 So I think this one's the ugly. So this was a 16-year-old girl who was referred by an outside retina specialist here to the Moran. Seven weeks prior to her presentation here, so when her whole set of issues started, her left eye was red and swollen in her and her parents' words. She had a little bit of pain in that eye and some blurry vision. She saw a local optometrist, they're not from Salt Lake City, who started cyclopenylate and durazole, each of them two to three times a day. Her vision got better and then she stopped cyclopenylate and she stopped the durazole. She restarted them later and it seemed like things were better with the drops than without them. Her parents also were taking her to see a naturopath close to where they live. So she was using colloidal silver drops, which they flat-out said didn't help, but they did use magnets taped to her forehead, which they think were helping things, so they kept those taped there. They went back to the optometrist who thought that the iris was stuck to the lens. It sounded like posterior synechia had formed. So restarted durazole and cyclopenylate. The vision remained blurry but on these drops the eye was a little less red than it was before. A little bit later she developed what she described as a milky spot on the inferior iris and then within a day the entire front of the eye had become milky. So that was when the naturopath prescribed an herb to bring down the inflammation but she ultimately saw this other doctor who actually referred her down here. A little bit of other history, she had a cavity filled four months prior to all this. Her maternal grandmother had a history of rheumatoid arthritis, no other rheumatologic conditions we could elicit in their family. Review of systems was entirely negative other than her actual ocular issues and the fact that the week prior to presentation she had achy shoulders and hands. But that was six weeks after her ocular symptoms started. She was a junior in high school from Idaho, she's traveled throughout the west but not really too many other places. She has chickens, cats and a dog and no history of drug use, sexual activity, anything like that. So she was actually referred to Dr. Crandall here for an iris tumor and we saw her the same day. On examination she was 20-20 in the right eye and light perception in the left eye. Her pressures were 13 and 9. Pupil was 6 in dark and 4 in light and by the time we saw her she had already been dilated so I'm not sure about an APD at that point. Full field in the right eye, can't really even test it in the left eye. And then the right eye was essentially normal on examination. A few pigment changes on the fundus exam but that's about it. So here's a photograph of the left eye on presentation. I'll go through just a couple of these. There obviously won't be fundus photos of the left eye. So I can't see because there's a big light in my face but does anyone in that back corner want to describe what you see? I can see Conrad, sorry, you're sitting in the wrong spot. So just why don't you go on and tell us what you're looking at here. You see it nice. It's hard to say if that's, well, a nice large white lesion whether that's on the end of the ombre or in the haze. What about the iris itself? I know it's a hazy view but you'll see. It's almost a little attached to this lesion but it's hard to say. I mean there's like distortion definitely on the margin of it and then here superiorly you have almost the iris there superiorly and then almost full strands or I can't really tell because it's a little hazy. It is hazy. It's a hard view and it was easier at the slow lamp but there's some neovascularization of the iris there and there's a little blood inferiorly in the interior chamber so she's bleeding a little bit in her interior chamber as well that white thing is inside the interior chamber and it's just a big white mass of what looks like an enormous fibrin plaque. That's what we were calling it. It did not look like an iris tumor to us which is why I think Dr. Crandall asked us to get involved and then obviously she's extremely injected and we didn't really have a view of anything behind what you see in this picture. So what are your all thoughts at this point? Anyone? Where would you go from here? What sort of paths can you take as far as what to do for this girl? Yep, so B-scan is important and would you try to biopsy that or would you try to rule out other systemic infections and let it quiet down in case it's really inflammatory and surgery would make it worse or what are your thoughts there with this sort of a presentation? Do you think it's endothelitis? Okay, yeah. We'll come back to that discussion. I don't know what I just did. Okay, so we were worried that this was just a really fulminant interior chamber inflammatory condition and that surgery would worsen it. So we started with a big lab workup including a chest x-ray among all the labs and started her on Durazol every hour and atropine along with systemic antibiotics to sort of cover ourselves. Azithromycin and Bactrum. And we did send her, she was. We did start Valtrex. She was also sent to Dr. Harry. An ultrasound showed vitritus, this AC collection but no obvious iris mass. There was anything on the iris hiding behind this that may have been seen before. No change over the next week with regards to vision and exam. All the labs came back negative or normal. So she was started on a prednisone taper along with calcium, vitamin D. The acyclovir was started before and the azithromycin and Bactrum were stopped. She came back the next week and she went into no light perception in the left eye. The fibrin plaque was smaller. The iris neovascularization was still present but it had improved. And the B-scan showed a similar vitreous debris. Now a shallow RD, probably cirrus in nature. In fact it was because we saw the retina later. And a thickened retina as well. So now we're really panicking. So we stopped prednisone that day. Diagnostic vitrectomy that day which was very difficult to pull off socially. Her father would not