Woman with white in her eye.

PATIENT PRESENTATION

A 77‐year‐old female with a past medical history of poorly controlled diabetes and hypertension presents for left eye pain and loss of vision. She reports receiving vitreous injections about 2 weeks ago by her private ophthalmologist. She cannot pinpoint the exact time her vision began to decrease in her affected eye, but her vision is nearly absent in the affected eye upon arrival to the emergency department (ED). Upon examination, vital signs were temp 98.7°F, HR 91, RR 18, and BP 206/94. Oxygen saturation was 99% on room air. The left eye gross physical examination was as shown (Figure 1, VIDEO S1). Visual acuity was 20/30 OD and No Light Perception OS. Intraocular pressure was measured at 22 OD and 48 OS. A bedside clinical ultrasound was performed by the emergency physician in the ED on the left eye (Figure 2/VIDEO S1). Her only abnormal laboratory study was an elevated blood glucose, which was managed conservatively with her home medications.

FIGURE 1

The physical examination of the left eye with clear purulent material within the anterior chamber

FIGURE 2

A still image from an ultrasound clip demonstrating vitreous debris and choroidal detachment

DIAGNOSIS

Endophthalmitis

Endophthalmitis is a true emergency medical condition with the potential for severe vision‐threatening complications whose prognosis is directly related to the time from symptom onset to treatment. Endophthalmitis develops by one of two pathways, either exogenously or endogenously. Endogenous endophthalmitis accounts for only 2% to 8% of all cases and is caused by either a yeast or bacteria seeding the choroid via hematogenous spread. If not promptly diagnosed the infection will spread into the vitreous body and eventually infiltrate the retina. Exogenous endophthalmitis is much more common and results from direct inoculation of an infective organism as a complication from intraocular injections, ocular surgical procedures, or penetrating eye trauma. Ocular symptoms can be very non‐specific early in the course of the disease and include ocular pain, redness, swelling, discharge, blurry vision, and floaters. Upon physical examination the “can't miss” finding is visible purulence within the anterior chamber. Ocular ultrasound may demonstrate moderate to extensive vitreous debris (low‐density mobile echoes), vitreous membranes, choroidal thickening and, eventually, choroidal and retinal detachment. ED treatment includes the initiation of broad‐spectrum intravenous antibiotics, typically with vancomycin and ceftazidine. Emergency ophthalmologic consultation is also mandatory for consideration of intravitreous antibiotic therapy or other surgical intervention, such as vitrectomy. Vision prognosis is usually poor making timely diagnosis even more crucial. Physical examination combined with bedside ultrasound confirmed the sight‐threatening emergency of endophthalmitis and provided important prognostic findings to ensure appropriate surgical therapy for our patient.

DISCLOSURE

The author team report no conflicts of interest.

SUPPLEMENTAL VIDEO 1

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