An 83-year-old monocular male presented with complaints of new floaters in his right eye. His visual acuity was counting fingers, intraocular pressure was 8 mmHg with 3+ cells in his anterior chamber, and a dense vitritis. Ultrasound confirmed vitritis with an attached retina. The patient was seen by a referring ophthalmologist the day before with similar complaints of floaters with visual acuity of 20/40 due to nuclear sclerosis.\nThe patient had been no light perception in his left eye for over a year due to endogeneous endophthalmitis from a fungal lung lesion. At that time, both vitreous and lung biopsies grew out S. apiospermum. Other than diabetes, a thorough infectious disease work-up revealed no other immunocompromising risk factors. The lung lesions were unchanged after a course of treatment, and the patient’s family did not want further work-up such as a re-biopsy due to the patient’s age. The patient was prescribed a maintenance dose of voriconazole 200 mg PO QD, but he was noncompliant and stopped taking his medicine.\nAt the time of presentation to our clinic, the patient had symptoms in his right eye for less than 24 h. An intravitreal biopsy was performed in conjunction with intravitreal voriconazole (100 μg/0.1 ml). Vitreous biopsy at this time grew out S. aspiospermum. The patient was also started on intravenous voriconazole. After 48 h with no improvement, the patient was brought to the operating room for a 23-gauge pars plana vitrectomy and repeat intravitreal voriconazole (100 μg/0.1 ml) injection. There were no intraretinal lesions seen at the time of surgery, although the view was hazy. The patient did not receive any intravitreal or oral steroids. His inflammation subsided slowly over the course of 3 weeks with moxifloxacin and prednisolone acetate eye drops. One month after presentation, his visual acuity returned to 20/40.
An 80-year-old male with diabetes mellitus, mild diabetic retinopathy, and mild dementia underwent reported uncomplicated, bilateral FESS for chronic sinusitis with polyposis at an outside hospital. He was provided an outpatient prescription for amoxicillin-clavulanic acid upon outpatient surgical discharge. Initial pathology specimen within the immediate postoperative period from the outside hospital was reported as non-invasive Aspergillus. He was seen by his original surgeon at the outside facility on postoperative day 3 without visual complaints or unexpected facial pain. On postoperative day 4, the patient reported sudden right-sided vision loss and presented to the walk-in ophthalmology clinic at the primary author’s tertiary care facility. An ophthalmology exam found no perception of light on the right and an abducens nerve palsy. Pupils were equal and reactive to light bilaterally with no pallor of the optic disc and normal ocular pressures. He was sent immediately to the emergency department for imaging, whereupon the otolaryngology team evaluated the patient. Intranasal exam by otolaryngology was only notable for moderate edema of the nasal mucosa without necrosis or pallor. There was no decreased sensation of the palate or midface. Computed tomography was performed and notable for violation of the lamina papyracea (Figure ). Preoperative imaging from the outside facility was not available for comparison. Magnetic resonance imaging suggested acute ischemic findings of the right optic nerve with diffusion restriction at the proximal optic nerve without evidence of thrombosis or hemorrhage. Subsequent imaging after admission noted an abnormal T2 signal without canalicular segment enhancement. There was, however, some adjacent enhancement extending to involve the optic and nerve sheaths in the orbital apex and superior orbital fissure. The enhancement of the right-sided nerve sheaths was thought to be contributing both to the vision loss and the abducens nerve palsy that was defining the OAS. In addition to those mentioned, the neurosurgery, neurology, and internal medicine teams evaluated the patient. It should be noted that repeated images were obtained at several time points due to poor images from motion artifact that did delay care. The clinical and radiologic findings were determined by the treating teams to be most suggestive of the surgical trauma from the FESS at the outside facility and not of an infectious origin. A non-surgical approach was initially pursued. The patient was provided broad-spectrum antibiotics and high-dose steroids to decrease inflammation with close neurologic monitoring. Re-evaluation by otolaryngology on flexible nasal endoscopy did not show any change in findings of the nasal mucosa.\nOn postoperative day 9 from the original FESS, the patient developed sudden vision loss of the left eye. An ophthalmology exam noted no light perception bilaterally, worsening ophthalmoplegia on the right with decreased supraduction, adduction, and infraduction in addition to the complete abducens palsy. These findings suggested now the involvement of the oculomotor and trochlear nerves. The posterior ocular exam now showed mild optic nerve pallor on the right with good color on the left and no evidence of edema. Repeat computed tomography and magnetic resonance imaging noted no new bony destruction; however, there was persistent inflammation of the right optic canal. An emergent multidisciplinary team meeting was held between all consulting specialties and infectious disease was also consulted as the initial diagnosis of traumatic neuropathy was questioned. The patient then underwent emergent FESS with otolaryngology and neurosurgery with decompression of both optic nerves, sphenoidotomy, septectomy, and mucosal stripping (Figure ). The lamina papyracea and bone adjacent to the root of the right orbital apex were dehiscent as had been suggested on imaging (Figure ). Additionally, there was a large amount of absorbable packing in the posterior ethmoid cavity on the right.\nA final culture from the initial FESS at the outside hospital was re-evaluated by the infectious disease team, which revised the diagnosis of Aspergillus to that of S. apiospermum. This pathologic diagnosis was made on postoperative day 10 (postoperative day 1 from emergent FESS). The patient was started on high-dose voriconazole and amphotericin B. The patient continued on maximum medical therapy and continued to worsen clinically and radiologically regarding the infection. Unfortunately, after prolonged hospitalization, he suffered a myocardial infarction and subsequent severe gastrointestinal bleeding. He passed away on postoperative day 47 from the initial FESS after being transferred to inpatient hospice services.