Traumatic Injury in One Eye Followed by a Hyperopic Shift in the Other: Are They Related?

Jessica Lee, MD; Jerome V. Giovinazzo, MD; Steve A. Agemy, MD; Ronald C. Gentile, MD

Disclosures

September 06, 2016

Clinical Presentation

A 30-year-old white woman sustained an injury to her right eye while working at a vineyard. When she bent over to remove a cluster of grapes, she was poked in the eye with a fastening wire. She was evaluated at the local emergency room, where she was treated with topical antibiotics for a corneal abrasion, and was referred to an ophthalmologist. However, that evening, the patient experienced increasing pain and redness and decreasing vision in the right eye.

During her ophthalmic examination the next day, the patient's medical history was found to be unremarkable, and she had no history of eye disease. Review of systems was negative for rash, fever, asthma, arthritis, tick bite, drug use, and sexually transmitted infections.

Distance vision was hand motion in the right eye and 20/20 in the left eye; near vision was similar. The right pupil was poorly visualized through a cloudy anterior segment and was sluggishly reactive to light. It appeared to be irregularly shaped, with a peaked area localized temporally. There was no relative afferent pupillary defect. The left pupil was normal. Anterior segment slit-lamp examination of the right eye revealed 2+ conjunctival injection and chemosis with a small full-thickness corneal laceration measuring 2.5 mm plugged with incarcerated iris. Seidel testing with a fluorescein strip demonstrated no leak. There was fibrin and a 1-mm hypopyon in the anterior chamber. The natural lens was cloudy and white, and the view of the anterior capsule and beyond was poor. Intraocular pressures, measured with applanation tonometry, were 15 and 20 mm Hg in the right and left eyes, respectively.

Funduscopic examination of the right eye was not possible because of media opacity. The left fundus was normal. B-scan ultrasonography of the right eye revealed a flat retina with vitreous debris but no masses or choroidals. No intraocular foreign body was identified on x-ray CT of the orbits.

The patient underwent surgical repair of the full-thickness corneal laceration of the right eye (Figure 1) and a biopsy of both the anterior chamber hypopyon and vitreous using a 25-gauge pars plana vitrector. Subconjunctival antibiotics and intravitreal injections (0.1 mL each) of intravitreal ceftazidime (2.25 mg), vancomycin (1.0 mg), and voriconazole (50 µg) were administered. Oral levofloxacin and topical fortified antibiotics were also started.

Figure 1. Right eye after placement of the initial suture to repair the full-thickness corneal laceration.

The patient's pain and inflammation continued to increase, despite continued treatment. Two days after the first surgery, she underwent a pars plana vitrectomy and a pars plana lensectomy and received repeat intravitreal injections of broad-spectrum antimicrobials, including antifungals. The intraocular cultures from the initial surgery revealed a polymicrobial infection with Bacillus cereus, Pseudomonas aeruginosa, and Aspergillus. Despite appropriate and aggressive intravenous antibiotics with repeat intravitreal injections, 2 weeks after the original trauma, the eye lost light perception. The ocular plastic surgeon recommended an evisceration, but this was rejected by the patient and her family.

Two months after the initial injury, the patient presented with blurry vision in the left eye, especially when reading. Distance vision without correction decreased to 20/80, and near vision decreased to 20/200. Manifest refraction revealed a hyperopic shift of +4.00 in the left eye, with best corrected distance vision of 20/40. Near vision was corrected to J6, with a +6.50 sphere. There was almost a total loss of accommodation, despite a reactive pupil. The lack of light perception remained in the right eye.

Additional symptoms included photophobia, metamorphopsia, and mild floaters in the left eye. Ocular examination of the right eye revealed early atrophic bulbi. Anterior segment examination of the left eye revealed mild conjunctival injection with a few granulomatous keratic precipitates on the corneal endothelium. There were a few cells in the anterior chamber and vitreous. Intraocular pressures, measured with applanation tonometry, were 5 and 20 mm Hg in the right and left eyes, respectively. Fundus examination of the left eye revealed multifocal chorioretinal lesions in the posterior pole and nasal to the disc (Figure 2).

Figure 2. Fundus photo of the left eye demonstrating multifocal chorioretinal lesions.

Fluorescein angiography of the chorioretinal lesions revealed early blockage (Figure 3) with late leakage (Figure 4).

Optical coherence tomography of the macula identified subretinal fluid (Figure 5).

Figure 3. Early fluorescein angiography at 20 seconds demonstrated normal retinal filling with a few areas of fluorescein blockage (white arrows).

Figure 4. Late fluorescein angiography at 5 minutes demonstrated leakage from pinpoint areas of hyperfluorescence with fluorescein pooling (white arrows).

Figure 5. Optical coherence tomography (top) horizontal scan through the fovea and (bottom) vertical scan through the fovea revealed elevation of the retinal layers, with subretinal hyporeflectivity corresponding to subretinal fluid.

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