In the Eye Lies the Truth to the Heart – Ocular Manifestations of Infective Endocarditis

Claire Ruan

Meeting:  2015 RANZCO


Date:      -

Session Title: Poster

Session Time:      -

To describe a case that highlights infective endocarditis as an uncommon source of endophthalmitis in an immunosuppressed patient. This case illustrates the dramatic onset of symptoms and clinical decision challenges in a 57yo Caucasian male with monocular visual loss.

The patient case explored is a 57yo solicitor who presented with acute left eye visual loss, preceded by fevers, abdominal pain and myalgia. Apart from ankylosing spondylitis treated with infliximab, he was systemically well. Initial examination identified low-grade fevers. Left VA recorded hand movements. Fundoscopy found an active anterior chamber with 3+ cells, hazy vitreous and appearance of a pale retinal lesion. Initial therapy with clindamycin, valgancyclovir and prednisone provided temporary symptomatic improvement, however, subsequent rigours and clinical deterioration ensued. Blood and vitreous cultures detected staphylococcus aureus. Steroids were ceased and treatment changed to IV flucloxacillin and vancomycin. Vitreous clarity improved and a 2x3mm subretinal abscess with overlying haemorrhage, retinitis, and subretinal exudate was observed. Additionally, a systolic murmur was found, confirmed by trans-oesophageal echocardiogram as 10×11 mm aortic valve vegetation. Definitive management was achieved through surgical replacement of the aortic valve, and medical treatment with six-weeks of intravenous flucloxacillin, cyclopentolate and dexamethasone eye drops.

The patient’s vision improved to 6/18 with residual subfoveal fluid. The patient remained stable with no systemic complications at three month follow up.

Infective endocarditis is a rare yet serious cause of endophthalmitis, which may particularly affect patients receiving biological immunosuppression. Clinicians should maintain a low threshold for consideration and management of endophthalmitis and sepsis.