Citrobacter koseri, an unusual exogenous endoftalmitis

Citrobacter koseri is a bacillus that causes infrequent endophthalmitis. 6% of cultures in endophthalmitis are Gram -, and as in these, C. koseri is associated with a poor visual prognosis. We present a 65-year-old man who works in an animal laboratory. He went to emergencies with loss of vision in his left eye due to a vitreous hemorrhage. A vitrectomy was performed and 3 days later, endophthalmitis was diagnosed. Vancomycin and Ceftazidime were applied in eye drops and in two intravitreal injections. 24 h later he returned with a lens extrusion. Due to the severity of the condition, an evisceration was performed. Subsequently, the samples confirm the microorganism. We assume that the entry point for the bacterium was the sclerotomies through the exposed suture material, after handling rodent feces.

Acute Horner syndrome secondary to glandular fever due to Epstein Barr virus infection

We present a clinical situation where a 47-year old female patient consulted with left partial ptosis and miosis that started, two weeks before, with an episode of glandular fever secondary to Epstein-Barr infection. Apraclonidine 0.5% and Phenylephrine 1% drop testing was performed with results consistent with suspected left Horner Syndrome (HS), with a probable postganglionic location. Magnetic Resonance Angiography (MRA) at the moment of the acute presentation did not show any image suggesting carotid arterial dissection but showed irregular narrowing of the left internal carotid artery on its paravertebral extracranial way, consistent to enlarged intra-carotid sheath lymphoid tissue. A week later, a Doppler ultrasound was performed, showing bilateral images compatible with internal carotid arterial dissection. When Postganglionar HS is suspected, the first aetiology to rule out is a carotid arterial dissection because of its potentially fatal outcome and for being a more described entity as postganglionic HS aetiology. However, it is also evidenced that a certain diagnose is not always possible. Furthermore, we describe the enlarged internal carotid artery sheath lymphoid tissue as a possible cause of sympathetic nerve disruption causing a Postganglionar HS, although not common.

Bacterial keratitis due to Moraxella nonliquefaciens

Moraxella keratitis can lead to important complications. Moraxella nonliquefaciens(M. nonliquefaciens) has the worst prognosis. Only three cases of corneal infections due to M. nonliquefaciens have been published. The case is presented of a 79-year-old man with bullous keratopathy, recently affected with severe infectious keratitis. Dense, deep, and central stromal infiltrates and hyphaema were detected. After the identification of M. nonliquefaciens in the culture, and given the progression of the condition, the initial empirical treatment was modified to topical ciprofloxacin and ceftazidime in accordance with the antibiogram, combining oral ciprofloxacin and amoxicillin-clavulanate. After 27 days, there was total resolution of the lesion, with central residual leucoma. Keratitis caused by M. nonliquefaciens is rare and must be suspected in elderly patients with local predisposing factors, such as corneal damage or previous eye surgery. Early antibiogram-guided treatment and close monitoring are important to avoid complications and poor compliance.

Delayed-onset bleb-related endophthalmitis caused by Moraxella nonliquefaciens

Bleb-related endophthalmitis is rare and appears months or years after surgery. The causative agents are usually streptococci or gram-negative bacteria. There are few cases in the literature of endophthalmitis caused by Moraxella nonliquefaciens, and most are delayed-onset associated with blebitis after glaucoma filtration surgery. The case is presented of a 90-year-old patient with endophthalmitis in the right eye due to Moraxella nonliquefaciens associated with blebitis 10 years after glaucoma surgery. After treatment, disappearance of blebitis is observed 2weeks later and resolution of vitritis 29 days later, with recovery of vision to previous values (20/200). Endophthalmitis due to Moraxella nonliquefaciens is rare, and is associated with late onset blebitis after glaucoma filtration surgery. Despite the virulence of the clinical symptoms, the visual prognosis is usually favourable.

Bilateral maculopathy after exposure to a laser pointer: Optical coherence tomography angiography findings

CASE REPORT

A 36-year-old man went to the emergency department the day after exposure to a laser pointer. Funduscopy revealed dispersed macular pigment alterations, and optical coherence tomography showed a disruption of the retinal layers. The visual acuity was counting fingers in both eyes. Nine months later, optical coherence tomography angiography showed a rarefaction in the choriocapillaris vascular flow in the area of the laser injuries.

