A multicenter study of Pneumocystis choroidopathy

Oculosystemic pneumocystosis in 2 sibling Chihuahuas

Sibling female and male Chihuahuas were evaluated for a 9-month history of tachypnea that failed to respond to fenbendazole, doxycycline, amoxicillin-clavulanate, and prednisone. Physical examination identified tachypnea, hyperpnea, and harsh bronchovesicular lung sounds. Fundic examination disclosed diffuse chorioretinitis, manifested as multifocal chorioretinal granulomas in the female dog and occasional chorioretinal scars in the male dog. Thoracic radiographs indicated moderate to severe interstitial to broncho-interstitial infiltrates in both dogs. Serum and urine antigen and antibody testing in the female dog failed to identify infectious agents, but cytologic assessment of hepatic lymph node, liver, and splenic aspirates identified Pneumocystis trophozoites. Infection was confirmed in both dogs by 28S rRNA PCR sequencing from multiple tissue samples. The female dog responded well to trimethoprim-sulfamethoxazole, but the male dog was euthanized because of liver failure, presumably related to antimicrobial treatment.

Choroiditis in a HIV-infected patient with disseminated cryptococcal infection: A case report and literature review

BACKGROUND

Ocular involvement in AIDS patients is a common event mainly caused by inflammation or infection. Despite the high prevalence rate of cryptococcosis in these individuals, ocular features have been occasionally described.

CASE REPORT

A 20-year-old Brazilian female with HIV infection recently diagnosed was admitted with a respiratory profile presumptively diagnosed as Pneumocystis jirovecii pneumonia; an ophthalmologic exam suggested choroiditis by this agent as well. She was complaining of headaches and blurred vision which led to cryptococcal meningitis diagnosis by a CSF positive India ink stain and Cryptococcus neoformans positive culture. Despite therapy based on amphotericin B plus fluconazole, her clinical state progressively worsened and the patient died one week later. At necropsy, disseminated cryptococcal infection was evidenced in several organs including eyes, which presented bilateral chorioretinitis.

CONCLUSIONS

Cryptococcal ocular involvement in AIDS patients has been occasionally proved among the cases already reported. Thus, the post mortem exam is still pivotal to improve the quality of the clinical diagnosis, especially in limited-resource settings.

Ciprofloxacin Ophthalmic Solution in the Treatment of Conjunctivitis and Blepharitis: A Comparison with Fusidic Acid

The efficacy and safety of ciprofloxacin ophthalmic solution (0.3%) and fusidic acid gel (1%) were compared in the treatment of bacterial conjunctivitis and blepharitis in a randomized, open, parallel group study. Thirty-nine patients, 21 treated with ciprofloxacin solution and 18 treated with fusidic acid gel, were culture-positive on admission and were evaluable for efficacy. At the end of a 7-day treatment, the infecting organism was eradicated in 81% of those treated with ciprofloxacin and 72% of those treated with fusidic acid gel. There was clinical cure or improvement in 95% and 89% respectively. The clinical cure rate appeared to be higher with ciprofloxacin than fusidic acid (62% compared with 28%) but this was related to the higher proportion of patients with acute conjunctivitis in the ciprofloxacin group. Two patients using ciprofloxacin had mild discomfort and stinging on instillation and one given fusidic acid had moderate edema and discomfort; the latter patient stopped treatment. Topical ciprofloxacin is effective and well tolerated and is a useful treatment of bacterial conjunctivitis and blepharitis.

The Penetration of Ofloxacin into Human Aqueous Humor Given by Various Routes

This study was designed to measure the concentration of ofloxacin in aqueous humor after topical, oral and intravenous administration in 50 patients undergoing cataract extraction. In Group 1, ofloxacin 0.3% eyedrops were topically instilled ten times and the aqueous humor concentration was 2.73 ± 0.88 μg/ml. In Group 2, ofloxacin 0.3% eyedrops were topically instilled six times and the aqueous humor concentration was 0.84 ± 0.61 μg/ml. Aqueous humor concentration 12 hours after 200 mg oral dose in Group 3, was 0.38 ± 0.12 μg/ml. In Group 4, patients were given ofloxacin as a single intravenous 200 mg dose and the aqueous humor concentration 2 hours after the end of infusion was 0.45 ± 0.11 μg/ml. Concentrations were determined by high performance liquid chromatography (HPLC) with fluorescence detection.

There was a significant difference between Group 1 and the other groups, but not between Group 2 and Groups 3, 4.

It was concluded that ofloxacin penetrates the corneal and the blood-aqueous barriers and can achieve good aqueous levels when given topically and systematically. Ofloxacin can be applied topically for external bacterial infections such as conjunctivitis and keratitis. Systematically administered ofloxacin reached higher levels than the MIC for some bacteria which cause endophthalmitis.

