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.

Human Vitreous Penetration of Imipenem

The purpose of this study was to determine imipenem concentrations in vitreous humor of non-infected human eyes. Ten patients undergoing vitrectomy were infused with a single dose of either 0.5g (5 patients) or 1g (5 patients) of imipenem. Vitreous humor was withdrawn 2 or 4 hours after the end of the infusion. Results differed in relation to the dose. After 0.5g, vitreous levels were stable (approximately 0.20 mg/l), but after 1g they were significantly higher (approximately 2 mg/l). These levels were above the minimum inhibitory concentration of imipenem for 90% (MIC 90) of the main species responsible for endophthalmitis.

Eyelid Hyperlaxity and Obstructive Sleep Apnea (O.S.A.) Syndrome

Purpose.

An association between the floppy eyelid syndrome and the obstructive sleep apnea syndrome (O.S.A.) has been reported. We studied eyelid tissue elasticity and other ophthalmologic findings in a large number of patients with sleep disorders.

Material and Methods.

Sixty-nine patients with sleep disorders were evaluated. Two thirds were found to have O.S.A., and one third was treated at night by nasal continuous positive airway pressure (nasal C.P.A.P.). Slit lamp examination, eyelid measurements and Schirmer test were performed.

Results.

Eyelid hyperlaxity was increased in patients with O.S.A. The floppy eyelid syndrome (associated papillary conjunctivitis), however, was rare. Associated corneal lesions were rare, and most patients were asymptomatic. In some cases, ocular irritation was due to air leaks from nasal C.P.A.P. A significant proportion of patients required treatment for primary open angle glaucoma.

Conclusions.

Our study of 69 patients found an association between O.S.A. and eyelid hyperlaxity.

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.

Treatment of Proptosis with Fat Removal Orbital Decompression in Graves’ Ophthalmopathy

Purpose

Retrospective evaluation of 41 proptosis reduction procedures using fat removal orbital decompression (FROD) according to a modified Olivari's technique.

Methods

Trans-septal excision of extraconal and intraconal fat was done under the microscope through the upper and lower eyelid blepharoplasty approach. Proptosis was measured with a Hertel exophthalmometer.

Results

Mean excision of 7.31 + 1.9 ml (range 3.25 - 12 ml) of orbital fat reduced proptosis on average by 4.7 + 2.4 mm (range 1–11 mm). Side effects were few, limited only to ocular motility disturbances. There was no significant effect on visual fileds. A postoperative drop in IOP was noted in patients with preoperative IOP above 21 mmHg. Efficient palpebral lengthening can be achieved with combined section of the levator aponeurosis horns in the upper eyelid, and/or auricular cartilage graft in the lower eyelid.

Conclusions

FROD reduces proptosis in Grave's ophthalmopathy.

Ectropion of the Lacrimal Point: The Shoelace Technique

Purpose

To describe an alternative technique to repair the ectropion of the lacrimal point, either alone or combined with an ectropion related to outer angle laxity.

Methods/Results

After diamond shape resection of the conjunctiva and the retractors, sutures are placed with each bridle interlacing on the posterior portion of the eyelid below the lacrimal point in a shoelace fashion.

Conclusions

The technique combines treatment of hyperlaxity of several anatomic structures in a single operation and has the advantage of reinforcing the Horner muscle, which is essential for the cure of this type of ectropion.

[Suspicious eyelid spots]

Flat lesions of the eyelids are in most cases related to precancerous skin lesions or malignant tumors of the eyelids. Rarely, the following diagnoses can be established: alkaptonuria, Addison disease, argyrosis, or toxicity to systemic medications.

[Tumors of the eyelids in the elderly]

The clinical aspect of tumors of the eyelids is polymorphous; however, the most frequent are benign tumors such as papillomas, basal cell carcinoma, squamous cell carcinoma, meibomian gland carcinoma, and melanomas. An important step in the management of the malignant types is to try to establish clear margins through histopathologic techniques: the Mohs technique, the rapid fixation technique, and the frozen section method are the most frequent technical tools used today. For the most malignant tumors such as malignant melanoma and Merkel cell tumor, lymph sentinel biopsy is a recent, valuable tool, but its benefit needs to be confirmed in large series.

Bone formation in hydroxyapatite tricalcium phosphate ceramic implants used in the treatment of the postenucleation socket syndrome

PURPOSE

To determine the histopathologic changes in coralline hydroxyapatite tricalcium phosphate (HA-TCP) blocks used in the treatment of the postenucleation socket syndrome (PESS).