DISCUSSION

The retinal layer mainly damaged by the laser injury was the retinal pigment epithelium. However, it is suggested that the laser injury could involve tissues beyond the retinal pigment epithelium, since a rarefaction of the choriocapillaris was found after exposure to the laser.

Choroidal osteoma with choroidal excavation and associated neovascular membrane: An OCT-angiography study

CLINICAL CASE

A case is presented of a unilateral choroidal osteoma with choroidal excavation and associated neovascular membrane that was studied using OCT-angiography. The OCT and OCT-angiography revealed an area of choroidal excavation and an active neovascular membrane. Three doses of aflibercept were administered to the patient, which stabilised the neovascularisation.

DISCUSSION

OCT-angiography was used to analyse the morphology of the superficial vascular network of the osteoma, as well as to monitor the evolution of the neovascular membrane.

Hydrophilic acrylic intraocular lens clouding: a clinicopathological review

PURPOSE

An analysis is made of a serious late complication (opacification) of different models of hydrophilic acrylic intraocular lenses (IOLs).

METHODS

Seven lenses were explanted from seven patients treated for cataracts with phacoemulsification and implantation of different types of hydrophilic acrylic IOLs (five SC60B-OUV from MDR, one Aquasense from OII, and one H60M Hydroview lens from Bausch & Lomb) who developed important vision impairment in the late postoperative period (1 to 3 years) due to lens opacification. The explanted lenses were subjected to exhaustive study involving photographic analysis, scanning electron microscopy, and energy dispersive X-ray spectroscopy.

RESULTS

Light and scanning electron microscopy revealed diffuse, variable-size granular deposits within the optic of the SC60B-OUV lens, and on the anterior and posterior optic surfaces of the H60M Hydroview lens, though without affecting the haptics in any of the models. Dispersive energy X-ray spectroscopy of the deposits revealed the presence mainly of calcium and phosphorus salts.

CONCLUSIONS

Hydrophilic acrylic IOL opacification is a serious late complication of unknown etiology. The condition is more frequent among diabetic patients, and the only management option is IOL explantation and replacement with a lens of some other material. More frequent and longer follow-up is required of those patients wearing lenses for which cases of opacification have been documented, particularly in the presence of predisposing factors (diabetes, uveitis). Caution is required with new lenses, avoiding their generalized use until they have successfully passed the test of time.

Diffuse unilateral subacute neuroretinitis in Europe

BACKGROUND

Diffuse unilateral subacute neuroretinitis is thought to be caused by a solitary helminth migrating within the subretinal space. Laser photocoagulation of the located worm is the preferred mode of therapy.

METHODS

We describe the clinical and electrophysiological features of a case of a 15-year-old Caucasian male with a longstanding diffuse unilateral subacute neuroretinitis (DUSN), in whom two worms were seen in the fundus examination. Focal photocoagulation of the worms was applied as treatment.

RESULTS

No signs of inflammation could be seen after treatment. Three months later, the patient was doing well. Follow-up examination 4 years later revealed an unchanged fundus appearance in the affected eye, with no evidence of progression of the syndrome.

CONCLUSIONS

If a worm is identified in DUSN, focal laser treatment of the located area is the treatment of choice, regardless of whether fundus changes suggest late stages of the disease. However, the eye of the patient should be thoroughly examined to rule out the presence of more than one worm that might cause the failure of therapy.

Endophthalmitis following open-globe injuries

Endophthalmitis following open-globe injuries is caused by a specific range of microorganisms, of which Bacillus sp. and coagulase-negative Staphylococcus are the most frequent. Risk factors include the presence of an intraocular foreign body, injury inflicted by organic material, delay in surgery, and the type of wound involved. Despite important advances in medical and surgical management, this type of endophthalmitis continues to pose a poor prognosis. In this sense, we consider prevention to be the best approach. We report our protocols for the prevention and treatment of endophthalmitis following open-globe injuries, based on recent experimental studies on the ocular pharmacokinetics of antibiotics and on multicenter studies of the treatment of endophthalmitis.

