OCHROCONIS GALLOPAVA ENDOPHTHALMITIS SUCCESSFULLY TREATED WITH INTRAVITREAL VORICONAZOLE AND AMPHOTERICIN B.

PURPOSE: Ochroconis gallopava is a darkly pigmented septated fungus that rarely infects humans, almost universally immunocompromised individuals. Only one previous case has been reported of O. gallopava endophthalmitis, in which the patient progressed to a visual acuity of no light perception. The authors currently describe the first successfully treated case of O. gallopava endophthalmitis. METHODS: A 65-year-old Hispanic woman on chronic immunosuppression after a right lung transplant was admitted to the hospital for O. gallopava respiratory tract infection and was found to have bilateral endogenous endophthalmitis. Examination revealed multiple, cream-colored, chorioretinal lesions in the fundus, including one near the temporal macula in the left eye. There was no diffuse vitritis. Visual acuity was 20/30 in both eyes at presentation but dropped to 20/400 in the right eye and counting fingers at 3 feet in the left eye over the hospital course despite receiving an intravitreal injection of voriconazole in the left eye and concurrent IV amphotericin B, posaconazole, and micafungin. The patient was then treated with multiple simultaneous intravitreal amphotericin B and voriconazole injections bilaterally, as well as IV posaconazole, which was switched to IV voriconazole for improved intraocular penetration. RESULTS: The chorioretinal lesions were noted to regress with treatment. Concomitantly, the patient's respiratory status improved, and she was discharged with a visual acuity of 20/40 in the right eye and 20/60 in the left eye. The patient completed a 1-year course of oral voriconazole as an outpatient without signs of recurrent activity. Seventeen months after the initial presentation, the patient had 20/40 vision bilaterally with a residual, white, fibrotic scar at the temporal macula in the left eye. CONCLUSION: This report describes the first successful treatment regimen against O. gallopava endophthalmitis using a combination of intravitreal amphotericin B and voriconazole injections, as well as IV posaconazole and voriconazole, which resulted in an excellent visual outcome.

Is it melanoma-associated retinopathy or drug toxicity? Bilateral cystoid macular edema posing a diagnostic and therapeutic dilemma.

PURPOSE: To report the clinical presentation, multimodal imaging, and management of a patient with metastatic melanoma who presented with cystoid macular edema (CME). OBSERVATIONS: We report a case of a 71-year-old Caucasian male with metastatic melanoma who presented with bilateral cystoid macular edema after being on treatment with a programmed T cell death ligand 1 inhibitor, MPDL3280, for 1 year. Multimodal imaging techniques, including color fundus photographs, autofluorescence, spectral domain optical coherence tomography (OCT), fluorescein angiography (Spectralis, Heidelberg, Germany), and spectral-domain OCT angiography (Zeiss; California, USA) were performed to evaluate the etiology of his CME and to monitor his response to treatment. Clinical examination and multimodal imaging revealed 1 + chronic vitreous cells, an epiretinal membrane, and mild macular edema in both eyes. Fundus autofluorescence showed paravenous hypoautofluorescence in the right eye and scattered hypoautofluorescent spots in the left eye. Optical coherence tomography angiography (OCTA) revealed mild drop out of superficial vessels in the peri-foveal region bilaterally. These findings were concerning for melanoma-associated retinopathy, drug-related uveitis, or activation of a previous chronic autoimmune process. The patient was started on prednisone 30 mg oral daily and ketorolac tromethamine 0.5% 1 drop four times daily. He was then treated with bilateral sustained-release dexamethasone intravitreal implants (Ozurdex). He had complete resolution of CME, and was tapered off of oral steroids within 6 weeks. CONCLUSIONS AND IMPORTANCE: Melanoma-associated retinopathy can be accompanied by CME, which presents a diagnostic and therapeutic dilemma in cases where a new drug has been recently initiated. By treating the condition locally, the ophthalmologist may be able to taper systemic immunosuppression more quickly.