METHODS

Twenty-four patients were treated with HA-TCP blocks placed directly into the orbital fat to correct the PESS. Eight of these patients required partial removal of the material for various reasons between 32 and 371 days after the initial operation. The orbital implants were decalcified and processed for light and electron microscopic examination.

RESULTS

Light microscopy demonstrated fibrovascular ingrowth into the pores of the implant in all cases. Osteogenesis was observed in three cases in the periphery of the implant. Ossification occurred in the implants after a mean implantation duration of 276 days versus 67 days in cases without ossification.

CONCLUSION

Implants of HA-TCP, a new material used in ophthalmology, demonstrate the presence of fibrovascular ingrowth, reflecting the excellent biointegration of this material.

[New ceramic materials for use in anophthalmia surgery]

Over the last 20 years eyeball replacement surgery has improved, especially with the widely accepted use of biocolonisable implants. These implants allow long-lasting biointegration, thus improving prosthesis motility and reducing the rate of postoperative exposure. In this article, we review the chemical structure, toxicity data and manufacturing procedures of the three main commercially available materials: aluminium, hydroxyapatite and porous polyethylene.

Abnormalities of orbital volume

New information on the physiopathology and treatment of orbital volumes pathologies is described: 1) In post-enucleation or evisceration socket syndrome placing of synthetic material (HA-TCP) directly in the intraconal orbital fat can correct most of the symptoms. However the best approach is to prevent orbital volume deficiencies during first surgery using an implant large enough to allow a future prosthesis of a volume less than 2 mL. New procedures for placing the implant after enucleation or evisceration are described. 2) In proptosis related to Graves' orbitopathy relative indications are given for orbital decompression by removal of fat or bone.

[Evisceration using the Russian doll or the parachute technique]

The authors describe two new techniques of evisceration after resection of the corneal epithelium and limbus with a conservative approach of the posterior lamella of the cornea and anterior sclera after a 360 degrees dissection of the sclera behind the insertion of the oculomotor recti muscles, and with a conservative approach of the recti oculomotor muscles. The technique is called "Parachute" when the posterior sclera is removed and "Russian Doll" when the posterior sclera is not removed and placed behind the orbital implant. The implant is then introduced with "bird cage" forceps. The indications of the technique are those of evisceration when the size of the remaining globe is at least one-third of the volume of a normal eye. The main advantage is to provide safely a large volume for the implant in order to prevent post enucleation socket syndrome.

The failed probing

The management of failed probing for congenital nasolacrimal duct obstruction is given by a panel of authors. Treatment options examined are repeat probing, inferiorturbinate infracture, closed lacrimal intubation and dacryocystorhinostomy. There is considerable variation as to the timing of these interventional techniques.

Comparative review of topical ophthalmic antibacterial preparations

The choice of an antibacterial is based on considerations of pharmacodynamic, pharmacokinetic and bacteriological characteristics, risk of selecting resistant mutants, and cost. In this article we review 16 commercially available ophthalmic antibacterial preparations. Fusidic acid and bacitracin are selective for gram-positive bacteria whereas polymyxin B targets gram-negative species. Aminoglycosides and quinolones are broad spectrum antibacterials. The widespread use of an antibacterial increases risks of selecting resistance to it. Acquired resistance is well documented for fusidic acid and rifamycin, and newly described for quinolones. The bioavailability of an antibacterial agent depends on the target bacterial species, the site of infection and the integrity of the haemato-aqueous barrier. Some agents (fusidic acid, quinolones) penetrate the cornea, passing into the anterior chamber of normal eyes at therapeutic concentrations, whereas others (polymixin B, bacitracin) have no penetrating powers and remain at the surface of the eye. Toxicity is mostly manifested by allergic reactions to excipients or active ingredients in topical antibacterial preparations. A few cases of haematological toxicity have brought suspicion on topical chloramphenicol, but the link has yet to be proven. Erythromycin and polymyxin B are probably okay to use as topical applications in pregnant women and nursing mothers. Costs of treatment must be evaluated as a whole (regimen, drug associations). Prices for a bottle of eyedrops may vary 3-fold. The cheapest drugs include chloramphenicol, polymyxin B and gentamicin, the most expensive being fusidic acid and the quinolones.

[Cyclosporin A eyedrops: manufacturing, toxicity, pharmacokinetics and indications in 2000]

INTRODUCTION

Cyclosporin eye-drops allow local immunoregulation without systemic side effects and is an alternate to local steroids. In this article we review specific problems of product setup and clinical studies published over the past 20 years. PRODUCT SETUP: The main problems in eye-drop preparation are sterility, pH, particles, and its lipophilic properties. Numerous excipients have been tested including oil solvents, alphacyclodextrin, collagen shields, liposomes, polyester nanocapsules, but documentation on stability of the molecule is inadequate.

