Occlusive vasculitis due to hyperacute Streptococcus mitis endophthalmitis after intravitreal ranibizumab

To report a case of hyperacute Streptococcus mitis endophthalmitis after intravitreal ranibizumab resulting in occlusive vasculitis.

Retrospective case report with ultra-wide-field color fundoscopic and fluorescein angiographic imaging.

An 83-year-old woman received an intravitreal injection of ranibizumab to her right eye and was evaluated the next day (less than 24 hours from the injection) because of acute loss of vision. Her vision had decreased from 20/50 to hand motions in the right eye at the time of reevaluation. Wide-field fundus photography demonstrated pallid optic nerve head edema, generalized vascular attenuation, diffuse vascular sheathing, and scattered large postequatorial intraretinal hemorrhages. Ultra-wide-field fluorescein angiography revealed a severely delayed AV transit time associated with extensive areas of retinal nonperfusion and late retinal vascular leakage consistent with occlusive vasculitis. She underwent immediate pars plana vitrectomy with extensive irrigation of the vitreous cavity and intravitreal injection of antibiotics. In light of a worsening clinical course, she was taken for repeat vitrectomy 1 week later with panretinal endolaser photocoagulation, instillation of silicone oil, and sub-Tenon triamcinolone acetonide. At postoperative month 1, she maintained 20/200 vision with improved retinal perfusion on fluorescein angiography.

We describe a hyperacute case of S. mitis endophthalmitis after intravitreal injection with ranibizumab, associated with severe occlusive vasculitis on ultra-wide-field fluorescein angiography. Aggressive early surgical intervention may be associated with better outcomes than previously reported.