Ciprofloxacin Ophthalmic Solution versus Rifamycin Ophthalmic Solution for the Treatment of Conjunctivitis and Blepharitis

The efficacy and safety of ciprofloxacin (0.3%) ophthalmic solution and rifamycin (1%) ophthalmic solution for the treatment of bacterial conjunctivitis and blepharitis was compared in this randomized, double-masked, parallel-group study. Forty-one patients, 19 on ciprofloxacin and 22 on rifamycin, were culture-positive on admission and evaluated for efficacy. There was clinical improvement in more than 90% of patients in each group at the end of the seven-day treatment period. However, clinical cure rates on day 7 appeared to be higher with ciprofloxacin (53%) than rifamycin (23%; p = 0.061, Mann-Whitney test). Bacteriological eradication rates were comparable: the infecting organisms were eradicated in 68% of patients on ciprofloxacin and 77% with rifamycin. There were no serious adverse reactions to either treatment. One patient in each group was withdrawn on account of a mild allergy. In conclusion, topical ciprofloxacin was effective and well tolerated and would be a particularly useful agent for the treatment of bacterial conjunctivitis and blepharitis.

Comparative Evaluation of Efficacy and Safety of Ciprofloxacin and Norfloxacin Ophthalmic Solutions

The efficacy and safety of ciprofloxacin ophthalmic solution 0.3% and norfloxacin ophthalmic solution 0.3% in the treatment of bacterial conjunctivitis and blepharitis were compared in a double masked randomised study. A total of 131 patients, 65 treated with ciprofloxacin (42 with conjunctivitis and 23 with blepharitis) and 66 treated with norfloxacin (39 with conjunctivitis and 27 with blepharitis) were enrolled in the study at five centres in France. In the efficacy population, pathogens were eradicated or reduced in 96% (24/25) of patients in the ciprofloxacin group and 89% (24/27) in the norfloxacin group. There was no difference between treatments with regard to eradication of particular pathogens. In the efficacy population, clinical cure or improvement was seen in 96% of the patients (24/25 in the ciprofloxacin group and 26/27 in the norfloxacin group). There were no significant differences between ciprofloxacin and norfloxacin with respect to improvements in four symptoms or ten clinical signs. No serious treatment-related adverse events were reported and both ciprofloxacin and norfloxacin were well tolerated.

NOCARDIA CHOROIDAL ABSCESS: Risk Factors, Treatment Strategies, and Visual Outcomes

PURPOSE

To describe the risk factors, clinical course, ancillary test findings, treatment strategies, and visual outcomes of a series of patients with choroidal abscesses caused by endogenous Nocardia.

METHODS

This retrospective, consecutive noncomparative case series included all patients with Nocardia ocular infections at 3 tertiary medical centers over the past 20 years.

RESULTS

Five eyes in 5 patients were identified with choroidal abscesses because of Nocardia. All patients were immunocompromised: one suffered from AIDS and four had autoimmune disorders. Three of the 5 patients (60%) underwent systemic evaluation, and in all 3, nonocular nocardiosis was identified. Four patients (80%) underwent diagnostic ophthalmic surgery and received systemic and intravitreal antibiotics. The final patient deferred these interventions. Outcomes at the last follow-up examination were 20/25, 1/200, hand motion at 1 foot, and 2 patients underwent enucleation. Mean follow-up (± standard deviation) was 159 (± 103) days.

CONCLUSION

Immunosuppression is the most significant risk factor for developing Nocardia choroidal abscesses. Definitive diagnosis generally requires subretinal biopsy, which is also critical to implementing appropriate antibiotic therapy.

Etiological agents of fungal endophthalmitis: diagnosis and management

Endophthalmitis caused by fungi is commonly diagnosed around the world in apparently healthy and immunocompromised individuals. An accurate clinical diagnosis for endophthalmitis confirmed by laboratory techniques is essential for early treatment with antifungal drugs, such as amphotericin B, imidazoles, and other antifungals. Here, we review endophthalmitis caused by fungi according to its classification into endogenous fungal endophthalmitis (EFE) and exogenous fungal endophthalmitis (EXFE). EFE is caused by endogenously acquired fungi, whereas the traumatic implantation of opportunistic fungal pathogens is the main feature of EXFE. We highlight the most important etiologies causing endophthalmitis and the steps required for a rapid diagnosis and management.

Paediatric bacterial keratitis cases in Shanghai: microbiological profile, antibiotic susceptibility and visual outcomes

PURPOSE

The purpose of this study was to review the microbiological profile, in vitro antibiotic susceptibility and visual outcomes of paediatric microbial keratitis in Shanghai, China over the past 6 years.