TOXICITY

Epithelial toxicity is well known and is probably mainly due to the excipient. No endothelial toxicity has been described in vivo. Repeated doses lead to uveal reactions in animals, which could limit the indications for intraocular diseases.

PHARMACOKINETICS

Bioavailability is mainly limited by the lipophilic properties. Oil excipients, the most widely used, lead to good corneal penetration but low intraocular concentrations. Cyclosporin bioavailability is improved when using hydrophilic excipients.

INDICATIONS

Every ocular surface disease that involves cytokines is a potential indication for cyclosporine eyedrops: keratoconjunctivitis sicca, vernal keratitis, adjuvant therapy of filtering surgery, stromal herpes keratitis, immunity limbal keratitis, and Thygeson's keratitis. There is biological evidence of efficacy, and encouraging results from many studies, yet few have tested a large number of patients. A large multicenter study on dry eye is currently in progress.

CT appearances of chronically retained wooden intraorbital foreign bodies

Identification of wooden intraorbital foreign bodies (WIOFB) is crucial for avoiding severe orbital infection. Despite careful clinical examination, WIOFB are often not recognised. We report the CT findings in chronically retained WIOFB. When not initially diagnosed, WIOFB create a granulomatous inflammatory foreign-body reaction. CT demonstrates the WIOFB as a linear dense structure surrounded by a soft-tissue mass with density similar to that of muscle, corresponding to the foreign-body reaction.

The bioceramic orbital implant: a new generation of porous implants

PURPOSE

The authors describe a new generation of porous orbital implant made of aluminum oxide (Al2O3) and compare it with the hydroxyapatite orbital implants (Bio-Eye and FCI hydroxyapatite).

METHODS

The authors examined the new implant macroscopically, with chemical analysis and microscopically with scanning electron microscopy. Animal implantation studies were performed using six adult male New Zealand albino rabbits. Implant vascularization was evaluated by means of magnetic resonance imaging and histopathologic sectioning.

RESULTS

The Bioceramic orbital implant was found to have very uniform pore structure with an average pore size of 500 microm. The implant was 99.9% aluminum oxide on x-ray diffraction. Magnetic resonance imaging in vivo vascularization studies demonstrated enhancement of the implant to its center by 4 weeks after implantation in the rabbit. Histopathologically, fibrovascularization occurred uniformly throughout the implant and was noted by 4 weeks.

CONCLUSIONS

The Bioceramic orbital implant represents a new porous orbital implant that has a very regular and extensive interconnected pore system, is as biocompatible as hydroxyapatite, is easy to manufacture, structurally strong, and free of contaminants. It is manufactured with no disruption to marine life ecosystems as may occur in the harvesting of coral for other orbital implants. It is less expensive than currently available hydroxyapatite implants and was approved by the U.S. Food and Drug Administration in April 2000.

Circulating antibodies to human and bovine cornea in human keratoplasty

PURPOSE

To compare anti-human cornea and anti-bovine cornea serum reactivity in corneal transplantation and pathology.

METHODS

We investigated the presence of IgG and IgM antibodies to bovine corneal extract (BCE) and human corneal extract (HCE) by ELISA in 48 healthy adults and in 30 corneal allograft recipients before and after grafting. Baseline levels of antibodies in healthy controls served to establish a positivity threshold. Anti-HLA antibodies were investigated in all patients.

RESULTS

Preoperatively, five and one patient were positive respectively for IgG and IgM anti-BCE; one and ten patients were positive for IgG and IgM anti-HCE. The presence or absence of antibodies was not modified after grafting, and was not associated with rejection. Anti-HCE of the IgM class were more frequent in patients with keratoconus. Two patients had anti-HLA antibodies.

CONCLUSIONS

Antibodies to non-HLA corneal antigens are detectable in corneal allograft recipients. Reactions against bovine and human substrates differ in frequency and class. This reactivity is not modified after grafting or rejection, but is increased in corneal disorders, including keratoconus.

