CASE REPORTS AND SMALL CASE SERIES Meningococcemia With Vitreous Opacities: Endophthalmitis or Vitreous Hemorrhage? Visual acuity after treatment with me- ningococcal endophthalmitis is vari- able.1,2 A child with meningococce- mia and disseminated intravascular coagulation (DIC) developed vitre- Figure 1. Left, External view of right eye shows periocular and conjunctival ecchymoses and edema ous opacities. Anterior segment in- without hypopyon. Right, Postvitrectomy view of the right fundus periphery shows chorioretinal scarring. flammation was never observed. time, vitreous opacities were be- Report of a Case. A 26-month-old, lieved to be hemorrhagic, second- previously healthy girl became le- ary to DIC, because ocular inflam- thargic with a petechial rash that pro- mation was absent. A second gressed to purpura. Intravenous ce- ultrasound examination 11 days later fotaxime sodium was given for demonstrated bilateral vitreous presumed meningococcemia. Blood opacities and a possible traction reti- cultures yielded Neisseria meningiti- nal detachment in the left eye. dis. Periocular ecchymoses prompted A pars plana vitrectomy, mem- an ophthalmic consultation. brane peel, gas fluid exchange, en- The patient was nonrespon- dolaser, and scleral buckle proce- sive and was receiving mechanical dure were performed in the left eye. ventilatory support during the ex- Extramacular areas of traction reti- amination. No relative afferent pu- nal detachment and necrotic retina Figure 2. A vitrectomy tissue specimen from pillary defect was present. The eye- were observed. The macula showed the left eye shows gram-negative intracellular lids and conjunctiva were edematous no abnormalities. Vitrectomy speci- organisms (arrow) (Gram stain, original and ecchymotic (Figure 1, left). In- men cultures were negative but magnification 3250). traocular pressures and portable slit- Gram stains demonstrated gram- lamp examination showed no ab- negative intracellular organisms with normalities. An undilated fundus vitreous hemorrhage (Figure 2). to a posterior subcapsular cataract. examination (due to the patient’s un- Pockets of neutrophils were ob- Cataract extraction and intraocular stable neurologic status) of the op- served in association with macro- lens placement were performed. Post- tic discs and posterior poles of both phages. Penicillin sodium was given operatively, the patient would not fix eyes showed no abnormalities. intravitreally in the right eye and and follow in the left eye. Amblyopia Multiorgan system failure de- subconjunctivally in both eyes for wasdiagnosedandfull-timeocclusion veloped with respiratory distress possible subclinical endophthalmi- therapy was started. syndrome, thrombocytopenia, DIC, tis. Intravitreal antibiotics were not and acute tubular necrosis requir- administered in the left eye be- Comment. Pain, photophobia, red- ing hemodialysis. Her unstable neu- cause signs of active infection were ness, decreased vision, and vitreal in- rologic status and high-frequency absent and intraocular gas was flammation are usually present with ventilation requirements pre- present. Three weeks later, vitrec- endogenous endophthalmitis. An- vented reliable sequential posterior tomy and scleral buckle were per- terior chamber inflammation, con- segment evaluations. The eyelid formed in the right eye. Intraopera- sidered typical of this condition, was edema and ecchymoses resolved. tive findings were similar to those in never seen in our patient. Four weeks after the initial exami- the left eye. We describe the occurrence of nation, anterior segments were still Postoperative visual acuity with meningococcal intracellular organ- quiet and bilateral dense vitreous correction was 20/40 OD and 20/80 isms associated with vitreous hemor- opacities were seen on dilated fun- OS. Extensive chorioretinal scarring rhages in a patient with meningo- dus examination. Retinochoroidal was seen (Figure 1, right) in the mid coccemia and DIC. The most likely thickening and vitreous cell were peripheral fundus. Subsequently, vi- explanation for the patient’s ocular noted on ultrasonography. At the sualacuitydecreasedinthelefteyedue lesions is subclinical meningoccal en- ARCH OPHTHALMOL / VOL 117, FEB 1999 268 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 dophthalmitis. The intravenous anti- Report of a Case. A 72-year-old biotics the patient received may have Conjunctival Melanoma Japanese man had a large pig- renderedtheorganismsnonviable,and Associated With Extensive mented area around his right eye the ocular findings may have been re- Congenital Conjunctival since birth, including the eyelid and lated to partially treated or subclini- conjunctiva. The black tone