METHODS

Medical records of patients aged ≤16 years were reviewed, who were diagnosed as having bacterial keratitis between 1 January 2005 and 31 December 2010. Bacterial culture results and in vitro antibiotic susceptibility were analysed. A logistic regression analysis was conducted to evaluate the relationship between visual impairment and possible risk factors.

RESULTS

Eighty consecutive cases of paediatric bacterial keratitis cases were included, among which 59 were identified as having positive culture. Staphylococcus epidermidis was the most commonly isolated organism (n=23; 39.0%), followed by Streptococcus pneumoniae (n=11; 18.6%) and Pseudomonas aeruginosa (n=6; 10.2%). Antibiotic sensitivities revealed that tested bacteria had low resistance rates to fluoroquinolones and aminoglycosides (8.3-18.4% and 12.5-24.4%, respectively). Multivariate logistic regression analysis proved that visual impairment was significantly associated with Gram-negative bacterial infection (odds ratio (OR)=7.626; P=0.043) and an increasing number of resistant antibiotics (OR=0.385; P=0.040).

CONCLUSIONS

S. epidermidis was the most common isolated organism in Shanghai paediatric keratitis. The fluoroquinolones and aminoglycosides remained good choices for treating these patients. Gram-negative bacterial infection and an increasing number of resistant antibiotics were associated with worse visual prognoses in paediatric keratitis.

In vitro susceptibility of bacterial keratitis isolates to fourth-generation fluoroquinolones

PURPOSE

To study the microbiological profile of bacterial keratitis in Northern India and to determine the antibiotic sensitivity pattern of bacterial keratitis isolates to fourth-generation fluoroquinolones.

METHODS

Laboratory records of all consecutive cases of clinically suspected bacterial corneal ulcers were retrospectively reviewed. Data noted included microorganism isolated and antibiotic culture sensitivity to cefazolin, tobramycin, gatifloxacin, and moxifloxacin. In vitro susceptibility toward individual antibiotics was determined and compared with the potential in vitro susceptibilities to cefazolin-tobramycin, cefazolin-gatifloxacin, and cefazolin-moxifloxacin combinations.

RESULTS

A total of 292 bacterial isolates were identified. Of these, 255 (87.3%) were Gram-positive and 37 (12.7%) were Gram-negative. Staphylococcus epidermidis (n=227, 77.7%) was the most common organism. Overall susceptibility of isolates was 95.52% to gatifloxacin, 92.83% to moxifloxacin, 90.07% to tobramycin, and 83.56% to cefazolin (p<0.000). Organisms which showed resistance to fourth-generation fluoroquinolones included Staphylococcus epidermidis, Pseudomonas aeruginosa, viridans streptococci, Streptococcus pneumoniae, Staphylococcus aureus, and Escherichia coli. Susceptibilities to gatifloxacin and moxifloxacin were comparable with each other (p=0.312) and with potential susceptibilities to cefazolin-tobramycin (p=0.479), gatifloxacin-cefazolin (p=0.134), and moxifloxacin-cefazolin (p=0.412) combinations.

CONCLUSIONS

Monotherapy with moxifloxacin or gatifloxacin can be an effective alternative to cefazolin-tobramycin combination as a first-line empirical therapy for bacterial keratitis. The addition of cefazolin to a fourth-generation fluoroquinolone is of limited value.

Posterior segment manifestations of human immunodeficiency virus/acquired immune deficiency syndrome

Ocular manifestations can occur in up to 50% of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) patients and posterior segment involvement is the most common presentation. The posterior segment manifestations of AIDS can be divided into four categories: retinal vasculopathy, opportunistic infections, unusual malignancies and neuro-ophthalmologic abnormalities. Retinal microvasculopathy and cytomegalovirus (CMV) retinitis are the most common manifestations, even in the era of highly active anti-retroviral therapy (HAART). Highly active anti-retroviral therapy has been shown to cause regression of CMV retinitis, reduce the incidence of CMV-related retinal detachments, and prolong patient survival. Immune recovery uveitis is a new cause of vision loss in patients on HAART. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.

Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease

The eye is a common site for complications of human immunodeficiency virus (HIV) infection. Although cytomegalovirus retinitis remains the most prevalent of the blinding ocular disorders that can occur in individuals with the acquired immunodeficiency syndrome (AIDS), several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae. Some of these entities, such as Kaposi sarcoma, were well described, but uncommon, before the HIV epidemic. Others, like microsporidial keratoconjunctivitis, have presentations that differ between affected individuals with HIV disease and those from the general population who are immunocompetent. The treatment of many of these diseases is challenging because of host immunodeficiency. Survival after the diagnosis of AIDS has increased among individuals with HIV disease because of more effective antiretroviral therapies and improved prophylaxis against, and treatment of, opportunistic infections. This longer survival may lead to an increased prevalence of anterior segment and external ocular disorders. In addition, the evaluation and management of disorders such as blepharitis and dry eye, which were previously overshadowed by more severe, blinding disorders, may demand increased attention, as the general health of this population improves. Not all individuals infected with HIV receive potent antiretroviral therapy, however, because of socioeconomic or other factors, and others will be intolerant of these drugs or experience drug failure. Ophthalmologists must, therefore, still be aware of the ocular findings that develop in the setting of severe immunosuppression. This article reviews the spectrum of HIV-associated anterior segment and external ocular disorders, with recommendations for their evaluation and management.

Absorption of Topical Moxifloxacin Ophthalmic Solution Into Human Aqueous Humor

PURPOSE

To investigate the absorption of moxifloxacin into human aqueous humor after administration of moxifloxacin hydrochloride ophthalmic solution, 0.5% as base.

METHODS

Cataract patients were randomly allocated to receive 1 drop every 15 minutes for 4 doses before surgery (group 1) or 1 drop 4 times per day on the day before surgery plus the same preoperative regimen as group 1 (group 2). The last dose was administered 0.25, 0.50, 1, 2, or 3 hours before aqueous humor sampling. Samples from 30 patients per group were analyzed by a validated HPLC/MS/MS method.

RESULTS

For group 1, the mean +/- SD C(max) was 1.50 +/- 0.75 microg/mL and occurred at 0.5 hour after dosing. The mean C(max) for group 2 was 1.74 +/- 0.66 microg/mL and was reached at 1 to 2 hours. Mean AUC(0-3h) for groups 1 and 2 were 3.16 +/- 0.29 and 4.41 +/- 0.48 microg.h/mL, respectively. The difference in AUC(0-3h) was statistically significant (P = 0.04), but the difference in Cmax was not.

CONCLUSIONS

Topical moxifloxacin was well absorbed. Maximum moxifloxacin concentrations were approximately 30 times higher than the median MICs for common pathogens in bacterial endophthalmitis, indicating that either regimen may provide sufficient concentrations to prevent postoperative endophthalmitis.

HIV-associated retinopathy in the HAART era

BACKGROUND

The effectiveness of highly active antiretroviral therapy (HAART) in restoring immune function in patients with acquired immunodeficiency syndrome (AIDS) has led to changes in the incidence, natural history, management, and sequelae of human immunodeficiency virus (HIV)-associated retinopathies, especially cytomegalovirus (CMV) retinitis.

METHODS

The medical literature pertaining to HIV-associated retinopathies was reviewed with special attention to the differences in incidence, management strategies, and complications of these conditions in the eras both before and after the widespread use of HAART.

RESULTS

In the pre-HAART era, CMV retinitis was the most common HIV-associated retinopathy, occurring in 20%-40% of patients. Median time to progression was 47 to 104 days, mean survival after diagnosis was 6 to 10 months, and indefinite intravenous maintenance therapy was mandatory. Retinal detachment occurred in 24%-50% of patients annually. Herpetic retinopathy and toxoplasmosis retinochoroiditis occurred in 1%-3% of patients and Pneumocystis carinii choroiditis, syphilitic retinitis, tuberculous choroiditis, cryptococcal choroiditis, and intraocular lymphoma occurred infrequently. In the HAART era the incidence of CMV retinitis has declined 80% and survival after diagnosis has increased to over 1 year. Immune recovery in patients on HAART has allowed safe discontinuation of maintenance therapy in patients with regressed CMV retinitis and other HIV-associated retinopathies. Immune recovery uveitis (IRU) is a HAART dependent inflammatory response that may occur in up to 63% of patients with regressed CMV retinitis and elevated CD4 counts and is associated with vision loss from epiretinal membrane, cataract, and cystoid macular edema.

CONCLUSIONS

The incidence, visual morbidity, and mortality of CMV retinitis and other HIV-associated retinopathies have decreased in the era of HAART and lifelong maintenance therapy may safely be discontinued in patients with restored immune function. Patients with regressed CMV retinitis, however, may still lose vision from epiretinal membrane, cystoid macular edema, and cataract secondary to IRU.

Posterior segment manifestations of HIV/AIDS

The ocular posterior segment manifestations of AIDS may be divided into four categories: retinal vasculopathy, unusual malignancies, neuro-ophthalmologic abnormalities, and opportunistic infections. Microvasculopathy is the most common manifestation. Opportunistic infections, particularly cytomegalovirus retinitis and progressive outer retinal necrosis, are the most likely to result in visual loss due to infection or subsequent retinal detachment. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.

