A 79-year-old woman presented complaining of decreased vision with floaters in the left eye for 2 weeks. Past medical history was significant for giant cell arteritis treated with 40 mg/day oral prednisone for 3 months.
Visual acuity (VA) was 20/25 in the right eye and 6/200 in the left eye. Slit-lamp examination of the right eye was unremarkable. Examination of the left eye revealed severe inflammation with fibrin in the anterior chamber, poorly dilated pupil, and early rubeosis (Fig. 1a). As there was no view of the posterior segment in the left eye, B-scan ultrasonography was performed, which showed vitreous opacities and partial retinal detachment with subretinal fluid (Fig. 1b).
The patient was started on intravenous broad-spectrum antibiotics and underwent diagnostic vitrectomy followed by intravitreal injections of vancomycin, ceftazidime, foscarnet, and amphotericin. When vitreous cultures grew Nocardia farcinica, the patient was admitted for further workup. During this admission, the patient remained afebrile and asymptomatic with a normal white blood cell count and negative blood cultures. Further diagnostic workup, including a CT of the chest and an MRI of the brain, did not reveal any lesions suggestive of any systemic source of infection. As such, after receiving a dose of intravitreal amikacin, the patient was discharged on oral trimethoprim-sulfamethoxazole (TMP-SMX) and advised to follow-up in clinic.
The patient later returned to the operating room to repair the retinal detachment. Intra-operatively, the patient was noted to have a tractional retinal detachment involving the macula that spanned from the 4–8 o’clock position. A fibrous, inflammatory subretinal mass was removed inferiorly just beyond the inferotemporal arcade and sent for pathology, which revealed numerous organisms morphologically consistent with Nocardia on silver stain (Fig. 2). Examination 1 week postoperatively revealed an attached retina with no additional foci of infection. Since then, the patient has remained stable with VA in the left eye of E card at 4 ft at her last visit. TMP-SMX was discontinued at that time as 6 months of treatment had been completed.