HLA-G and classical HLA class I transcripts in various components of the adult human eye

HLA-G transcripts have previously been detected in the ocular cell line HS738, in foetal eyes and in global ocular extract. Using RT-PCR and hybridization, we searched for HLA-G and classical HLA class I transcripts in the corneas of eye donors (n = 6) and in various components of eyes collected at time of surgery: lens (n = 3), iris (n = 2), vitreous body (n = 2) and retina (n = 2). Whereas HLA class I mRNA was abundant in the ocular tissues of all donors, we could not find HLA-G transcript in any ocular tissues obtained from subjects in vivo. The absence of HLA-G in adult eye cornea limits its interest as a possible target in corneal transplantation. Classical HLA class I transcripts were abundant in the cornea and other components of the eye. These results highlight the role of classical HLA class I antigen in eye immunity and corneal transplantation.

[Ocular bacterial infections : present and prospective methods of diagnosis]

Bacteriological samples and tests are essentiel for the diagnosis of superficial ocular infections and endophtalmitis. The direct examination and the traditional culture of the samples can be in the futur associated with new diagnostic approach using antigen detection (immunofluorescence, enzyme immunosorbent assays) and genome research by hybridation or better by amplification for Chlamydia and for the most frequent species responsible of endophtalmitis. An original genomic strategy of bacterial endophtalmitis diagnosis was developped.

Treatment of the postenucleation socket syndrome with a new hydroxyapatite tricalcium phosphate ceramic implant

PURPOSE

Surgical correction of the postenucleation socket syndrome (PESS) is challenging. Various biomaterials are used for reconstruction of the anophthalmic orbit, often with unsatisfactory long-term results. Implants have been placed between the periorbital and the orbital floor. The authors describe a new material composed of hydroxyapatite tricalcium phosphate (HA-TCP) in the form of ceramic blocks, to be placed into the orbital fat as a new surgical site.

METHODS

Ten patients with PESS underwent surgery to compensate the volume deficit of the anophthalmic orbit. Blocks of HA-TCP were created by fragmentation of a larger piece, tailored as needed, and implanted in the orbital fat. The patients were monitored regularly with clinical and radiologic examinations to evaluate the behavior of the implants.

RESULTS

The volume of the HA-TCP was measured in 5 cases (mean, 2.95 +/- 1.08 ml). A significant reduction of enophthalmos was obtained: mean Hertel exophthalmometry measured 12.7 +/- 2.5 mm preoperatively and 14 +/- 2.4 mm postoperatively (p < 0.05). The average prosthesis volume was significantly reduced in the cases measured: 2.7 ml +/- 0.94 ml preoperatively and 1.8 +/- 0.7 ml postoperatively (p < 0.02). There was a negative correlation between the HA-TCP implant volume and postoperative prosthesis volume (correlation coefficient = -0.925; p < 0.05). According to photographic evaluation, correction of the enophthalmos and of the superior sulcus depression were obtained in 70% and 90% of cases, respectively. Magnetic resonance imaging seems to demonstrate that the blocks become well integrated into the surrounding orbital tissue.

CONCLUSION

The HA-TCP blocks correct some anomalies of PESS. Placement of the blocks directly into the orbital fat is a promising alternative to the traditional subperiosteal location.

[Intra-orbital decompression of the optic nerve by opening the peri-optic meninges in the treatment of severe optic neuropathies complicating benign intracranial hypertension]

Papilledema from benign intracranial hypertension can cause severe loss of visual acuity and visual field, with an optic neuropathy. We report a study of 5 patients with benign intracranial hypertension, and severe visual loss (visual field loss and visual acuity reduced to 1/10 or less) not improved by medical therapy (acetazolamide). We performed unilateral orbital decompression of the optic nerve sheath. No major operative complication was noted. Follow-up ranged from 11 months to 23 months, with an average of sixteen months. Visual function improvement was noted within 3 months after operation in 4 patients (for 2 eyes on the surgical side improvement of 2/10 and 5/10, for 3 eyes on the opposite surgical side average improvement of 4.6/10). The other patient showed improvement, but no significant. Optic nerve sheath decompression in benign intracranial hypertension seems to be a safe procedure and a therapeutic option in the management of raised intracranial pressure complicated by optic neuropathy with severe visual loss.

[Secondary reconstruction of anophthalmic orbits by intraorbital biomaterial implantation]

Poor cosmetic symptoms related to enucleation or evisceration, lead to the post enucleation socket syndrome. A surgical technique is described, with implantation of hydroxyapatite tricalcium phosphate ceramic blocks in the intraorbital fat.

[Value of delayed botulinum toxin injection in esotropia in the child as first line treatment]

PURPOSE

Evaluation of botulinum toxin to treat esotropia in children over 3 years old.