Current perspectives on ophthalmic mycoses

Fungi may infect the cornea, orbit and other ocular structures. Species of Fusarium, Aspergillus, Candida, dematiaceous fungi, and Scedosporium predominate. Diagnosis is aided by recognition of typical clinical features and by direct microscopic detection of fungi in scrapes, biopsy specimens, and other samples. Culture confirms the diagnosis. Histopathological, immunohistochemical, or DNA-based tests may also be needed. Pathogenesis involves agent (invasiveness, toxigenicity) and host factors. Specific antifungal therapy is instituted as soon as the diagnosis is made. Amphotericin B by various routes is the mainstay of treatment for life-threatening and severe ophthalmic mycoses. Topical natamycin is usually the first choice for filamentous fungal keratitis, and topical amphotericin B is the first choice for yeast keratitis. Increasingly, the triazoles itraconazole and fluconazole are being evaluated as therapeutic options in ophthalmic mycoses. Medical therapy alone does not usually suffice for invasive fungal orbital infections, scleritis, and keratitis due to Fusarium spp., Lasiodiplodia theobromae, and Pythium insidiosum. Surgical debridement is essential in orbital infections, while various surgical procedures may be required for other infections not responding to medical therapy. Corticosteroids are contraindicated in most ophthalmic mycoses; therefore, other methods are being sought to control inflammatory tissue damage. Fungal infections following ophthalmic surgical procedures, in patients with AIDS, and due to use of various ocular biomaterials are unique subsets of ophthalmic mycoses. Future research needs to focus on the development of rapid, species-specific diagnostic aids, broad-spectrum fungicidal compounds that are active by various routes, and therapeutic modalities which curtail the harmful effects of fungus- and host tissue-derived factors.

Scanning electron microscopic study of a Ciloxan bottle blocked by ciprofloxacin crystals

PURPOSE

To report blockage of a commercially available ciprofloxacin bottle by white crystalline deposits. This study evaluated the ultrastructural features of the ciprofloxacin crystals.

METHODS

A patient underwent intensive topical treatment of an infectious corneal ulcer with commercially available ciprofloxacin 0.3% ophthalmic solution. During treatment, the patient was unable to obtain medication from the ciprofloxacin bottle and required a new prescription. Examination of the bottle revealed that about 50% of the medication remained, but compression of the bottle with any amount of force failed to deliver any medication. On closer examination, a white material partially filled the nozzle track of the bottle and was on the outer bottle near the nozzle and the inner surface of the bottle cap. These white crystalline deposits were evaluated by scanning electron microscopy.

RESULTS

Plate-like, needle, cable and spaghetti-like crystals were found. The needle crystals formed multiple petaloid patterns.

CONCLUSIONS

This is the first report of blockage of a commercially available ciprofloxacin 0.3% bottle by ciprofloxacin crystals and the inability to deliver medication from the bottle. Ultrastructural study of the white crystalline deposits revealed four types of ciprofloxacin crystals.

Fungal and parasitic infections of the eye

The unique structure of the human eye as well as exposure of the eye directly to the environment renders it vulnerable to a number of uncommon infectious diseases caused by fungi and parasites. Host defenses directed against these microorganisms, once anatomical barriers are breached, are often insufficient to prevent loss of vision. Therefore, the timely identification and treatment of the involved microorganisms are paramount. The anatomy of the eye and its surrounding structures is presented with an emphasis upon the association of the anatomy with specific infection of fungi and parasites. For example, filamentous fungal infections of the eye are usually due to penetrating trauma by objects contaminated by vegetable matter of the cornea or globe or, by extension, of infection from adjacent paranasal sinuses. Fungal endophthalmitis and chorioretinitis, on the other hand, are usually the result of antecedent fungemia seeding the ocular tissue. Candida spp. are the most common cause of endogenous endophthalmitis, although initial infection with the dimorphic fungi may lead to infection and scarring of the chorioretina. Contact lens wear is associated with keratitis caused by yeasts, filamentous fungi, and Acanthamoebae spp. Most parasitic infections of the eye, however, arise following bloodborne carriage of the microorganism to the eye or adjacent structures.

Fungal and parasitic infections of the eye

The unique structure of the human eye as well as exposure of the eye directly to the environment renders it vulnerable to a number of uncommon infectious diseases caused by fungi and parasites. Host defenses directed against these microorganisms, once anatomical barriers are breached, are often insufficient to prevent loss of vision. Therefore, the timely identification and treatment of the involved microorganisms are paramount. The anatomy of the eye and its surrounding structures is presented with an emphasis upon the association of the anatomy with specific infection of fungi and parasites. For example, filamentous fungal infections of the eye are usually due to penetrating trauma by objects contaminated by vegetable matter of the cornea or globe or, by extension, of infection from adjacent paranasal sinuses. Fungal endophthalmitis and chorioretinitis, on the other hand, are usually the result of antecedent fungemia seeding the ocular tissue. Candida spp. are the most common cause of endogenous endophthalmitis, although initial infection with the dimorphic fungi may lead to infection and scarring of the chorioretina. Contact lens wear is associated with keratitis caused by yeasts, filamentous fungi, and Acanthamoebae spp. Most parasitic infections of the eye, however, arise following bloodborne carriage of the microorganism to the eye or adjacent structures.

