title: Occlusive vasculitis due to hyperacute Streptococcus mitis endophthalmitis after intravitreal ranibizumab.
abstract: OBJECTIVE
  To report a case of hyperacute Streptococcus mitis endophthalmitis after intravitreal ranibizumab resulting in occlusive vasculitis.
  
  
  METHODS
  Retrospective case report with ultra-wide-field color fundoscopic and fluorescein angiographic imaging.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: *St John Providence Health System, Joseph H. Wyatt Ophthalmology Residency, Patrick Murray Eye Center, Detroit, Michigan; and †Associated Retinal consultants, William Beaumont Hospital, Royal Oak, Michigan.
authors.forename: Kevin R
authors.initials: KR
authors.lastname: Baxter
authors.forename: Joshua E
authors.initials: JE
authors.lastname: Robinson
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Ruby
mesh_terms: D000369:Aged, 80 and over; D020533:Angiogenesis Inhibitors / Q000009:adverse effects*; D009877:Endophthalmitis / Q000382:microbiology*; D005260:Female; D006801:Humans; D058449:Intravitreal Injections / Q000009:adverse effects*; D000069579:Ranibizumab / Q000009:adverse effects*; D012166:Retinal Hemorrhage / Q000209:etiology; D031300:Retinal Vasculitis / Q000209:etiology*; D012189:Retrospective Studies; D013290:Streptococcal Infections; D034361:Streptococcus mitis
chemical_list: D020533:Angiogenesis Inhibitors; D000069579:Ranibizumab