MATERIAL AND METHODS

Eight children (6 boys and 2 girls), aged from 3 to 6 years (mean 4), underwent bilateral injection of 1.25 UI botulinum toxin Botox in medial rectus muscles, under general anesthesia. Preoperative diagnosis was infantile esotropia in 7 cases, and decompensated esophoria in 1 case. Six children had alternating isoacuity before injection, and two had amblyopia. Mean follow-up was 1.8 months (6 to 24 months).

RESULTS

One transient exotropia, and one transient ptosis were reported. Lasting orthotropia was achieved in four children (including one who presented again spasms in near vision), and lasting angle reduction in another child. Another child had late recurrence at 18 months. The injection was a failure for the two amblyopic children.

DISCUSSION

Botulinum therapy allowed to avoid surgery in three cases, and to perform a more limited operation in one case.

CONCLUSION

Botulinum toxin injection in extraocular muscles is of interest in infantile esotropia as a first treatment, even in children over 3 years. The success relies principally on the absence of deep amblyopia, and muscular elongation troubles. However, the use of botulinum is limited, because it requires general anesthesia, and because of its price.

[Treatment with cyclosporin A, with low doses, in high-risk penetrating keratoplasties. A bi-centric study of 90 cases]

PURPOSE

Evaluation of cyclosporin-A in prevention of immune reaction in high-risk penetrating keratoplasties.

MATERIAL AND METHODS

Cyclosporin A was given to 45 corneal allograft recipients, 5 mg/kg/j (cyclosporinemy between 100 and 150 ng/l), for three months following surgery. 45 controls have undergone penetrating keratoplasty during the same period. Mean follow-up was respectively 431 days and 402 days. Survival was analysed according to Kaplan-Meier's method, and then using Cox model.

RESULTS

The significant predictive factors were the number of neovascularized quadrants, and the graft diameter. No significant effect of cyclosporin is evidenced. Side effects are marginal.

CONCLUSION

Three hypothesis may explain the absence of prognosis improvement in the Cyclosporin A treated group: insufficient dose or duration of treatment, individual risk factors that prevents correct pairing, or corneal-specific immunological mechanisms.

[Simplification in locating and dissecting the levator muscle of the upper eyelid in surgery for ptosis]

BACKGROUND

While repairing eyelid ptosis by aponeurotic resection by anterior approach, the risk of damaging the levator complex and the conjunctiva is significant. In order to simplify the dissection between Müller's muscle and the underneath conjunctiva, we use a modification of the usual surgical technique.

METHODS

Before the skin incision, the eversion of the upper eyelid allows to dissect the conjunctiva from the Müller's muscle under direct visual control, starting from the upper tarsal margin. A silicone band is then passed through the so created horizontal subconjunctival tunnel. The upper eyelid can be physiologically replaced, and the levator muscle aponeurosis exposed. The two ends of the band are then pulled on surface through two lateral incision performed close to the upper tarsal edge. Now the band plays the role of a useful landmark: every tissue above the band is levator complex; when stretched downwards, it points the upper edge of the tarsal plate. We operated by this technique 24 eyes, affected of acquired or congenital ptosis. Fourteen eyelids had already undergone ptosis surgery elsewhere.

RESULTS

We achieved good-to-excellent results in all cases, without any important postoperative complications.

CONCLUSIONS

The proposed manoeuvre makes easier the dissection of the inner aspect of the levator complex, because of the material control. Therefore it minimises the tissue trauma and the postoperative complications, particularly in complicated cases characterised by scarring and fibrosis.

[Biocompatibility of a porous alumina orbital implant. Preliminary results of an animal experiment]

PURPOSE

Evaluation of clinical tolerance and scanning electron microscopy study of the bio-colonisation of a porous ceramical alumina implant after evisceration of the rabbit. Preliminary results.

METHODS

Sixteen white New Zealand rabbits were eviscerated. A porous hydroxyde alumina ball was implanted in the opened sclera and explanted 15, 30, and 90 days after implantation. Clinical tolerance was assessed and implant tissular ingrowth was analyzed by scanning electron microscopy.

RESULTS

One infection was observed and there was no conjunctival breakdown. Fibrovascular ingrowth occurred as soon as 15 days after implantation, and was full at one month.

CONCLUSION

Porous alumina implant orbital tissue tolerance and fast fibrovascular ingrowth in the rabbit socket suggest promising result in the human anophthalmic socket.

Anterior chamber concentrations of vancomycin in the irrigating solution at the end of cataract surgery

PURPOSE

To verify that therapeutic levels of vancomycin were present in the irrigating solution at the end of cataract surgery.

SETTING

Service d'ophtalmologie, Université de Limoges, France.