Intravitreal pefloxacin therapy in postoperative endophthalmitis

PURPOSE

To study the efficacy of intravitreal pefloxacin in the management of suspected bacterial endophthalmitis.

METHODS

Twenty eyes with suspected postoperative bacterial endophthalmitis were given an intravitreal injection of pefloxacin (200 microg in 0.1 mL). If required the injection was repeated after 24 h. The main parameters evaluated were visual acuity, response to intravitreal therapy and any complications due to intravitreal pefloxacin.

RESULTS

Fourteen eyes (70%) responded to intravitreal pefloxacin therapy alone, while an additional pars plana vitrectomy was required in six eyes (30%). Nineteen eyes retained a visual acuity of 6/60 or better at 3 months after the initiation of therapy. A retinal detachment developed in one of the eyes which received intravitreal therapy.

CONCLUSIONS

Intravitreal pefloxacin may be a useful aternative therapy in bacteria endophthalmitis.

Aqueous humour levels of topically applied ciprofloxacin and ofloxacin in the same subjects

PURPOSE

To evaluate aqueous humour levels of topical 0.3% ciprofloxacin and 0.3% ofloxacin in the same subjects.

METHODS

Thirty-two bilateral cataractous patients received topical 0.3% ciprofloxacin in one eye and 0.3% ofloxacin in the other eye before each cataract extraction. Eyedrops were repetitively instilled for 6 h. Aqueous humour samples were collected and assayed for drug concentrations by a method described originally by us using high-performance liquid chromatography.

RESULTS

Mean aqueous ciprofloxacin and ofloxacin levels were 0.33 +/- 0.04 microgram/ml (mean +/- SEM) and 1.34 +/- 0.14 micrograms/ml respectively (p < 0.0001).

CONCLUSION

Ofloxacin level in the aqueous humour is 4 times higher than that of ciprofloxacin in the same subjects.

Human aqueous and vitreous humour levels of ciprofloxacin following oral and topical administration

PURPOSE

To assess aqueous and vitreous humour ciprofloxacin concentrations following oral and topical administration of ciprofloxacin in patients with non-inflamed cornea and an intact crystalline lens, and to compare the concentrations of the drug given by either route.

METHODS

In this prospective study, 34 patients undergoing pars plana vitrectomy for various ocular pathologies were divided into two groups. Eighteen patients received 2 drops of 0.3% ophthalmic solution of ciprofloxacin every 30 min for 3 h and then every 60 min for the next 3 h, and 16 patients received a single oral dose of 1000 mg ciprofloxacin 6 h before surgery. The aqueous and vitreous humour samples were simultaneously harvested after oral or topical administration during pars plana vitrectomy to assess penetration of the drug. These samples were assayed for ciprofloxacin concentrations by a method described previously by us using high-performance liquid chromatography.

RESULTS

The aqueous and vitreous humour levels of ciprofloxacin were 0.59 +/- 0.06 microgram/ml (mean +/- SEM) and 0.64 +/- 0.06 microgram/ml after oral and 0.44 +/- 0.07 microgram/ml and 0.22 +/- 0.04 microgram/ml after topical ciprofloxacin administration, respectively. Aqueous humour levels were not statistically significantly different following oral and topical administration (p = 0.069). However, the vitreous level of the drug after oral administration was significantly higher than that after topical administration (p < 0.001).

CONCLUSION

Ocular bioavailability of ciprofloxacin in aqueous humour following oral and topical administration is found to be similar when the drug was applied as described above. Penetration of ciprofloxacin into vitreous humour is less than that into aqueous humour after topical administration.

Chronic multifocal retinal infiltrates in patients infected with human immunodeficiency virus

PURPOSE

To describe the clinical features of a disorder characterized by chronic multifocal retinal infiltrates and uveitis in individuals with human immunodeficiency virus (HIV) disease.

METHODS

We reviewed the medical records of HIV-infected patients with multifocal retinal infiltrates of unknown cause seen by investigators at four institutions. The following data were collected: demographic characteristics, presenting signs and symptoms, laboratory test results, and course of disease.