Endophthalmitis following penetrating eye injuries

Postinjury endophthalmitis is the eye infection with the worst prognosis. A retrospective 9-year study was made of penetrating eye injuries, with an analysis of the incidence of infection and its relation to the type of wound and the presence of intraocular foreign bodies. There were 403 cases of penetrating eye injury; of these, 233 affected the cornea and 170 involved the posterior pole. Intraocular foreign bodies were present in 40 cases. Endophthalmitis developed in 4.2% of cases (17/403), and was more common in patients with posterior pole involvement (7%) than in purely corneal trauma (2.1%) (p = 0.03, Chi-square). Infection was in turn more frequent in the presence of intraocular foreign bodies (15%) (p = 0.17, Chi-square). Staphylococcus epidermidis was the most common cause (23.4%), while in three cases (17.6%) mixed infection was detected. The visual results were evisceration or non-perception of light in 82.3% of cases.

Endothelial toxicity of ceftazidime in anterior chamber irrigation solution

Due to the high toxicity of aminoglycoside antibiotics, many authors prefer to use third generation cephalosporines in the prophylaxis and treatment of intraocular infections. The aim of the present study was to determine safe ceftazidime levels in anterior chamber irrigation solution. Twenty-two eyes of 12 white New Zealand rabbits were divided into six groups of two animals each. Double paracentesis was performed in both eyes, irrigating the right eye with 250 ml of BSS-Plus (BSS+) solution, and the left eye with 250 ml of BSS+ solution with increasing concentrations of ceftazidime (2, 3, 4, 6 and 8 mg ml-1). Each rabbit was killed at the end of surgery, except the last group, which received BSS+ and BSS+ with 8 mg ml-1 of ceftazidime, respectively, in one eye, and were then killed 24 hr later. Endothelial lesions were assessed by silver nitrate staining. We considered lesions endothelial silver affinity ranging from minimal (1-2+) to intense (3-4+). 1-2+ silver affinity was found in 4 +/- 1.35% of endothelial cells in the controls; this percentage in turn increased with antibiotic concentration (6.1 +/- 1.13%, 6.7 +/- 0.4%, 7.2 +/- 1.36%, 7.3 +/- 1.93% and 7.5 +/- 1.83%, respectively). The percentage of 3-4+ silver affinity was 0.18 +/- 0.17% in the controls, and likewise increased with antibiotic concentration (0.22 +/- 0.11%, 0.37 +/- 0.09%, 2.8 +/- 0.63% and 3.1 +/- 0.46%, respectively). The increase in affinity was greatest up to the 4 mg ml-1 concentration. In the last group there were zones of endothelial alterations in morphology and size, with signs of attempted repair in the eye treated with antibiotic, but none in the case treated only with BSS+. Ceftazidime concentrations above 3 mg ml-1 in intraocular infusions induce endothelial cell toxicity.

Anterior chamber contamination following uncomplicated cataract surgery: comparative results using intravenous imipenem

BACKGROUND AND OBJECTIVE

An attempt was made to establish the effect of an intravenous antibiotic on anterior chamber (AC) fluid contamination when administered before surgery.

PATIENTS AND METHODS

A prospective study of AC contamination was conducted in 60 patients undergoing extracapsular cataract extraction (ECCE)/intraocular lens (IOL) implantation. The final 20 patients received 1 g of intravenous imipenem 1 hour before surgery.

RESULTS

There were 4 positive AC cultures from the 20 patients in the imipenem group, and 13 positive AC cultures from the 40 control patients (P = .4, chi-square test). Of the 60 eyes, 17 had positive AC aspirate cultures and 23 had positive conjunctival smears. Only in one instance was the microorganism isolated from each case the same (1.7%).

CONCLUSIONS

An insignificant decrease in AC contamination was observed when intravenous imipenem was used before surgery. The results also suggest that conjunctiva might not be the main source of contamination during surgery.