A 41-year-old Caucasian man presented to the emergency department with left eye pain and loss of vision after complicated cataract surgery 2 days prior. His past ocular history was significant for blunt trauma to the left eye with a stick while riding an all-terrain vehicle 8 months ago; over the following 3 months, the eye became painful with deterioration of vision for which he sought ophthalmic care. At that initial examination, outside records indicated that his vision was light perception, and there was significant conjunctival injection, corneal edema, and anterior chamber reaction precluding a view of the fundus. There was no recorded sign of previous ocular trauma, keratic precipitates, hypopyon, or afferent pupillary defect, and his poor vision was attributed to the inflammation from initial injury. He was treated for non-granulomatous anterior uveitis with topical and subtenon's corticosteroid injection for several months. The lens developed progressive cataract changes with corticosteroid treatment, and he underwent cataract surgery that was complicated and unsuccessful due to significant sequela from uveitic changes. An intraocular lens was not placed due to questionable lens capsule integrity.
Our examination revealed a visual acuity of 20/30 right eye (OD) and no light perception of the left eye (OS). The right pupil was reactive to light, but the left pupil was fixed and non-reactive, with a left relative afferent pupillary defect. He had marked restriction of ocular motility of the left eye due to pain. The left upper eyelid was ptotic and edematous. The orbit was slightly tense to retropulsion, but no proptosis was appreciated. The intraocular pressures were 19 mmHg OD and 27 mmHg OS.
Slit-lamp biomicroscopy of the left eye revealed injected and chemotic conjunctiva. The cornea was hazy with diffuse fluorescein staining of the epithelium. The cataract wound incision was intact, and Siedel test was negative. The anterior chamber was without hypopyon, but moderate cells and flare were seen. A pupillary membrane precluded view to the fundus of the left eye. The patient's vital signs were normal. Complete blood count revealed an elevated white blood cell count (11,300 cells per dL) without a left shift.
B-scan ultrasonography of the left eye revealed diffuse vitritis and choroidal thickening. No retinal detachment was seen. The patient was admitted to the hospital for anterior chamber washout with removal of pupillary membrane, diagnostic vitrectomy, and intravitreal injection of vancomycin (1 mg/0.1 ml), ceftazidime (2.5 mg/0.1 ml), dexamethasone (0.4 mg/0.1 ml), and amphotericin B (0.4 mg/0.1 ml). Intraoperative findings included significant fibrin anterior chamber reaction, purulent material filling the vitreous cavity, funnel retinal detachment, and multiple choroidal infiltrates. Retinal detachment repair was not attempted due to the poor status of the retinal tissue. Initial gram stain revealed several polymorphonuclear cells with rare budding yeast and very rare pseudohyphae. Fungal culture subsequently revealed C. dubliniensis sensitive to amphotericin, caspofungin, and fluconazole (Figure 1). Serologic work-up for infection and inflammation included blood culture, rapid plasma reagin, fluorescent treponemal antibody-absorption, tuberculosis quantiferon gold, chest X-ray, angiotensin-converting enzyme, tick-borne disease panel, sedimentation rate, C-reactive protein, and human leukocyte antigen B27 which all were within normal limits.
The patient was treated with fluconazole 800 mg daily and evaluated by the infectious disease service who found no signs of extra-ocular infection. He had a normal cardiac exam, and additional cardiac imaging was not recommended by the infectious disease service. He adamantly denied intravenous drug use but was found to be hepatitis B and C positive without prior history of vaccination. Human immunodeficiency virus testing was negative, and hemoglobin A1c was 5.6. The patient did not recover his vision and continued to experience severe pain for which enucleation surgery was offered. He underwent enucleation surgery with placement of a porous implant without complication. He was treated for 4 weeks with fluconazole and had an uneventful recovery at 3-month follow-up.