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1. Grand Ward Round
Dr Lai Yen Sheong

2. HISTORY OF PRESENTING ILLNESS
• Mr K, a 67-year-old Malay gentleman, with underlying hypertension and
slipped disc under private hospital follow up.
• He was also diagnosed as Rheumatoid Arthritis (ANA positive) in private
hospital in 2021 and was given methotrexate and prednisolone but patient
defaulted after 6 months.
• Presented with LE painless blurring of vision progressively associated with
redness and floaters since early April, claims first episode.
• He then seek consultation from private ophthalmologist and was treated as
LE panuveitis secondary to ?RA.
• He was given oral prednisolone 10mg BD for 4 days and gutt maxidex QID
LE, he claimed had slight improvement.
• During TCA, patient was referred to us for further management.

3. Otherwise,
• No flashes of light
• No photophobia/glaring
• No loss of appetite
• No loss of weight
• No URTI/UTI symptoms
• No fever
• No rashes/oral ulcers
• No recent alopecia
• No bowel symptoms
• No history of TB contact/chronic cough/night sweats
• No recent travelling/swimming at waterfall
• No rat contact
• Denies trauma
• Has cat at home, vaccinated and no recent history of cat scratch
• No bleeding tendency

4. PAST MEDICAL HISTORY
• Hypertension
- Under private hospital follow up
- Defaulted medication for 1 year
- Previously on T perindopril 4mg OD
• Slipped disc
- Under private orthopaedic follow up
- Under rehabilitation
• Rheumatoid arthritis
- Diagnosed in July/August 2021
- Initially presented with lower back pain, no small joints pain or swelling
- ANA positive speckled 1:80, RF <20 IU/ml negative
- Previously treated with methotrexate and prednisolone but defaulted
follow up and medications after 6 months

5. PAST OCULAR HISTORY
• No history of ocular trauma
• No history of ocular surgical intervention
• Wearing glasses for near vision
ALLERGIC HISTORY
• No known food or drug allergies

6. SOCIAL HISTORY
• Non smoker
• Non alcoholic
• Married and blessed with 5 children
• No high risk behaviours
FAMILY HISTORY
• No family history of malignancy
• No ocular disease in family

7. EXAMINATION DURING PRESENTATION (26/4/23)
RE LE
6/9 VA 2/60, ph 2/60
Unable to assess (pharmacodilated) RAPD Unable to assess (pharmacodilated)
Normal LIDS Normal, no swelling
White CONJUNCTIVA White
Clear CORNEA Clear, few pigmented KPs on
endothelium
Deep, quiet ANTERIOR CHAMBER Deep, occasional cells
Normal IRIS No iris nodules
NS+ LENS NS+, iris pigments on anterior capsule
12mmHg IOP 12mmHg
Vitreous clear, OD pink, CDR 0.4,
macula normal, retina flat, no lesions
seen
FUNDUS Anterior vitreous cells 3+, hazy view,
vitritis more intense nasally and
inferiorly with multiple vitreous clumps
inferiorly ?snowbanking, OD pink,
unable to comment CDR, exudative RD
seen superiorly and nasally

9. B scan of LE: Dense vitritis, superior retina detachment, no choroidal
mass seen, no T sign

10. IMPRESSION
• Left eye panuveitis for investigation
• Ddx: LE endogenous endophthalmitis
• Bilateral eye immature cataract

11. PLAN
• Admit ward
• Take investigations(FBC, RP, RBS, Blood C&S, Blood fungal C&S, Urine
C&S, Mantoux, CXR, RF, ANA, VDRL, Hep B, Hep C, HIV, ESR, CRP,
Toxoplasma IgG/IgM)
• Gutt maxidex QID LE
• Refer rheumatology team CM
• For family to bring previous medical records from private hospital

12. EXAMINATION IN WARD (27/4/23)
RE LE
6/9 VA 6/36, ph 6/36
RAPD Positive over LE
100% RED DESATURATION 100%
100% LIGHT BRIGHTNESS 90%
Full, no diplopia EOM Full, no diplopia
Normal LIDS Normal, no swelling, no proptosis
White CONJUNCTIVA White
Clear CORNEA Clear, few pigmented KPs on endothelium
Deep, quiet ANTERIOR CHAMBER Deep, occasional cells
Normal IRIS No iris nodules
NS+ LENS NS+, iris pigments on anterior capsule
12mmHg IOP 12mmHg
Vitreous clear, OD pink, CDR 0.4,
macula normal, retina flat, no lesions
seen
FUNDUS Anterior vitreous cells 3+ with mobile snowball, hazy
view, vitritis with multiple vitreous clumps inferiorly,
OD pink, unable to comment CDR, exudative RD seen
superiorly and nasally, no choroiditis/vasculitis/retinitis

13. SYSTEMIC EXAMINATION
• Cervical/inguinal lymph nodes not enlarged
• No oral ulcers
• Lungs: clear
• CVS: S1S2, no murmur
• Abdomen: soft, non tender, no hepatosplenomegaly

14. PLAN
• Cont G maxidex QID LE
• Trial of Tab ciprofloxacin 750mg BD
• Ultrasound HBS to look for abscess or mass

15. REFER RHEUMATOLOGY TEAM
• In view of patient only has back pain, no small joints pain, and noted
previous MRI lumbar report done on 6/5/22 noted L2-S1 disc
prolapsed, unlikely rheumatoid arthritis.
• To take C3/C4, hand X ray, lumbosacral X ray, pelvis X ray
• Trace ESR, ANA, RF, C3, C4 and all X ray, then to update rheumatology
team again

