A 69-year-old woman with mitral valve prolapse presented with 2-day history of fever, painful, red right eye, and decreased vision. Her right conjunctiva was injected, associated with a hypopyon (A, arrowheads). An erythematous, nontender macular lesion found on her left palm (B, arrows) was highly suggestive of a Janeway lesion. A loud pansystolic murmur was audible at the apex. Transesophageal echocardiography revealed vegetation (veg) measuring 10 mm in maximal dimension (C, and Online Video 1) on a myxomatous mitral valve leaflet, associated with severe mitral regurgitation. Three consecutive blood cultures were positive for Staphylococcus aureus.

Endogenous bacterial endophthalmitis is a rare but potentially vision-threatening medical emergency that results from bacterial seeding of the eye, with endocarditis being the most common cause (1). The diagnosis should be considered in a patient with a painful eye or decreased vision in the setting of bacteremia.