Bilateral Branch Occlusive Retinal Vasculitis Induced by Septic Embo-lism in Endogenous Klebsiella Endo-phthalmitis

Dear Editor, Endogenous Klebsiella endophthalmitis (KE) is usually fulminant and associated with high rates of evisceration and enucleation [1]. This report describes the first case of a patient with bilateral hemorrhagic occlusive vasculitis mimicking branch retinal artery occlusion as a complication of nephrogenic KE. A 50-year-old woman with a history of type 2 diabetes mellitus was transferred to Asan Medical Center to manage Klebsiella bacteremia with multiple abscesses in her left kidney. As she reported painless blurred vision, the ophthalmologic service was consulted. Her visual acuity was 20 / 32 in her right eye and 20 / 100 in her left eye. Slit lamp examination revealed moderate inflammations in the anterior chambers, but hypopyon was absent. Obliterative periarteritis surrounded by multiple retinal hemorrhages appeared in the infero-temporal artery of her right eye (Fig. 1A). Localized severe vitritis with hemorrhage was observed in the supero-temporal area and posterior pole in her left eye (Fig. 1B). Aspirated aqueous humor from both eyes was promptly cultured, and ceftazidime (2.25 mg/0.1 mL) and amikacin (0.4 mg/0.1 mL) were intravitreally administered to both eyes. Fluorescein angiography of her right eye showed a sectoral pattern of non-perfused area due to infero-temporal arterial occlusion, as well as a round-shaped hyperfluorescent chorioretinal infiltration at the first bifurcation site of the infero-temporal major vascular arcade (Fig. 1C and 1D). Fluorescein angiography of her left eye showed diffuse vascular staining and blocked fluorescence caused by vitritis. Because visual acuity and vitreal opacity in her left eye had worsened despite antibiotic injection, a vitrectomy was performed (Fig. 1E and 1F). Microbiologic cultures from aqueous and vitreous humor specimens were all negative. Angiography following the vitrectomy revealed supero-temporal non-perfusion involving the macular area in her left eye, along with another hyperfluorescent lesion at the first bifurcation site of the involved vessel, similar to her fellow eye (Fig. 1G and 1H). Her final visual acuity was 20 / 20 in her right eye and 20 / 160 in her left eye, the latter due to macular ischemia. Areas of non-perfusion in both eyes were treated with scatter laser photocoagulation. Korean J Ophthalmol 2017;31(2):175-176 https://doi.org/10.3341/kjo.2017.31.2.175