RESULTS

We identified 26 HIV-infected patients (50 involved eyes) with this syndrome. Median CD4+ T-lymphocyte count at presentation was 272 per microl (range, 7 to 2,118 per microl). The most common presenting symptom was floaters. Median visual acuity of involved eyes at presentation was 20/20 (range, 20/15 to 20/100) and remained stable (median, 20/20; range, 20/15 to 20/70) after a median follow-up period of 9 months (range, 0 to 110 months). Typical retinal lesions were gray-white or yellow, irregular in shape, and less than 200 microm in greatest dimension. All were located in the midperiphery or anterior retina and enlarged slowly or remained static in size. Mild to moderate anterior chamber or vitreous humor inflammatory cells were present in 47 of 50 eyes (26 of 26 patients). Retinal lesions possibly responded to zidovudine but not to acyclovir or ganciclovir. Anterior chamber and vitreous humor inflammatory reactions responded to topical or periocular injections of corticosteroid.

CONCLUSIONS

Uveitis with chronic multifocal retinal infiltrates is a distinct clinical entity of unknown cause that occurs in HIV-infected patients. Retinal lesions may respond to antiretroviral therapy. Visual prognosis is good.

Pneumocystis carinii infection of the conjunctiva in a patient with acquired immune deficiency syndrome

BACKGROUND

Ocular disease, especially the development of choroidal lesions, is a known extrapulmonary manifestation of Pneumocystis carinii infection in the acquired immune deficiency syndrome (AIDS). To our knowledge, conjunctival involvement due to P. carinii has not been described previously.

METHODS

The authors describe a 33-year-old homosexual male with AIDS in whom a large placoid, white lesion developed involving the tarsal conjunctiva of the right upper lid. Conjunctival malignancy was suspected and biopsies and swabs were taken. At this time, the patient had been receiving monthly aerosolized pentamidine prophylaxis for 18 months, and there was neither a history of pneumonia nor any clinical signs of disseminated infection due to P. carinii.

RESULTS

Histopathologic examination results of the conjunctival biopsy specimen showed a necrotic, frothy tissue surrounded by activated fibroblasts. Within this material, Gomori methenamine silver stains showed numerous round and cup-like cysts of P. carinii, confirming the diagnosis that had already been obtained by an indirect fluorescent-antibody stain of a conjunctival smear specimen.

CONCLUSIONS

The presence of white placoid conjunctival lesions in a patient with AIDS may indicate an infection due to P. carinii. Conjunctival disease due to P. carinii widens the spectrum of AIDS-associated ophthalmic pneumocystosis.

A comparison of ciprofloxacin and tobramycin in bacterial conjunctivitis in children

A study was conducted to determine the safety and efficacy of topically applied ciprofloxacin ophthalmic solution in a pediatric population experiencing acute bacterial conjunctivitis. Topically applied ciprofloxacin (3 mg/mL) is known to be a safe and effective treatment for adults suffering from bacterial conjunctivitis; however, the safety and effectiveness of this broad-spectrum fluoroquinolone in pediatric patients is not well established. Ciprofloxacin was evaluated in a double-blind, randomized, controlled study of 257 patients ranging from 0 (i.e., less than 1 year) to 12 years of age from 33 geographically diverse medical centers. The children received either 0.3% ciprofloxacin ophthalmic solution (Ciloxan, Alcon Laboratories, Fort Worth, TX) or tobramycin ophthalmic solution (Tobrex, Alcon Laboratories, Fort Worth, TX). Both test medications were administered topically every 2 hours on days 1 and 2 followed by every 4 hours on days 3 through 7. Eyes were cultured prior to enrollment and again on day 7. Treatment efficacy as determined by microbiological culture data and physicians' judgment of overall resolution was similar for the ciprofloxacin and tobramycin groups. Microbiological eradication was observed in 90.1% of the ciprofloxacin group and 84.3% of the tobramycin group (P = 0.29). Physicians judged 87.0% of the ciprofloxacin patients and 89.9% of the tobramycin patients clinically cured on day 7 (P > 0.5). There were no serious adverse medical events attributable to either treatment. This study showed that topically applied ciprofloxacin ophthalmic solution is safe and effective in a pediatric population experiencing acute bacterial conjunctivitis.

Skin involvement with Pneumocystis despite dapsone prophylaxis: a rare cause of skin nodules in a patient with AIDS

Pneumocystis carinii pneumonia is among the most common life-threatening opportunistic infections that occurs in those with HIV infection and a depleted absolute CD4+ T-lymphocyte count. Fortunately, with the advent of effective prophylaxis, this AIDS-defining complication is diminishing. Rarely, Pneumocystis carinii (P carinii) occurs outside the lungs, typically in the setting of prophylaxis with aerosolized pentamidine or no prophylaxis at all. This is the case of a man with advanced AIDS and bilateral hyperpigmented axillary nodules secondary to cutaneous pneumocystosis. Unlike most other examples of extrapulmonary P carinii, dissemination occurred without documented pulmonary infection and despite prophylaxis with high-dose dapsone. A biopsy should be performed on unusual cutaneous lesions in the setting of advanced AIDS because unexpected findings may have important therapeutic implications.

