History of Present Illness
A 44-year-old man with a history of sarcoidosis-associated panuveitis both eyes (OU) controlled on mycophenolate mofetil 1000 mg by mouth (PO) twice a day (BID) presents urgently to your office 2 days after an intravitreal injection. At the previous appointment earlier in the week, the uveitis was quiescent but he had cystoid macular edema in the left eye (OS) with visual acuity (VA) decreased to 20/60 from his baseline of 20/40. Intravitreal triamcinolone 2 mg/0.05 cc was injected. Today, he states that his vision has become much cloudier. He is accustomed to seeing many large floaters after the injection, which clear after a few days, but this is different. His vision is totally blurred and has been getting worse over the last day.
| OD | OS | |
|---|---|---|
| Vision | 20/30 | 20/400 |
| Intraocular pressure (IOP) | 16 | 15 |
| Lids and lashes: | Normal | Normal |
| Sclera/conjunctiva: | White and quiet | White and quiet |
| Cornea: | Clear | Clear |
| Anterior chamber (AC): | Deep and quiet | See Fig. 80.1 |
| Iris: | Flat | Flat |
| Lens: | Posterior chamber intraocular lens (PCIOL) | PCIOL |
| Anterior vitreous: | Clear | Poor view, +cells |
| Dilated fundus examination (DFE): | Deferred | Poor view |
B scan OS: 3+ vitreous opacities, retina attached.
Questions to Ask
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Are you in pain? If so, how much?
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Have you had any discharge from the eye?
The patient denies any pain or discharge. He says the eye feels fine, but he simply cannot see out of it.
Assessment
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Severe, acute inflammation with hypopyon OS after intravitreal injection of triamcinolone
Differential Diagnosis
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Infectious endophthalmitis
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Noninfectious, postinjection inflammation (“sterile endophthalmitis”)
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Less likely: flare of sarcoid panuveitis, migration of triamcinolone into the anterior chamber (AC)
Working Diagnosis
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Infectious endophthalmitis OS
Management
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Vitreous tap and injection of vancomycin 1 mg/0.1 cc and ceftazidime 2.25 mg/0.1 cc
Follow-up
The patient returns the following day. He notes the vision is no different. Gram stain of the vitreous sample was negative for organisms, and polymerase chain reaction (PCR) showed no bacterial or fungal deoxyribonucleic acid (DNA).
