This Week's Eye-Openers

JAMA Ophthalmology

Written by: Taha Mujahid

When the source lies beyond the eye

Negative blood cultures may not rule out an infection hidden in a chemotherapy port.

A patient in their late 70s with colon cancer, chronic kidney disease, and a central venous chemotherapy port presented with four days of painless blurred vision, floaters, and photophobia in the left eye. There was no recent ocular surgery or trauma. Visual acuity was 20/40 OS, with anterior chamber inflammation, vitreous cells, and haze. B-scan ultrasonography showed vitreous opacities and focal superonasal choroidal thickening (Figure A).

Initial blood cultures and infectious serologies were negative. Despite intravitreal antibiotics and antifungals, vision declined to 20/400, and a white superonasal chorioretinal lesion developed (Figure B). Vitreous cultures grew Cutibacterium acnes, but the clinical course suggested a fungal infection rather than this potentially misleading isolate. Repeat blood cultures remained negative, and serum β-D-glucan was indeterminate.

Culture of the central venous port grew Candida tropicalis, identifying the likely source of endogenous fungal endophthalmitis. The port was removed, and treatment continued with systemic fluconazole and serial intravitreal antifungal injections. After a transient decline to 20/800, vision recovered to 20/25 without vitrectomy, leaving only a small chorioretinal scar.

This case highlights the importance of source control: persistent intraocular inflammation in a patient with an indwelling device warrants investigation beyond the eye, even when blood cultures are negative. 

A 26-year-old man presents with several years of progressively worsening blurry vision in both eyes with frequent changes in his glasses prescription. He has a history of seasonal allergies and reports frequently rubbing his eyes. His best-corrected visual acuity is 20/40 in the right eye and 20/50 in the left. Retinoscopy reveals a scissoring reflex, and slit-lamp examination shows subtle Vogt striae. Corneal tomography shows bilateral inferior corneal steepening and thinning, more pronounced in the left eye. Six months after the initial tomography, the left eye shows further steepening and thinning.

What is the most appropriate next step in management of the left eye?

A. Continue observation with annual corneal topography

B. Fit rigid gas-permeable contact lenses alone

C. Perform corneal collagen cross-linking

D. Proceed directly to penetrating keratoplasty

E. Perform LASIK to correct the irregular astigmatism 

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