16. INVESTIGATIONS
FBC: Normal (WCC 9.7)
RP: Normal
LFT: Normal
RBS: 5.1
Blood C&S: So far no growth
Blood fungal C&S: So far no growth
Urine C&S: Mixed growth
UFEME: Normal
Mantoux: Not done yet
CXR: clear lung field
RF: Negative
ANA: Pending
VDRL: Non reactive
Hep B: Non reactive
Hep C: Non reactive
HIV: Non reactive
ESR: 11
CRP: 1.6
Toxoplasma IgG: Reactive
Toxoplasma IgM: Non reactive
C3: 0.99
C4: 0.30
Ultrasound HBS: No sonographic
evidence of liver abscesses

17. Lumbosacral X ray
1. Reduced vertebral body height at L1 may
represent compression fracture.
2. Irregular and sclerosis of the inferior
endplate of L1 and superior endplate of
L2 with reduced intervertebral disc space,
may represent degenerative spine
disease. Unable to completely exclude
discitis.
3. Loss of lumbar lordosis.

18. Case D/W Dr Amelia (MR consultant HKL)
• TRO masquerade syndrome
• To send tumour markers/ FBP/ LDH/ TB quantiferon
• TCA MR HKL on 2/5/23
• Cont Tab ciprofloxacin and G maxidex

19. Results
CEA: 2.4
PSA: 0.3
CA 19-9: 7.4
LDH: 231 (slightly raised)

20. S/B MR team in HKL (2/5/23)
• LE endogenous endophthalmitis (bacterial/fungal)
• IVT tapping and antibiotic given
• Referred VR Hospital Selayang for vitreous biopsy

21. Endophthalmitis
• Purulent inflammation of the intraocular fluids (vitreous and aqueous)
usually due to infection.
• Types:
Exogenous
- Acute Postoperative
- Chronic Postoperative
- Traumatic
- Filtering Bleb-Associated
- After Intravitreal Injections
- Corneal ulcer
Endogenous
- Bacterial or fungal endogenous chorioretinitis +/- vitritis

22. Endogenous Endophthalmitis
• Uncommon intraocular infection, responsible for roughly 2% to 8% of all
endophthalmitis.
• In North America and Europe, the most frequently identified causative
bacteria are Staphylococcus aureus and Streptococcus pneumoniae.
• In East Asia, Klebsiella pneumoniae is chiefly responsible.
• Among fungal etiologies, Candida albicans is the most common yeast,
and Aspergillus is the most common mold.
• Infectious extraocular focus can be found in 90% of the cases, such as tooth
abscess, pneumonia, endocarditis, liver abscess, urinary tract infection and
bacterial meningitis

23. Risk Factors
• Immunocompromised states (for example, chronic
corticosteroid use, malignancy, end-stage liver/renal disease,
organ transplant, diabetes mellitus)
• Intravenous drug use
• Indwelling catheter
• Dental procedures

24. Presentation
• Asymptomatic
• Symptoms typical of severe uveitis, including a red, painful eye
with photophobia, floaters, or reduced vision.
• Mostly unilateral, up to a third of cases have bilateral
involvement.

25. Ocular Examination
• Reduced visual acuity, lid swelling, conjunctival injection and chemosis,
corneal edema, hypopyon, anterior chamber cells, and vitritis.
• A key diagnostic finding associated with an endogenous cause is the
presence of a white infiltrate originating in the choroid and sometimes
erupting into the vitreous cavity.

26. Differentiation between Bacteria and Fungal
• Endogenous S. aureus endophthalmitis • Fungal endophthalmitis
• Presents acutely, often within days • Subacute presentation with symptoms
worsening over days to weeks
• Intraocular inflammation tends to occur in
“clumps”
• Intraocular inflammation is typically diffuse

27. • The fundus may be obscured because of vitreous haze or
vitritis.
• B-scan ultrasound can help identify vitritis or chorioretinal
infiltrates.
Ultrasound B scan with numerous hyperechoic densities
in vitreous chamber. The blue arrow marks a detached
retina.

28. Exudative Retina Detachment
• Occurs when fluid accumulates in the subretinal space between the sensory
retina and the retinal pigmented epithelium (RPE) resulting in retina detachment.
• Causes for fluid accumulation include inflammatory, infectious, and neoplastic
diseases of the choroid or retina.

29. Differential Diagnosis

31. Vitreous fluid biopsy
• Vitreous fluid obtained by means of vitrectomy has a higher
diagnostic yield than vitreous fluid from needle biopsies, most
likely because the sample is taken closer to the infectious nidus.
• Blood cultures are positive in only a third of cases.
• Polymerase chain reaction (PCR) can identify both bacteria and
fungi, even in culture-negative cases.

32. Treatment
• As soon as endophthalmitis is suspected.
• Prompt intravitreal antibiotic administration, combined with
hospitalization, infectious disease consultation, and intravenous
antibiotics.
• Avoid corticosteroids when fungal infection is suspected.

33. Take Home Message
• The clinical picture of endogenous endophthalmitis can vary
significantly.
• Diagnostic dilemmas for endophthalmitis arise when any of the key
signs are missing, such as pain, redness, chemosis, hypopyon.
• The patient's history may lack clues to the source of a blood-borne
infection causing an endogenous endophthalmitis.
• Neoplastic conditions can also mimic intraocular infections.

34. References
• Malgorzata et al. (2022) Endogenous endophthalmitis-the clinical
significance of the primary source of infection. Journal of Clinical
Medicine, 11(5), 1183.
• J L Davis et al. (2012) Diagnostic dilemmas in retinitis and
endophthalmitis. The Scientific Journal of The Royal College of
Ophthalmologists; 26(2): 194-201.
• Endogenous Endophthalmitis: Diagnosis and Treatment.
American Academy of Ophthalmology.