-1 OU IOP: 15 OD, 16 OS CVF: full OD, superonasal deficit OS Pupils: 4 → 2 OU, no RAPD Motility: Full OU External: WNL Exam

  5. SLE LLL: quiet OU Conj: quiet OU K: clear OU A/C: D&Q OU, no cell/flare Iris: Intact Lens: PCIOL OD, 2-3+ NSC OS Exam

  6. VA now 20/400 OU

  7. Further Images from OS

  8. DFE: Vitreous: vitritis OD>OS Disks: hazy view C/D: small cups OU Macula: round white lesion with well defined edges near fovea OD Periphery: similar lesions superiorly & nasally OS Vascular: wnl Exam

  9. Differential Diagnosis

  10. Infectious Bacterial endophthalmitis Fungal endophthalmitis Toxoplasmosis Syphilis CMV retinitis HZV/HSV retinitis Nocardia Tuberculosis Inflammatory/Infiltrative Sarcoid Wegener’s PAN Neoplastic Large cell lymphoma Differential Diagnosis

  11. Fever spike of 102.7 with tachycardia 4 days prior PICC line removed Cultures grew out Coag Negative Staph and Candida albicans On IV Vancomycin & Diflucan Additional History

  12. Diagnosis:Endogenous Multifocal Infectious Chorioretinitis – likely staphylococcal due to multifocal nature, recent fever spike, diffuse vitritis

  13. Tx with IV Vancomycin, PO Diflucan Day 3 – Minimal improvement, added PF 1% QID for AC reaction Week 2 – PF not started, Posterior Synechiae developed OS Week 4 – No better, new lesions OS, increased vitritis with “string of pearl appearance” VA= 6’/200 E OU → Revised diagnosis: Endogenous Fungal Endophthalmitis Course

  14. Week 4 – Intravitreal injection of amphotericin OU Switched to IV caspofungin and PO voriconazole Week 5 – PPV, intravitreal inj of Amphotericin OS Week 6 – PPV, intravitreal inj of Amphotericin OD Vitreal cultures – no growth OU Course

  15. Candida – most common History of risk factors Mild/Mod inflammation, focal/multifocal yellow-white chorioretinal lesions May coalesce, forming mushroom shaped nodules extending into vitreous Classic: “string of pearls” appearance Dx: systemic/intraocular cultures, PPV Relatively favorable outcome for Candida if treated aggressively early. Endogenous fungal endophthalmitis

  16. Rare before 1950 Incidence in patients with candidemia reported from 28% to 45% Donahue, et al, showed in 1992 that Candida endophthalmitis was rare when properly defined 118 patients, no endophthalmitis, 9.3% chorioretinitis only Risk factors: visual symptoms, C. albicans species, immunosuppression, multiple + blood cultures Feman, et al (2002): incidence of <2% Candidemia

  17. Intravenous amphotericin B – first used in 1960 Significant systemic side effects Poor intraocular penetration Systemic fluconazole Better side effect profile O’Day, et al: Better intraocular penetration May be effective monotherapy for chorioretinitis Fungistatic Treatment

  18. Vitrectomy First reported in 1976 Provides specimen for diagnosis Removes pathogen load Improves ocular penetration of systemic tx Intraocular amphotericin B Potential retinal toxicity, but rarely seen clinically Used commonly for advanced cases Treatment

  19. Vitrectomy with oral fluconazole alone may be an effective option Christmas & Smiddy (1996): Case series 6 of six eyes PPV and 4-weeks of oral fluconazole Five achieved final VA of 20/40 or better Treatment

  20. Intraocular corticosteroid injection is controversial Theoretically should not alter host defense as no affect on neutrophils If used, must assure appropriate antimicrobial coverage Intraocular imidazoles may be useful in cases of resistance to therapy, or for Aspergillus PO/IV voriconazole and caspofungin for tx failure Treatment

  21. Last visit (1/2/07 – Week 10) VA: 6/200 OD, 20/60 with correction OS Inactive punched out scars in both eyes. Resolved vitritis Update on our patient

  22. Relatively favorable prognosis Keep this diagnosis in mind Early and aggressive therapy Treatment options are expanding To Remember

  23. Donahue SP, et al. Intraocular candidiasis in patients with candidemia. Ophthalmology 1994;101:1302-1309. Flynn, HW. The Clinical challenge of endogenous endophthalmitis. Retina 2001;21:572-574. Gupta A, et al. Fungal endophthalmitis after a single intravenous administration of presumably contaminated dextrose infusion fluid. Retina 2000;20:262-268. O’Day DM. Ocular uptake of fluconazole following oral administration. Arch Ophthalmol 1990;108:1006-1008. Smiddy, WE. Treatment outcomes of endogenous fungal endophthalmitis. Current Opinions in Ophthalmology 1998;9:66-70. Snip RC, Michels RG. Pars plana vitrectomy in the management of endogenous Candida endophthalmitis. Williams, MA, et al. Diagnosis and treatment of endogenous endophthalmitis. Ophthalmologica 2006;220:134-136. References

  24. Thank you

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