Henry Gelender

Management of Infectious Endophthalmitis

Diagnostic anterior chamber and vitreous aspiration confirmed an infectious etiology in 78 of 140 eyes (56%) with suspected endophthalmitis. In 27 eyes the vitreous aspirate was positive, while the anterior chamber aspirate was negative. Intraocular antibiotics were used in 88 eyes including 50 which underwent therapeutic vitrectomy. Vision of 20/20 to 20/400 was achieved in 57% of recently operated, culture-positive eyes treated with intraocular antibiotics, and in 59% of those treated with combined vitrectomy and intraocular antibiotics.

Late Onset Endophthalmitis Associated with Filtering Blebs

Thirty-six cases of late onset endophthalmitis in patients with filtering blebs are presented. Onset of endophthalmitis ranged from 4 months to 60 years after bleb formation. Possible contributing factors could be identified only in a minority of patients. Aqueous, vitreous or both were cultured in all cases. Eighty-three percent of eyes were culture positive. Streptococci were the most frequent causative organisms, isolated from 57% of culture positive eyes. Twenty-three percent of eyes grew Hemophilus influenzae. Only two cases were caused by staphylococci. In general, the visual outcome was poor, probably primarily due to the virulence of the infecting organisms. Endophthalmitis remains a risk even many years after creation of a filtering bleb. The microbiologic spectrum in this clinical setting is considerably different from that of recent postoperative endophthalmitis. Based on the bacteriology and clinical course of the patients presented, recommendations for management are discussed.

Bacterial Endophthalmitis Resulting from Radial Keratotomy

Staphylococcus epidermis endophthalmitis developed nine days after surgery in a 47-year-old man who underwent a 16-incision radial keratotomy during which the cornea was inadvertently perforated. The anterior chamber showed marked cellular reaction and flare and there was a 5% hypopyon inferiorly. There was also a marked cellular reaction in the vitreous, which contained many fluffy white balls. Visual acuity decreased to counting fingers at 1 foot. A pars plana vitrectomy and intraocularly, periocularly, intravenously, and topically administered antibiotics resulted in recovery of the visual acuity to 6/9 (20/30).

A retrospective review of endophthalmitis due to coagulase-negative staphylococci.

We retrospectively reviewed 28 cases of postoperative endophthalmitis due to coagulase-negative staphylococci. There was an average delay between surgery and the acute presentation of 7 X 2 days (SD 3 X 3). All patients were treated with intraocular antibiotics (IOAB) or therapeutic vitrectomy with IOAB. In six of the 28 cases the organisms were resistant to gentamicin as measured by the Kirby-Bauer technique; none was resistant to cephalosporins. Isolates that had been stored by lyophilisation were reconstituted and tested by serial dilution; none was resistant to gentamicin, though two were borderline. The final visual acuity was 6/18 or better in 72% of the eyes.

Gentamicin-Resistant Pseudomonas aeruginosa Corneal Ulcers*

Six cases are described of Pseudomonas aeruginosa ulcerative keratitis in which antibiotic sensitivity studies demonstrate organism resistance to gentamicin sulfate but sensitivity to other aminoglycosides such as tobra-mycin and amikacin. In four cases, community-acquired infections represent the source of these ulcers. This paper documents the emergence of aminoglycoside resistance among Pseudomonas aeruginosa keratitis within the general community.

Bacterial endophthalmitis following cutting of sutures after cataract surgery.

Bacterial endophthalmitis developed in four patients after cataract surgery sutures were cut. Wound dehiscence was present in three cases, but in one the wound remained intact. Vitreous cultures identified Streptococcus viridans in two cases and Staphylococcus aureus and St. epidermidis in one case each. Antibiotic therapy was administered by intraocular, periocular, topical and systemic routes and three patients underwent vitrectomy. Visual function recovered to 20/50 in two cases and to 20/100 in a third. Retinal detachment in the fourth case resulted in loss of all visual function.

Corneal Endothelial Cell Loss, Cystoid Macular Edema, and Iris-supported intraocular Lenses

Endothelial cell loss, persistent cystoid macular edema and a chronic low-grade uveitis may complicate intracapsular cataract extraction combined with iris supported intraocular lenses. Clinical examination of 19 eyes of 17 patients, at 1.1 to 5 years after cataract surgery, and correlation with wide field specular microscopy and fluorescein angiography, documents this problem. The mean central corneal endothelial cell count was 497 cells/mm2 (standard deviation, 119). In ten cases, focal edema was localized to the corneal periphery. Cystoid macular edema was present in all but one case. Intermittent cornea/implant touch or low-grade intraocular inflammation, possibly from iris/implant contact, may explain the natural history of the endothelial cell loss and cystoid macular edema. Monitoring endothelial cell counts and macular function in patients with iris-supported implants may afford the early recognition of this problem. In such cases, early implant removal may alter the natural history and preserve corneal and macular function.

Corneal ulcer due to Listeria monocytogenes

We present a patient with a corneal ulcer due to Listeria monocytogenes, which has not previously been considered to be a feature of human listeriosis. The ulcer responded to topical and subconjunctival gentamicin and cephaloridine. Subsequent management was complicated by the development of a fibrinous pupillary membrane leading to pupillary block requiring iridotomy and later vitrectomy with trabeculectomy. Listeria monocytogenes may be confused with diphtheroid contaminants seen in corneal ulcer scrapings and is probably underreported as a cause for microbial keratitis.

Persistent Torulopsis magnoliae endophthalmitis following cataract extraction.

Postoperative fungal endophthalmitis typically manifests as an indolent uveitis, weeks to months after surgery. In our patient, Torulopsis magnoliae endophthalmitis appeared as an acute, purulent postoperative endophthalmitis on the third day following extracapsular cataract extraction with implantation of a posterior chamber intraocular lens (IOL). The patient required three separate vitrectomy operations with instillation of intravitreal Amphotericin B; the last operation also included complete removal of the posterior capsule and IOL. This case, which is to our knowledge the first reported case of T. magnoliae endophthalmitis, is unusual in that it manifested as an acute, fulminant infection in the early postoperative period and was recalcitrant to standard endophthalmitis therapy.

Management of corneal astigmatism after cataract surgery

High degrees of surgically induced astigmatism following cataract surgery may limit the desired visual rehabilitation. The induced astigmatism is a reflection of the cataract incision, its closure, and subsequent wound healing. Excessively tight sutures induce central corneal steepening. Wound dehiscence and wound gap cause a flattening of the central cornea along this axis. Wound compression steepens the central curvature. The management of induced astigmatism is directed to the underlying problem. Suture cutting and removal will reduce suture compression of the wound. Repair of wound dehiscence and wound gap will reestablish wound integrity. Incisional keratotomy will compensate the corneal steepening induced by limbal wound compression. The reduction of astigmatism aids visual function by realizing the visual potential of the operated eye.