*5.2.2. Branch retinal arterial occlusion*

**3. Physiopathology**

96 Contemporary Challenges in Endocarditis

**4. Microbiology**

**5.1. Roth dots**

**5. Ocular clinical findings**

**5.2. Retinal arterial occlusion**

*5.2.1. Central retinal arterial occlusion*

(**Figure 1**). It is commonly seen near the optic disk.

loskeletal, 11%; and (F) mesenteric, 3% [1, 2].

Infective endocarditis, especially when associated with prosthetic cardiac valves, carries a very high complication rate. Among the most dreaded complications are perivalvular abscesses, intracardiac fistulae, acute heart failure (typically from acute aortic insufficiency—a very poorly tolerated physiologic condition), complete heart block, septic emboli, and pseudoa‐ neurysms. In fact, embolic events occur in as many as 50% of all patients with infectious endocarditis. Specific organs and/or systems involved, from most to least common, include (A) central nervous system, 65%; (B) spleen, 20%; (C) hepatic, 14%; (D) renal, 14%; (E) muscu‐

*Streptococcus* is seen in over 58% of cases of infectious endocarditis. The most common germs seen in endophthalmitis and chorioretinitis are *Staphylococcus aureus*, *Staphylococcus epidermi‐ dis*, and *Streptococcus viridians*. *S. aureus* can lead to ocular complications in over 56% [3, 4]. Fungal endocarditis affects intravenous drug users and severe immunodeficiency patients

A Roth dot is a cluster of superficial retinal hemorrhages ovally shaped, with pale center

In endocarditis, this cluster represents red blood cells which surround inflammatory cells that have collected in the area in response to a septic embolism from valvular vegetations [1].

Retinal arterial occlusion occurs as a complication of septic or aseptic embolism. Clinical

Patient, if conscious, presents sudden, complete, and painless loss of vision in one eye. Fundoscopy shows pale edema of the retina, particularly in the posterior pole where the nerve fiber and ganglion cell layers are thickest. The orange reflex of the foveola with intact choroidal vasculature contrasts with the surrounding opaque neural retina, producing the cherry red spot. Central retinal arterial occlusion (CRAO) has a poor prognosis. If not treated in the first

manifestations depend on the localization of occlusion. We distinguish the following.

hour, it can lead to permanent loss of vision and other ocular complications [6].

(onco‐hematology) [5]. *Candida* is the most common seen in fungal endocarditis.

Branch retinal arterial occlusion (BRAO) may be clinically asymptomatic. If symptomatic, patient may report a loss of vision or visual field amputation. Fundoscopy shows a pale edema due to infarction of the inner retina in the distribution of the affected vessel. With time, the occluded vessel recanalizes, perfusion returns, and the edema resolves; however, a permanent field defect remains.

#### *5.2.3. Ophthalmic arterial occlusion*

This event is responsible for an interruption of both retinal and posterior ciliary circulations. The visual prognosis, in this entity, is usually worse. If conscious, patient presents pain, sudden and complete loss of vision. Ophthalmic examination revealed no light perception, ophthal‐ moplegia (**Figure 2**), and nonreactive mydriasis. Fundoscopy showed remarkable edema of the entire retina, resulting from inner and outer retinal ischemia and whitened retinal vessels (**Figure 3**). The cherry‐red spot is not noted in this case because of choroidal compromise and probable retinal pigment epithelial or choroidal opacification, or both, in about 40% of eyes. Fluorescein angiography revealed impairment of retinal vascular and choroidal flows (**Figure 4**). A cherry‐red spot may be initially absent, but then appear over a several‐day period as choroid perfusion improves [7].

**Figure 2.** Ophthalmoplegia of the left eye.

**Figure 3.** Fundus photograph showing edema of the entire left retina and whitened retinal vessels without cherry‐red spot.

**Figure 4.** Fluorescein angiography showing late onset of choroidal perfusion and nonopacification of both retinal ar‐ tery and vein.