Ophthalmic complications of HIV/AIDS

As a result of improved treatment and patient survival, ophthalmic complications are now being seen with increasing frequency in AIDS, occurring in up to 75% of patients during the course of the disease. The eye may be involved by an AIDS-related microvasculopathy, which gives rise to cotton wool spots, and by opportunistic infections caused by a wide range of organisms, including cytomegalovirus, herpes simplex virus, varicella zoster, Toxoplasma gondii, Mycobacterium avium-intracellulare, Treponema pallidum, Pneumocystis carinii and various fungal agents. Opportunistic infections may be the presenting sign of disseminated infection. The eye may also be involved by neoplasms such as Kaposi's sarcoma and lymphoma, and by intracranial disease. Ocular involvement may lead to blindness if untreated and prompt ophthalmological referral is essential. This article reviews the range of ocular diseases seen in HIV and AIDS, current therapeutic options and outcome.

Ophthalmic complications of HIV infection

HIV retinopathy, a noninfectious microangiopathy, is the most common ocular manifestation of HIV infection. Opportunistic infections, neoplasms, neuro-ophthalmic lesions, and drug-induced lesions may also cause ocular problems. Opportunistic ocular infections, particularly CMV retinitis, are a major cause of morbidity in patients with AIDS. Because of the underlying chronic and progressive immune dysfunction, the ocular symptoms, signs, clinical course, and treatment are often atypical and severe, requiring protracted medical therapy.

Antimicrobial activity and in vitro corneal epithelial toxicity of antimicrobial agents for gram-positive corneal pathogens

We assessed in vitro the antimicrobial activity of four agents (vancomycin, teicoplanin, mupirocin, and imipenem) which are effective against Gram-positive cocci causally associated with bacterial keratitis, as well as their corneal epithelial cytotoxicity. Minimal inhibitory concentrations inhibiting 90% of strains (MIC90s) against 10 strains each of methicillin-susceptible and -resistant Staphylococcus aureus and Staphylococcus epidermidis, penicillin-susceptible and -resistant Streptococcus pneumoniae, and viridans group streptococci were as follows: vancomycin (MIC90s 0.25-2 micrograms/ml), teicoplanin (MIC90s 0.25-4 micrograms/ml, mupirocin (MIC90s 0.12-4 micrograms/ml), and imipenem (MIC90s 0.008-0.25 micrograms/ml, except for methicillin-resistant staphylococci with MIC90 of 16 micrograms/ml). Cytotoxicity was assayed by uptake of 3H-thymidine by rabbit corneal epithelial cell cultures at drug concentrations of 12.5-100 mg/ml for vancomycin and teicoplanin, 1-8 mg/ml for mupirocin and 0.125-8 mg/ml for imipenem, with exposure times of 5, 30 and 60 min. Cytotoxicity was as follows: imipenem < mupirocin < vancomycin < or = teicoplanin. Resistance to methicillin-resistant S. aureus and S. epidermidis for imipenem and resistance to S. epidermidis and cytotoxicity for teicoplanin limit their consideration for suspected Gram-positive keratitis. On the other hand, vancomycin and mupirocin, because of their excellent therapeutic indices, should be considered for this indication.

Methicillin-resistant Staphylococcus aureus keratitis in the rabbit: therapy with ciprofloxacin, vancomycin and cefazolin

To determine the efficacy of a fluoroquinolone antibiotic in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) keratitis, topical administration of 0.3% ciprofloxacin was compared with topical 5.0% vancomycin or 5.0% cefazolin in experimental infections in the rabbit eye. The infections were established by intrastromal injection of 100 colony forming units (CFU) of MRSA, which resulted in greater than 10(6) CFU per cornea by 12 hr postinfection. Chemotherapy (one drop every 15 min) was given from 4-9, 10-15, or 10-20 hr postinfection. Early therapy (4-9 hr postinfection) with ciprofloxacin rendered all eyes free of bacteria; ciprofloxacin was significantly more effective than vancomycin or cefazolin. When treatment was initiated 6 hr later (10-15 hr postinfection), no corneas became free of bacteria, but ciprofloxacin was again more effective than vancomycin or cefazolin. Bacterial killing by ciprofloxacin after treatment from 10-20 hr postinfection was also significantly greater than that of vancomycin. Overall, the results show that ciprofloxacin is effective in killing methicillin-resistant staphylococcus aureus, and is most effective when applied during the very early stages of infection.