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Snapshot of the Month

An otherwise healthy 43 year old female, originally from the Phillipines, living in Calgary for 38 years, presented to Emergency Department with a fever and flu- like symptoms. Blood cultures were positive for Klebsiella Pneumoniae. The patient was found to have a liver abscess, pneumonia and was started on Intravenous (IV) Ceftriaxone 1 gram BID. One week after admission to the hospital she began to notice decreased vision in her left eye. On ophthalmic evaluation her BCVA was 20/20 in the right eye and HM in the left eye. SLE of the left eye revealed an anterior chamber reaction of 1+ cells and 2+ vitriitis. Fundus examination of the same eye revealed a large chorioretinal abscess with hemorrhages affecting the macula. Right eye exam was remarkable for a cotton wool spot. The Ceftriaxone IV dosage was doubled and an intravitreal injection of Ceftazidime 2.25 mg/0.1 cc was administered. Nine days post-injection she had significant improvement of the chorioretinal abscess, however there was notable macular atrophy with Count Fingers as visual acuity.



Title:

Made in Asia

Credits:

Julia Farah (Retina Fellow - University of Calgary), Rayan Alshareef, Vikram Lekhi, Amin Kherani, MD. FRCSC (Clinical Associate Professor, U. of Calgary)

Location:

University of Calgary

Description:

An otherwise healthy 43 year old female, originally from the Phillipines, living in Calgary for 38 years, presented to Emergency Department with a fever and flu- like symptoms. Blood cultures were positive for Klebsiella Pneumoniae. The patient was found to have a liver abscess, pneumonia and was started on Intravenous (IV) Ceftriaxone 1 gram BID. One week after admission to the hospital she began to notice decreased vision in her left eye. On ophthalmic evaluation her BCVA was 20/20 in the right eye and HM in the left eye. SLE of the left eye revealed an anterior chamber reaction of 1+ cells and 2+ vitriitis. Fundus examination of the same eye revealed a large chorioretinal abscess with hemorrhages affecting the macula. Right eye exam was remarkable for a cotton wool spot. The Ceftriaxone IV dosage was doubled and an intravitreal injection of Ceftazidime 2.25 mg/0.1 cc was administered. Nine days post-injection she had significant improvement of the chorioretinal abscess, however there was notable macular atrophy with Count Fingers as visual acuity.

Klebsiella species are gram-negative, encapsulated, anaerobic bacteria that are present in the normal nasopharyngeal and gastrointestinal flora. They are known to cause pneumonia and urinary tract infections. In recent years Klebsiella species have emerged as a prevalent cause of pyogenic liver abscesses in Asia. The reason for the predominance of this syndrome in the Asian population is unclear. It is associated with a 3 –11% incidence of endogenous endophthalmitis. This rate of ocular involvement is notably higher than with other systemic infections.


References:

Siu LK1, Yeh KM, Lin JC, Fung CP, Chang FY., Klebsiella pneumoniae liver abscess: a new invasive syndrome . Lancet Infect Dis 2012;12: 881–87.

Sridhar J, Flynn HW, Kuriyan AE, Dubovy S, Miller D. Endophthalmitis caused by Klebsiella species. Retina (Philadelphia, Pa). 2014;34(9):1875-1881.

Jackson TL, Paraskevopoulos T, Georgalas I, Systematic Review Of 342 Cases Of Endogenous Bacterial Endophthalmitis, Survey of Ophthalmology (2014), doi: 10.1016/ j.survophthal.2014.06.002.

Fundus examination OD revealed a whitened posterior pole with sparing in the papillomacular bundle. Spectral-domain optical coherence tomography OD revealed inner retinal hyperreflectivity with fovea sparing.

Fig. 1A

 Fluorescein angiography showed a central retinal artery occlusion (CRAO) with cilioretinal sparing OD.

Fig. 1B

Title:

Luck of the Draw

Credits:

Fannie Nadeau, Ananda Kalevar MD

Location:

Department of Ophthalmology, HD Hospital, Sherbrooke University, Sherbrooke, Quebec

Description:

A 80-year-old female experimented nasal visual field loss in her right eye (OD) with preserved temporal visual field. Her past medical history was significant for age-related macular degeneration and hypertension. Best-corrected visual acuity was 6/6 OD and 6/9 OS. A pupillary afferent defect was present OD. Slip lamp examination was unremarkable in both eyes. Fundus examination OD revealed a whitened posterior pole with sparing in the papillomacular bundle. Spectral-domain optical coherence tomography OD revealed inner retinal hyperreflectivity with fovea sparing (Fig 1A). Fluorescein angiography showed a central retinal artery occlusion (CRAO) with cilioretinal sparing OD (Fig 1B).

Cilioretinal artery is an anatomic variant found in 15 to 30% of the population that often supplies the papillomacular bundle, but that supplies the foveola in only 10% of eyes 1, 2. Therefore, its presence and specifically its distribution makes it possible of maintaining central vision in the event of a CRAO 2, 3, 4.


References:

1 Biousse V, Newman N. Retinal and optic nerve ischemia. Continuum (Minneap Minn). 2014 Aug. 20 (4 Neuro-ophthalmology):838-56.

2 Lorentzen SE. Incidence of cilioretinal arteries. Acta Ophthalmol (Copenh). 1970. 48 (3):518-24.

3 Pirasath S, Suganthan N, Malaravan M, Cilioretinal Artery Sparing Central Retinal Artery Occlusion, Austin Journal of Clinical Ophthalmology, 2015; 2(5): 1059

4 Hayreh SS, Zimmerman MB. Central retinal artery occlusion: visual outcome. Am J Ophthalmol. 2005;140:376-391.

Fig. 1

Congenital macrovessel Fluorescein angiography (late phase) OS revealing congenital macrovessel coursing temporally and inferiorly from its origin at the central retinal artery, giving off multiple branches with no observable leakage.

Title:

The Road Less Travelled

Credits:

Amit V Mishra MD, Mark E Seamone MSc MD, Hesham Lakosha MD, Rishi Gupta MD

Location:

Department of Ophthalmology, QEII Hospital, Dalhousie University, Halifax, Nova Scotia

Description:

A 49-year-old male presented after blunt trauma OS. His past medical history was remarkable for blunt ocular trauma OD. Best-corrected visual acuity was 6/15 OD and 6/12 OS. Slit lamp examination of the anterior segment revealed traumatic mydriasis and an area of zonular insufficiency nasally from previous trauma OD. Slit lamp examination was unremarkable OS. Fundus examination OD revealed chronic chorioretinal scarring from previous trauma. Fundus examination OS revealed a retinal macrovessel extending through the macula and just inferior to the fovea. This finding was confirmed using fluorescein angiography (Figure 1A and B).

Congenital retinal macrovessels are large anomalous vessels that cross the horizontal raphe1,2. This is a rare finding3 that has been associated with decreased visual acuity and serous retinal detachments4.

References:

de Crecchio G, Mastursi B, Alfieri MC, Pignalosa B. Congenital retinal macrovessel. Ophthalmologica. 1986;193:143-5.

Jager R, Timothy N, Joseph M, et al. Congenital Retinal Macrovessel. Retina. 2005;25(4):538-540.

Hayasaka S, Katsube T, Ugomori S, Setogawa T. Abnormally Distributed Branches of the Retinal Vessels, Enlarged Macular Arteries and Long Cilioretinal Arteries. Ophthalmologica. 1990;200:194-197.

Arai J, Kasuga Y, Koketsu M, Yoshimura N. Development and spontaneous reolution of serous retinal detachment in a patient with a congenital retinal macrovessel. Retina. 2000;130:527-528.