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Chung, Yoon, and Kim: Multiple Subretinal and Intraretinal Hemorrhages as a First Sign of Infective Endocarditis
Case Report

Journal of the Korean Ophthalmological Society 2017; 58(12): 1416-1419.

Published online: 14 December 2017

DOI: https://doi.org/10.3341/jkos.2017.58.12.1416

Multiple Subretinal and Intraretinal Hemorrhages as a First Sign of Infective Endocarditis

Gyu Chul Chung, MD1, 2, Chang Ki Yoon, MD1, 2, Hyun Woong Kim, MD, PhD3

1Department of Ophthalmology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea.

2T2B Infrastructure Center for Ocular Disease, Inje University Busan Paik Hospital, Busan, Korea.

3Department of Ophthalmology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.

Address reprint requests to Hyun Woong Kim, MD, PhD. Department of Ophthalmology, Inje University Haeundae Paik Hospital, #875 Haeun-daero, Haeundae-gu, Busan 48108, Korea. Tel: 82-51-797-0119, Fax: 82-51-797-0298, maekbak@hanmail.net

Received 20 July 2017       Revised 22 September 2017       Accepted 20 November 2017

©2017 The Korean Ophthalmological Society

The Korean Ophthalmological Society

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To report a patient with multiple subretinal and intraretinal hemorrhages in the absence of retinal/choroidal lesions, diagnosed with infective endocarditis (IE).

Case summary

We describe the case of a 44-year-old male with an acute decrease of vision in his right eye. Ophthalmic evaluation revealed multiple subretinal and intraretinal hemorrhages, but no choroidal or other retinal lesions. A systemic examination revealed a pansystolic murmur and blood cultures with echocardiography were suggestive of IE.

Conclusions

Thorough systemic evaluations are important when patients present with subretinal and intraretinal hemorrhages in the absence of other retinal/choroidal lesions.

Keywords: Infective endocarditis, Retinal hemorrhage, Roth spot

Figures and Tables

Figure 1

Fundus photograph and Optical coherence tomography images at the fist visit. (A) Fundus photograph of the right eye at the time of presentation. Multiple subretinal and intraretinal hemorrhages in the juxtafoveal area are apparent. Optical coherence tomography (OCT) images and red-free photographs of the right eye obtained at the time of presentation. Subretinal and intraretinal hemorrhages observed on OCT images corresponded with those on red-free photographs. (B) One line scan shows that the external limiting membrane (ELM) is intact, even though a hyper-reflective lesion is present between the ellipsoid zone and the retinal pigment epithelium layer. (C) A different line scan shows a disrupted ELM and hyper-reflective lesions that extend from the ganglion cell layer to the ellipsoid zone. The light blue line on the fundus shows the position at which the shown OCT line scan was obtained.

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Figure 2

Fluorescein angiography (FA) and indocyanine green angiography (ICGA) images. (A, B) These images are arterial phase of FA and ICGA. (C-F) Both focal and round-shaped, juxtafoveal, hypofluorescent lesions are visible in venous phase and late phase. Hypofluroescent lesions indicate choroidal fluorescence blockage.

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Figure 3

Transesophageal echocardiography showed multiple vegetations on the mitral valve (★). Accessory mitral valve leaflet prolapse (medial and middle portions) with severe eccentric mitral valve regurgitation (☆) was also apparent.

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Figure 4

Ocular imaging obtained 1 month after the medical treatment. (A) The red-free photograph of the right eye shows a substantial decrease in hemorrhage size. (B) Optical coherence tomography (OCT) images showed only minor residual defects in the submacular ellipsoid and interdigitation zones. The light blue line on the fundus en face image shows the position at which the OCT line scan was obtained.

jkos-58-1416-g004

Notes

Conflicts of Interest The authors have no conflicts to disclose.

References

1. Hochman MA, Seery CM, Zarbin MA. Pathophysiology and management of subretinal hemorrhage. Surv Ophthalmol. 1997; 42:195–213.
2. Silverman ME, Upshaw CB. Extracardiac manifestations of infective endocarditis andtheir historical descriptions. Am J Cardiol. 2007; 100:1802–1807.
3. Walpot J, Klazen C, Blok W, van Zwienen J. Embolic events in infective endocarditis: a review and report of 4 cases. Acta Clin Belg. 2005; 60:139–145.
4. Sandhya V, Shafquat S. Choroidal neovascularization (CNV) secondary to septic emboli from endocarditis: a case report. Eye (Lond). 2005; 19:822–823.
5. Ling R, James B. White-centred retinal haemorrhages (Roth spots). Postgrad Med J. 1998; 74:581–582.
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