METHODS

An irrigating solution that contained 20 mg/L of vancomycin was used in 15 patients having phacoemulsification. Antibiotic concentrations in the phacoemulsification handpiece and in the aqueous humor were measured at the end of surgery.

RESULTS

Passage through the phacoemulsifier did not affect antibiotic concentration. In the aqueous humor, after wound closure, the concentration constantly exceeded the minimal inhibitory concentration of the principal gram-positive bacteria responsible for human endophthalmitis.

CONCLUSION

Vancomycin added to the irrigating solution used during cataract surgery was found in effective concentrations in the anterior chamber at the end of surgery.

Local antimicrobial prophylaxis in cataract surgery: recent controversies and clinical guidelines

The best prevention of endophthamitis is the use of strict surgical hygiene. Supplementing the irrigating solution with aminoglycosides and/or vancomycin is a rational, convenient and cost effective method of antimicrobial prophylaxis. However emerging resistance to vancomycin entails restrictions to its daily use. In conclusion, two options are possible: limit the use of prophylaxis in the irrigating solution to only those patients at high risk of injection, or use topical and general antibioprophylaxis with low cost drugs.

Comparison of ciprofloxacin ophthalmic solution 0.3% to fortified tobramycin-cefazolin in treating bacterial corneal ulcers. Ciprofloxacin Bacterial Keratitis Study Group

PURPOSE

The purpose of the study is to compare the clinical efficacy and safety of ciprofloxacin ophthalmic solution 0.3% (Ciloxan) with a standard therapy regimen (fortified tobramycin, 1.3%-cefazolin, 5.0%) for treating bacterial corneal ulcers.

METHODS

This randomized, parallel group, double-masked, multicenter study was conducted in 324 patients at 28 centers in the United States, Europe, and India. Patients were randomized into 2 treatment groups: 160 to ciprofloxacin and 164 to fortified tobramycin-cefazolin. Positive microbiologic cultures were obtained in 188 (58%) of 324 patients. Of these, 176 patients met protocol criteria and were evaluated for treatment efficacy: 82 in the ciprofloxacin group and 94 in the standard therapy group. The dosing schedule for both treatment groups was 1 to 2 drops of the first study medication (ciprofloxacin or fortified tobramycin) every 30 minutes for 6 hours, then hourly for the remainder of day 1; 1 to 2 drops every hour on days 2 and 3; 1 to 2 drops every 2 hours on days 4 and 5, followed by 1 to 2 drops every 4 hours on days 6 to 14. The second medication (ciprofloxacin or cefazolin) was instilled 5 to 15 minutes after the first drug, following the same dosing frequency. Physician's judgment of clinical success, cure rate, changes in ocular sings, and symptoms and the rate of treatment failures were the primary efficacy criteria.

RESULTS

Topical ciprofloxacin monotherapy is equivalent clinically and statistically to the standard therapy regimen of fortified antibiotics. No statistically significant treatment differences were found between ciprofloxacin (91.5%) and standard therapy (86.2%) in terms of overall clinical efficacy (P = 0.34). Similarly, no differences were noted in resolution of the clinical signs and symptoms (P > 0.08) or the time to cure (P = 0.55). The incidence of treatment failures was less in the ciprofloxacin group (8.5%) compared with the standard therapy group (13.8%). Significantly fewer patients treated with ciprofloxacin reported discomfort than did patients treated with the standard therapy regimen (P = 0.01).

CONCLUSION

Ciprofloxacin ophthalmic solution 0.3% monotherapy is equivalent clinically and statistically to standard therapy (fortified tobramycin-cefazolin) for the treatment of bacterial corneal ulcers and produces significantly less discomfort.

The role of hyaluronidase on lidocaine and bupivacaine pharmacokinetics after peribulbar blockade

