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Sir,

Age-related macular degeneration (AMD) is the most common cause of choroidal neovascularization (CNV) in individuals over the age of 50 years. We report a case of CNV secondary to septic emboli from prosthetic valve endocarditis.

Case report

A 63-year-old Caucasian male was brought to the hospital in a confused state with fever, lethargy, breathlessness, and abdominal pain. He later developed multiple lesions suggestive of vasculitis or septic embolism. He had an aortic valve prosthesis inserted 10 years ago, for severe aortic regurgitation and atrial fibrillation.

Urinanalysis showed proteinuria and microscopic haematuria. He had raised ESR, CRP, and leucocytes count. Blood cultures were positive for Staphylococcus aureus, which was highly sensitive to vancomycin. A diagnosis of prosthetic valve endocarditis was made.

Intravenous vancomycin was given for 40 days. After 10 days of intravenous vancomycin, he recovered consciousness fully and he noticed distortion of vision (metamorphopsia) in the right eye. He was at this stage referred to ophthalmologist for opinion.

His visual acuity on presentation in the eye clinic was 6/18 in the right eye and 6/5 in the left. The anterior segment in the right eye was unremarkable, while the posterior segment showed a juxta foveal well-demarcated, grey, elevated choroidal neovascular membrane surrounded by subretinal blood (Figure 1a). The left eye was normal. This membrane was successfully treated by argon laser (Figure 1b). Figure 2a and b shows prelaser fundus fluorescein angiography pictures confirming the presence of CNV and postlaser blockage of the membrane after successful laser treatment. He was symptomatically better within 2 weeks. Visual acuity in the right eye at 4 months was 6/5 and was maintained at discharge.

Figure 1
figure 1

(a) Fundus photograph of the right eye showing discrete greyish juxtafoveal lesion surrounded by subretinal haemorrhage and serous detachment of macula (before laser). (b) Scarring at site of CNV with absorbed SRF (after laser).

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Figure 2
figure 2

(a) Fundus angiogram of the same eye showing juxtafoveal classic CNV (before laser). (b) No leakage of fluorescein from CNV (after laser).

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Comment

The proposed theories of septic CNV are a combination of acute suppurative choroiditis and choriocapillaries ischaemia1 producing necrosis of the overlying Bruch's membranes. Factors that increase the risk of metastatic choroidal infection are intravenous drug abuse, cardiac abnormalities, diabetes mellitus, use of immunosuppressive drugs, and malignancy.2, 3 It can be an isolated lesion in the fundus but usually are multiple.

The possible time interval between the embolic events and subsequent CNV is 1–3 weeks.1, 2 The incidence of visual symptoms in patients with endocarditis is 5%.4 The frequency of moderate to severe visual loss in patients who develop CNV following bacterial endocarditis is high. The visual loss could be due to sequelae of CNV itself or due to endophthalmitis, retinal artery occlusion by the septic emboli and iris abscesses. In reported cases,2, 3 due to bacterial endocarditis where only systemic antibiotics were tried, there is evidence that the vision can be stabilized but not significantly improved.

Information regarding systemic illnesses should be sought in all patients with CNV, especially, when there is no evidence of AMD or local ocular pathology in either eye. We report a case of isolated lesion, most likely due to septic prosthetic endocarditis which responded well to systemic antibiotics and laser treatment. The vision improved remarkably well to immediate laser treatment.

The answer to feasibility of immediate laser treatment to the CNV secondary to septic endocarditis needs further research and in large number of case studies.