Sid Mandelbaum

Pseudophakic endophthalmitis: diagnosis and management

Eighty-three cases of endophthalmitis occurring in eyes with intraocular lenses are presented. A problem with the cataract section was felt to contribute to development of the endophthalmitis in 22% of patients. Seventy-five percent of eyes were culture positive with a microbiologic spectrum similar to other reported series without lens implants. Staphylococcus epidermidis was the most common organism accounting for 38% of the isolates. Therapeutic vitrectomy was performed in 46 cases (55%), generally in those eyes with the most severe inflammation. Intraocular lenses were removed in 23 cases (28%), usually to facilitate vitrectomy. Only 1 of 57 eyes with bacterial endophthalmitis could not be sterilized while the intraocular lens was retained. Visual acuity of 20/400 or better was achieved in 63% of culture positive cases, in 78% of eyes infected with S. epidermidis, and in 94% of culture negative eyes.

Ulcerative keratitis associated with contact lens wear.

From October 1982 through June 1986, 658 patients developed ulcerative keratitis. In 196 of these patients it was contact lens-related. Fifty-nine patients wore extended-wear contact lenses for cosmetic purposes. On culture, Pseudomonas species was the organism most frequently isolated from the ulcers associated with contact lens wear. No cases of fungal keratitis were found in the contact lens group as compared to 40 cases (17%) in the noncontact lens group. Compared to results of a similar study covering January 1977 through September 1982, current results showed a larger number of patients using extended-wear lenses for cosmetic reasons (59 vs one) and overall younger age.

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.

Microbial Endophthalmitis Resulting from Ocular Trauma

Twenty-seven cases of culture-positive endophthalmitis that developed after ocular trauma were reviewed. The intraocular culture specimens showed a virulent microbiologic spectrum with Bacillus sp as the most common isolate (8 eyes). The visual prognosis was poor, with only 22% of patients retaining 20/400 or better vision. This level of vision was achieved in 2 of 22 (9%) bacterial cases and in four of five (80%) fungal cases. Retinal detachment (5 cases) or retinal breaks (2 cases) at the time of the initial injury had a uniformly poor visual prognosis. Postoperative retinal detachment not associated with phthisis bulbi occurred in five eyes, three of which had successful retinal reattachment surgery. Delayed onset retinal detachment after successful initial management of traumatic endophthalmitis had a greater frequency of successful retinal reattachment surgery.

Exogenous Fungal Endophthalmitis

The authors report 19 cases of exogenous fungal endophthalmitis managed between 1969 and 1986. These developed after ocular surgery (5 cases), after trauma (6 cases), by intraocular spread from fungal keratitis (4 cases), after therapeutic keratoplasty for keratitis (3 cases), and by spontaneous infection of a filtration bleb (1 case). The diagnosis of endophthalmitis was made from 3 days to 4 months after surgery or trauma. In patients with preexisting keratitis, endophthalmitis was noted 2 weeks to 5 months after the onset of keratitis. Seventeen cases were caused by filamentous fungi; two were caused by yeast. Fusarium (6 cases) and Acremonium (3 cases) accounted for approximately one half of the isolates. Forty-two percent of the patients recovered 20/400 or better acuity (3 of 5 postoperative cases, 4 of 6 trauma cases, and 1 of 4 keratitis cases). The clinical and microbiologic features of these cases are presented, and recommendations for management are offered.

Preliminary report on corneal incisions created by a hydrogen fluoride laser.

We created corneal incisions in eye bank eyes with a pulsed hydrogen fluoride infrared laser. This laser was selected because its emission spectrum (2.7 to 3.0 micron) closely corresponds to the absorption peak of water in the infrared region. Short pulses (200 nsec) of hydrogen fluoride laser light focused with a cylindrical lens resulting in radiant exposures of 1.3 J/cm2 at the corneal surface created linear cuts in the cornea with minimal thermal damage adjacent to the incision, suggesting that the pulsed hydrogen fluoride laser may be useful for corneal surgery.

Effective Treatment of Phlyctenular Keratoconjunctivitis with Oral Tetracycline

PURPOSE To determine the clinical characteristics, possible etiologic agents, and response to oral antibiotic therapy in patients with phlyctenular keratoconjunctivitis. METHODS The authors reviewed the medical records of the 17 patients with phlyctenular keratoconjunctivitis who were seen and treated at the Bascom Palmer Eye Institute between 1981 and 1991. RESULTS All 17 patients were younger than 18 years of age at the onset of their disease. Girls (n = 14) outnumbered boys (n = 3) 4:1. Significant incapacitating symptoms and ocular morbidity occurred frequently, including three perforated corneas. Five of ten patients who were tested for Chlamydia infection had positive test results and five patients possibly had early rosacea dermatitis. All patients experienced long-term remission of their ocular disease after a course of oral tetracycline or erythromycin. Two patients demonstrated unique linear (fascicular) corneal phlyctenules. CONCLUSION Oral tetracycline or erythromycin treatment produces long-lasting remission of phlyctenular keratoconjunctivitis in affected children.

Noncontact trephination of the cornea using a pulsed hydrogen fluoride laser

We used a pulsed hydrogen fluoride infrared laser and a specially designed axicon lens to perform circular corneal trephinations in ten eye bank eyes. This noncontact system focused each laser pulse into an annulus on the cornea. Corneal perforation was achieved in seven to nine seconds at a repetition rate of 10 Hz, using a laser output energy of 100 mJ per pulse. A trephination, 90% of corneal thickness, 6.5 mm in diameter, was produced with 70 pulses.

Potential Bacterial Contamination in Fluorescein-Anesthetic Solutions

To determine the ability of fluorescein-anesthetic combination solutions and their applicators to regain sterility, we contaminated four commercially available fluorescein-anesthetic solutions and their dropper tips with inocula of either Pseudomonas species or Staphylococcus species. No organisms could be cultured from Fluress one minute after inoculation of the solution or five minutes after inoculation of the dropper tip. In contrast, organisms were cultured from the other fluorescein-anesthetic preparations for at least one hour after bacterial inoculation into the solution or onto the dropper tip. These differences in the ability of fluorescein-anesthetic solutions to regain sterility after bacterial contamination were statistically significant.

Granular Epithelial Keratopathy as an Unusual Manifestation of Pseudomonas Keratitis Associated With Extended-Wear Soft Contact Lenses

We describe four patients who, using extended-wear soft contact lenses for myopia, abruptly developed ocular irritation and injection associated with elevated granular opacities initially confined to the central corneal epithelium. Cultures of the granular epithelial lesions were positive for Pseudomonas aeruginosa in all patients. Cultures of the contact lenses and lens case solutions grew Pseudomonas species and other gram-negative organisms. All patients responded to discontinuation of lens wear and frequent topical antibiotics. All recovered baseline visual acuity, and three have successfully resumed contact lens wear. These cases document that Pseudomonas keratitis may be manifested as a granular epithelial keratopathy.