be- Nevus and Split Nevus cal endophthalmitis; however, throm- came more intense in the patient’s botic events from DIC could cause a of Eyelid first decade of life and had not similarclinicalfinding.IfDICwerethe changed since then. He first visited explanation,theneutrophil-containing Primary acquired melanosis and our institute on March 15, 1991, organisms may have entered the vit- acquired conjunctival nevi are rec- with his right vision obstructed by reous cavity in association with the ognized to be precursors of con- a black-brown nodule in the infe- hemorrhage. Necrotic areas of retina junctival melanoma; however, it rior bulbar conjunctiva. were likely the result of septic emboli has not been known that congeni- The visual acuity and intra- or vascular occlusion from DIC. tal conjunctival nevi can be a pre- ocular pressure showed no abnor- To avoid amblyopia, bilateral vit- cursor of conjunctival melanoma. malities. The right eyelid, conjunc- rectomies were necessary to clear the We report a case of fatal conjunc- tiva, and caruncle were black, and visualaxes.Thiscaseillustratestheim- tival melanoma in a 72-year-old the inferior aspect of the bulbar portanceofconsideringintraocularin- Japanese man. He was born with a conjunctiva had a black elevated fection in the setting of meningococ- large congenital black mole nodule. Small cystic lesions were cemiaandpresentsalternativehypoth- involving the right upper and present in other areas of the bul- eses to explain the clinical events. lower eyelids and conjunctiva. He bar conjunctiva (Figure 1 and had a brown-black nodule in his Figure 2). The ocular media, fun- Kristie K. Shappell, DVM, MS, MD inferior bulbar conjunctiva and dus, and optic nerve head showed Karen M. Gehrs, MD the right parotid and submandibu- no abnormalities. The right aspect Ronald V. Keech, MD lar lymph nodes showed marked of the parotid and submandibular Thomas C. Cannon, MD swelling. Chemotherapy was per- lymph nodes showed marked Robert Folberg, MD formed to clinically diagnose swelling that was hard and did not Iowa City, Iowa metastatic conjunctival mela- reduce in size despite antibiotic noma, but he died 5 months later therapy. This study was supported in part by due to systemic metastasis. Au- Metastatic malignant mela- an unrestricted grant from Research topsy revealed conjunctival mela- noma of the conjunctiva was clini- to Prevent Blindness Inc, New York, noma associated with extensive cally diagnosed. Several treatment NY (Dr Folberg). conjunctival nevi and split nevus options, including orbital exentera- Reprints: Karen Gehrs, MD, De- of the eyelid. tion, radiation therapy, and chemo- partment of Ophthalmology and Vi- Seventy-five percent of con- therapy, were offered to the patient sual Sciences, University of Iowa Hos- junctival melanomas arise in and the family. They desired che- pitals and Clinics, Iowa City, IA 52242 association with primary acquired motherapy only. The patient’s con- (e-mail: [email protected]). melanosis.1 Histologic evidence of dition deteriorated; he died 5 months 1. Hull SH, Patipa M, Cox F. Metastatic endoph- nevus or a history of a conjunc- later due to systemic metastasis of thalmitis: a complication of meningococcal men- tival lesion dating to childhood malignant melanoma. ingitis. Ann Ophthalmol. 1982;14:29-30. may be discovered in 20% to 30% Autopsy revealed a mass of 2. Brinser JH, Hess JB. Meningococcal endophthal- mitis without meningitis. Can J Ophthalmol. 1981; of patients with conjunctival mel- conjunctival melanoma, composed 16:100-101. anoma.1 of large epithelioid cells, in the Figure 1. A 72-year-old Japanese man with a brown-black nodule in the Figure 2. Small, cystic lesions were present in other areas of the bulbar inferior aspect of the bulbar conjunctiva in the right eye. The eyelids and conjunctiva. bulbar conjunctiva had wide areas of pigmentation. ARCH OPHTHALMOL / VOL 117, FEB 1999 269 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 Figure 3. A gross photographic view of the tumor located in the inferior Figure 4. The tumor nodule is located in the conjunctiva (hematoxylin-eosin, bulbar conjunctiva. original magnification 3100). Figure 5. The tumor is composed of moderately pigmented, markedly Figure 6. The bulbar conjunctiva has extensive compound nevi with cysts pleomorphic, large epithelioid cells (hematoxylin-eosin, original (hematoxylin-eosin, original magnification 3100). magnification 3400). Figure 7. The skin of the eyelid, with foci of intradermal nevus present in the Figure 8. The nevus is composed of moderately pigmented, small round dermis (hematoxylin-eosin, original magnification 3100). cells (hematoxylin-eosin, original magnification 3400).