Orbital regional anesthesia is the only circumstance where hyaluronidase is routinely added to local anesthetics to accelerate the onset of the block. The aim of this study was to compare the pharmacokinetics of lidocaine and bupivacaine with or without hyaluronidase for peribulbar blockade. Twenty-one patients scheduled for cataract surgery with lens implantation were included in this prospective randomized study. Peribulbar blocks were achieved with plain bupivacaine 0.5% (5.5 mL), lidocaine 2% (5.5 mL), and hyaluronidase (100 IU = 2 mL) (n = 10) ir sterile water (2 mL) (n = 11). Plasma bupivacaine and lidocaine concentrations were measured by high-performance liquid chromatography at regular intervals from the end of the local anesthetic injection until the 360th minute. Maximum plasma concentration (Cmax) and time to reach Cmax (Tmax) were obtained for all the patients except one who needed a supplementary injection and was excluded from the study. The time to onset and duration of the analgesia and akinesia were monitored at the times of sampling. Motor blockade was incomplete in two patients in each group without affecting surgery. The Tmax and absorption half-life (t1/2a) of lidocaine and bupivacaine were not different within each group (P > 0.05). The Tmax of lidocaine was shorter in the presence of hyaluronidase (17.1 +/- 2.6 min vs 32.7 +/- 6.0 min) as well as the Tmax of bupivacaine (16.8 +/- 3.0 min vs 26.5 +/- 4.4 min). The Cmax of lidocaine and bupivacaine were not modified by the addition of hyaluronidase. The clearance, terminal half-life, and volume of distribution were not different between groups. The absorption of lidocaine and bupivacaine from the peribulbar space are hastened by the addition of hyaluronidase. The Tmax of lidocaine is not different from that of bupivacaine within each group suggesting that the absorption of local anesthetics is minimally influenced by the liposolubility of the drugs. Moreover, hyaluronidase influences the absorption kinetics of both lidocaine and bupivacaine in the same manner.

[Efficacy and tolerability of a combination of indomethacin and gentamicin for preventing inflammation after cataract surgery]

PURPOSE

The aim of the study was to compare 2 combinations of anti-inflammatory drug and antibiotic, in patients undergoing cataract surgery: 0.1% indomethacin/gentamicin or 0.1% dexamethasone/ neomycin.

METHODS

Two hundred and two patients undergoing extra-capsular cataract extraction with posterior chamber lens implantation were included in a randomized, double-blinded multicentric study comparing 2 parallel groups of treatment. Treatment was administered the day before surgery, the day of surgery and for the following 7 days. On the 8th post-operative day, the antibiotic was stopped and the anti-inflammatory treatment continued alone until the 30th post-operative day. Post-operative ocular inflammation was assessed clinically on the 1st, 7th, 15th and 30th post-operative days. The main evaluation criterion of treatment efficacy was the assessment of anterior chamber flare and cells.

RESULTS

No statistically significant difference-was observed between the 2 treatment groups concerning post-operative inflammation. Both treatments were well tolerated.

CONCLUSION

Eye drops combining 0.1% indomethacin and gentamicin proved to be effective and well tolerated in preventing inflammation after cataract surgery.

[Acute painful and red eyes]

Pain or redness of the eye are frequent symptoms of out patient ophthalmological visit. Diagnosis is based both on the patient symptoms and a careful eyeball examination. After an eye trauma, it is necessary to check the absence of corneal or subpalpebral foreign body, and the absence of an eyeball laceration or an intraocular foreign body. Without traumatism, pain or redness of the eye suggest an anterior segment pathology with various diagnosis: keratitis is mostly due to bacterial infection, a significant intraocular pressure elevation is frequently due to angle closure glaucoma or inflammation of the anterior uvea in case of iridocyclitis. When pain and redness of the eye are associated with visual impairment, it is mostly due to a severe ocular pathology. In that case an ophthalmological referral is mandatory.

[Diffusion of piperacillin in the eye]

Intraocular diffusion of piperacillin was studied in 42 patients scheduled for cataract surgery (n = 35) or vitrectomy (n = 7). Piperacillin was administered intravenously (4 g/injection). Thirty-four patients were given a single dose and 8 were given two doses 12 hours apart. Peak piperacillin levels in the aqueous (7.3 mg/l) occurred one hour after the injection; levels in the vitreous were low (less than 0.6 mg/l). Intraocular diffusion of piperacillin was also studied in rabbits with an experimental Staphylococcus epidermidis infection of one eye; the other eye served as the control. In pigmented rabbits (6 Fauve de Bourgogne animals), increased diffusion and decreased elimination of piperacillin were seen in the aqueous, iris and cornea of the infected eyes, as compared with uninfected control eyes. In albino rabbits (6 New Zealand animals), results were less conclusive, with a difference between the infected and healthy eyes appearing only during the second hour following the injection. The good diffusion of piperacillin in the aqueous, especially in infected eyes (at least in rabbits), suggests that this drug may be useful for the treatment of ocular infections provided it is initiated early and given in combination with another antimicrobial exhibiting good intraocular diffusion.

