CASE OF THE MONTH: January 2022

White stuff in the retina

Maxwell Stem, MD; Pennsylvania Retina Specialists, PC


  • HPI: 30 y/o woman s/p failed kidney transplant admitted for spiking a fever during dialysis session
  • Past Ocular History: None
  • Past Medical History: Nephrotic syndrome s/p kidney transplant x 2 (both failed)
  • Multiple prior infections including pseudomonas peritonitis and pneumonia
  • Currently immunosuppressed with tacrolimus and prednisone
  • Current anti-infectious agents include:
  • Active infection: Cefepime, Metronidazole
  • Prophylaxis: Bactrim, Valganciclovir
  • Sent to ICU and treated for sepsis
  • Reason for ophthalmology consultation: "Look for fungal or other manifestations of infection in the eye"
  • Patient has altered mental status but denies ocular complaints


The case:

Differential Diagnosis: "white stuff" in the retina

  • Viral retinitis
    • CMV
    • HSV
    • VZV
  • Fungal
  • Bacterial
  • Ischemia
  • Inflammatory

Assessment and Plan

  • Intravitreal injection of foscarnet OS for presumed CMV retinitis
  • Anterior chamber paracentesis
    • PCR for HSV, VZV, CMV
  • Start IV ganciclovir

Clinical Course

  • Blood negative for CMV
  • Aqueous negative for CMV, HSV, VZV
  • Repeat exam 5 days post foscarnet injection reveals new exudative RD and subretinal hypopyon

New Diagnosis – Aspergillus Retinitis

The case for Aspergillus Retinitis

  • Sputum fungal culture + for Aspergillus
  • Respiratory culture + for Aspergillus
  • Fungitell (β-D-Glucan): 35,120 (off the charts)
  • Blood cultures negative during this hospitalization
  • CT chest and MR brain have lesions consistent with infectious process

  • Intravitreal voriconazole injection OS
  • IV voriconazole

Aspergillus retinitis


  • 2nd most common cause of fungal endophthalmitis after candida
  • Risk factors:
    • IV drug abuse
    • Immune deficiency (organ transplant patients)
    • Corticosteroid use
  • Riddell J et al. Medicine. 2002.

  • Pathogenesis
    • Hematogenous spread of infection to choroid
    • Proliferation of fungus in blood vessels promotes ischemia and necrosis

Rao N et al. Am J Ophthalmol. 2001

Clinical Manifestations

Weishaar PD et al. Ophthalmology. 1998

Making the diagnosis of aspergillus retinitis

  • Blood cultures and aqueous/vitreous cultures often negative for aspergillus
  • Appropriate clinical context
    • Immunosuppressed
    • Aspergillus elsewhere

Bodoia R et al. Retina. 1989


  • No RCTs to guide choice/duration of therapy
  • Systemic therapy with:
    • Amphotericin B or Voriconazole
  • Intravitreal therapy with:
    • Amphotericin B or Voriconazole


  • 8% of patients regained useful vision in one series (endophthalmitis + retinitis)
  • Poor initial vision predicts poor outcome
  • 50% mortality

Riddell J et al. Medicine. 2002.

Clinical Course

  • Most recent repeat exam 12 days post intravitreal voriconazole shows improvement with resolved exudative detachment and smaller area of retinal whitening.
  • Was doing well systemically and transferred from ICU to floor
  • One day after the most recent eye exam, she developed acute mental status change and aphasia

  • Transferred back to ICU
  • Underwent hemicraniectomy with partial clot evacuation
  • Neurologic status worsens with decerebrate posturing
  • Decision made to make her comfort measures and she passes away

Key Points

  • Retinal whitening in an immune compromised patient should raise concern for HSV/VZV/CMV
  • Aspergillus retinitis can look like CMV
  • Talk to Infectious Diseases and review systemic labs/imaging for help making diagnosis


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