consent to the surgery unless he got the naturopath on the phone and this naturopath told us it was an okay thing to do. So there were a lot of social currents going on that made this treatment difficult in addition to the disease to begin with. So vancomycin, septazidine, voraconazole and foscarnet were all injected. The specimen was sent for multiple PCRs and cultures. And it came back with two plus listeria. Also a PCR for Epstein-Barr virus. So listeria was not what we were expecting. So at that point we got infectious disease involved from primary children. She was admitted for a full work up including lumbar puncture, blood cultures and IV antibiotics. She was continued on the durazole now that she was being treated with antibiotics. The atropine neofoxicin were continued. The acyclovir was stopped. I don't know why this keeps doing that. All of her studies came back negative or normal so we didn't find any evidence of systemic involvement although it came from somewhere. She was ultimately sent home on IV ampicillin, switched to oral bactriom. She got a rash from that so she was changed to levofloxicin and she seemed to do well on that as far as systemically. She remained no light perception in that eye. Her right eye remained unaffected. She developed a shallow AC. She had all these posterior syneca. Her pressure went up to 31 in one visit but she had no pain. And all the visits after that her pressure's been back within a normal range still with no pain. So, Listeria's grand positive rod most commonly found in newborns, the elderly and pregnant women, but it can be found outside of those demographics and when it is, it's usually associated with the ingestion of something that's not prepared properly. Undercooked chicken, hot dogs, things like that. So we went back and asked her once we had her diagnosis and they drink only unpasteurized milk which is also a potential source of this infection. So that's likely where this came from and that wasn't a question that we asked them from the outset because it's not part of what we normally think about. But that's probably the source. Just a couple brief case reports. There's not really a lot out there in the literature on this. There are only case reports. There isn't even a case series of two patients. So this first one was a 58-year-old man with diabetes, came in 2400 and one eye with a high pressure and a fibrinous enter chamber reaction. Started on everything possible to lower his pressure and had an AC tap. The next day he was 2070, still had a high pressure. Started on antivirals and topical Predforte. The next day he had a hypopion and vitreous cell on B-scan so that's the picture of him on day three. He had a tap and inject with vancomycin and septazidine and was started on antibiotic drops as well. The hypopion got larger so he started on prednisone. The culture ultimately grew listeria. So the steroids were stopped. ID got involved. He was given amicase and intravitrally and he was also started on ampicillin. Then this turned into a mass and he was starting to look familiar to our patient. He had an AC washout performed and he actually got back to 2020 and he kept getting these recurrences even though he was on these antibiotics for long periods of time. When they stopped him, all this would come right back so they'd restart him on antibiotics and at the time of publication of this paper they still had him on back room. They were afraid to take him off of it because every time they stopped it, this would come back. He's a bit abnormal in 2020. Almost all of these patients that are read about ended up light perception or no light perception. So this is not a good prognosis with this bacteria. There's another one with a 27-year-old man who had had PRK six months earlier. K-man was diagnosed with conjunctivitis. He started on Tobromycin drops. His vision got worse and then ultimately was hand motion in the right eye still with normal pressures. At this point he had a brown hypopion. That's another thing that's common in these case reports. These patients have these colored hypopions usually described as gray or brown. Ours had a plaque by the time we saw her but I don't know what she looked like before. There was vitreous debris. He had a tap and inject. The culture showed and I could hear our service screaming at this point. Grand positive bacilli, but it was thought to be a contaminant so it was thrown out. The whole course worsened. Had a repeat vitrectomy and this time it grew listeria. Started IV penicillin but ultimately went to no-light perception and developed tyces. In the interest of time, I'll skip the last case report that I have. Essentially the last one I was going to talk about just showed that this is a systemic disease that last patient developed meningitis and got really sick. A nasty bug that didn't have a good outcome for our patient. Back at the first decision branch point when we were worried about inciting worse inflammation and already extremely inflamed eye, vitrectomy was the right way to go so I guess I wish Dr. Huang had been in the room at the time. But what are the thoughts on that in the room? Does anyone have any strong opinions? I can't see who's raising their hand. I was just wondering, what's the source of it? I think it's both. People don't seem to really know but people get all of the above. The common theme in these patients is they develop a horrible anterior chamber reaction that prevents the view to the back. Everybody always ends up getting a B scan that shows inflammation in the back. Sometimes they do have a rectomy and they get a view to the back and the retina looks inflamed and sometimes they just do a tap and inject that's blind so you never see to the back and then the eye goes into tisis. That seems to be the common theme with the exception of that patient who ended up 20-20 on lifelong back trim. So that's a good question. High pressure is a common issue. It wasn't for our patient, at least as far as we know. She might have had a pressure of 50 a few weeks before we saw her and we just didn't know about it.