[Study of intraocular diffusion of ofloxacin in humans and rabbits]

The diffusion of ofloxacin in infected and healthy human and rabbit eyes was investigated. In the human study, cataract surgery patients were given intravenous ofloxacin either as a single 200 or 400 mg dose or as two 400 mg infusions 12 hours apart. Samples of aqueous humor and plasma were collected between 1 and 12 hours after the end of the infusion. Levels in the anterior chamber increased with the dose; peak levels, which occurred after three hours, were 0.33 mg/l after 200 mg and 1.24 mg/l after two 200 mg doses given 12 hours apart. In the rabbit study, 16 hours after experimental infection of the left eye by injection of S. epidermidis into the vitreous, animals were given an intraperitoneal injection of 20 or 50 mg/kg ofloxacin. Dosages in the various ocular tissues showed that penetration into the eye varied with race (albinos greater than pigmented) and dose. Intraocular ofloxacin levels, including in the vitreous, increased two fold when the eye was infected; however, penetration into the sclera, choroid, and retina was comparable in infected and noninfected eyes. These findings in humans and animals suggest that ofloxacin in a dose of a least 400 mg is a useful agent for the treatment of prophylaxis of ocular infections.

[Conjunctivitis and lacrimal apparatus infections]

The term conjunctivitis covers all inflammatory processes affecting the conjunctiva. Bacterial and viral infections are the most frequent causes. Infectious conjunctivitis is rarely severe in industrialized countries, but trachomatous kerato-conjunctivitis is still the main cause of blindness all over the world. Most cases of bacterial conjunctivitis are treated with topical antibiotics. Viral conjunctivitis is frequent and, with the exception of herpetic conjunctivitis, has no specific treatment. Canaliculitis and dacryocystitis are rare but require specialized examination, treatment and follow-up.

[Intraocular penetration of topical norfloxacin in humans. Preliminary study]

The aim of this bicentric study was to assess the intraocular penetration of topical Norfloxacin. Herein, are only reported the results from one center. Topically applied Norfloxacin 0.3% was given to patients who underwent cataract surgery. The first group received 5 drops between 7.55 A.M. to 8 A.M. and after each hour until cataract surgery. The second one received one drop each quarter from 7 A.M. until the surgery. Aqueous and sera samples were dosed using HPLC. In the first group, the aqueous average was 0.066 mg/l and 0.112 mg/l in the second group. Using a T test and Mann Whitney test, we could not find a significant difference between the two groups.

[Experimental and clinical study of conjunctivo-scleral tolerance of PTFE (Goretex) sutures compared to polyglactine (Vicryl)]

The authors report a study of the modifications observed with sutures of PTFE (Goretex) and polyglactin (Vicryl) at the level of the sclera and the conjunctival. Inflammatory cells are fewer with PTFE both in the rabbit eyes (14 cases) from 3 to 110 days and in the human eye in a clinical study of 28 cases.

[Intraocular passage of imipenem in man]

Twenty two patients (mean age: 69 years) undergoing cataract surgery were perfused with imipenem (1g for 1 hour). The samples of serum and aqueous humor were taken simultaneously 0.5-1-2-5-7 hours after the end of perfusion and immediately stabilized by MES or MOPS buffers and ethylene glycol. The antibiotic concentrations were determined with Bacillus subtilis ATCC 6633. Aqueous humor levels increased from the end of perfusion to 2nd hour (peak 5.2 mg/l) and decreased after (mean level 2.8 mg/l). The concentrations were well above MIC-90 of the species commonly involved in bacterial endophthalmitis. Imipenem appears to have an exceptional penetration into ocular fluids.

[Intraocular penetration of ciprofloxacin after infusion and oral administration]

Thirty five patients (mean age: 70 years) undergoing cataract surgery or vitrectomy were perfused with ciprofloxacin (400 mg IV/for 1 hour) or received either a single, 2, 6 or 8 preoperative orale doses (750 mg each). The samples of serum, aqueous humor or vitreous fluid were taken simultaneously at 1, 2, 3, 4, 6, 9 or 12 hours after the last administration of antibiotic. The antibiotic concentrations were determined by microbiological techniques (using Bacillus subtilis ATCC 6633). Aqueous humor levels, after perfusion of 400 mg, were stable during 3 hours (mean: 0.22 mg/l); after a single oral dose of 750 mg were stable during 12 hours (mean: 0.18 mg/l) but were significantly lower than after multiple doses (up to 0.8 mg/l) which suggest accumulation in anterior chamber. In vitreous fluid, levels were elevated from one to six hours after the end of the perfusion (up to 0.4 mg/l). The levels are above the MIC 90 of enterobacteriaceae, and around the MIC 50 of Staphylococcus or Pseudomonas.