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Bacillus cereus Panophthalmitis Appearing as Acute Glaucoma in a Drug Addict
334
AMERICAN JOURNAL OF OPHTHALMOLOGY
August, 1985
Figure (Gerber). Lens loop-iris spatula.
single handle facilitates delivery of the lens nucleus during planned extracapsular surgery. The stainless steel instrument (Figure) consists of a 6 x 7-mm ultrathin blade lens loop (modified Gills/Welsh-type) at one end attached by a round knurled handle, 88 mm in length, to a 12-mm angled, round-tipped spatula (Cleasbytype) on the opposite end. The lens loop may be used to express or slide the nucleus. If the nucleus becomes trapped, the spatula end may be used to impale the nucleus or rotate it out of the eye under direct visualization.
Bacillus cereus Panophthalmitis
Appearing as Acute Glaucoma in a Drug Addict Hans Grossniklaus, M.D., William E. Bruner, M.D., K. Ellen Frank, M.D., and Edward W. Purnell, M.D. Division of Ophthalmology, University Hospitals of Cleveland, and Case Western Reserve University. This study was supported in part by the Ohio Lions Research Foundation.
Fig. 1 (Grossniklaus and associates). Ultrasonographic B-scan shows diffuse uveal thickening and uveal effusion (arrowhead). uveal thickening. The diagnosis was uveal effusion with displacement of the lens-iris diaphragm causing secondary angle-closure glaucoma. The patient was treated with topical prednisolone acetate 1 % and systemic prednisone. The next day he had left periorbital edema, a markedly chemotic left eye, and an anterior chamber hypopyon (Fig. 2). Anterior chamber and vitreous aspirates grew B. cereus. The patient admitted intravenous drug abuse. He was treated with intravitreal, topical, and systemic gentamicin sulfate and systemic chloramphenicol but his condition failed to improve and after three days required evisceration. Our patient was remarkably similar to the first patient described by Young and associates." Both were young male intravenous drug abusers who were treated for acute glaucoma in the left eye and who proved to have B. cereus panophthalmitis within 24 hours. We believe that early B. cereus panophthalmitis must be
Inquiries to William E. Bruner, M.D., 1611 S. Green Rd., Cleveland, OH 44121.
Endogenous Bacillus cereus panophthalmitis may result from intravenously administered drugs in drug addicts.P We recently examined a patient who had acute glaucoma as the initial manifestation of B. cereus panophthalmitis. He later admitted to being a drug abuser. This 27-year-old man had had acute pain in the left eye for eight hours. The intraocular pressure was 52 mm Hg. The angle was closed and the cornea was hazy. He was treated initially with topical pilocarpine hydrochloride 2%, oral glycerin, and intravenous mannitol. His intraocular pressure decreased to 32 mm Hg after one hour but the eye remained painful. B-scan ultrasonography (Fig. 1) showed diffuse
Fig. 2 (Grossniklaus and associates). Marked chemosis and hypopyon in the left eye the morning after admission.
Vol. 100, No.2
Letters To The Journal
considered in the differential diagnosis of acute monocular glaucoma in intravenous drug abusers.
References 1. Bouza, E., Grant,S., Jordan, C., Yook, R. H., and Sulit, H. L.: Bacillus cereus endogenous panophthalmitis. Arch. Ophthalmol. 97:498, 1979. 2. Hatem, G., Merritt, J. c.. and Cowan, C. L.: Bacillus cereus panophthalmitis after intravenous heroin. Ann. Ophthalmol. 11:431, 1979. 3. Young, E. J., Wallace, R. J., Ericson, C. D., Harris, R. A., and Clarridge, J.: Panophthalmitis due to Bacillus cereus. Arch. Intern. Med. 140:559, 1980.
Anaerobic Peptostreptococcal Keratitis Richard A. Eiferman, M.D., Lynn L. Ogden, M.D., and James Snyder, Ph.D. University of Louisville (R.A.E.), the Jewish Hospital (L.L.O), and Kosair-Childrens Hospital 0.5.). Inquiries to Richard A. Eiferman, M .. D., Department of Ophthalmology, University of Louisoille School of Medicine, 301 E. Muhammad Ali Blvd., Louisville, KY 40202.
An 83-year-old woman underwent a penetrating keratoplasty for pseudophakic bullous keratopathy. Five months postoperatively she developed a white, filamentous midstromal infiltrate without evidence of internal or external inflammation. Cultures and scrapings on two occasions were negative and the filaments
Fig. 1 (Eiferman, Ogden, and Snyder). Slit-lamp photograph demonstrating filamentous midstromal infiltrates.
335
eventually invaded the visual axis (Fig. 1) despite multiple antibiotics. A 9.5-mm penetrating keratoplasty completely removed the involved donor button. The specimen was bisected; one-half was sent for light and electron microscopy and the other half was immediately placed on anaerobic and aerobic media. All cultures except the ones placed on strict anaerobic media were negative. A choppedmeat broth grew a pure culture of Pepiostrepiococcus. Light microscopy disclosed deep stromal cords of bacteria without concomitant inflammation and a totally intact corneal epithelium. Brown-Bren stains showed a massive collection of confluent gram-positive cocci (Fig. 2); this was confirmed by electron microscopy. Peptostreptococcus is a rare cause of ocular disease and has been reported in anaerobic sites such as brain abscesses! and the vitreous cavity.v" One previously reported case of a corneal ulcer caused by Peptostreptococcus did not resemble this case. 4 Meisler and associates" reported a similar clinical pattern caused by Streptococcus viridans. This facultative aerobe and the anaerobic Pepiostreptococcus are both capable of inducing a refractory infectious keratitis. In our case, the correct diagnosis was only obtained when the specimen was placed in a tissue grinder and immediately placed on anaerobic media to minimize exposure to oxygen. Although thioglycolate broth can support anaerobic growth, fastidious obligate organisms will only grow in chopped-meat- or carbohydrate-enriched media or "laked' blood agar. As Perry, Brinser, and Kolodner" emphasized, ophthalmologists should be cognizant of corneal disease caused by anaerobic infections. Proper culture technique using tissue fragments in the appropriate media is essential.
Fig. 2 (Eiferman, Ogden, and Snyder). Confluent midstromal cocci without surrounding inflammation (hematoxylin and eosin, x 100).
AMERICAN JOURNAL OF OPHTHALMOLOGY
August, 1985
Figure (Gerber). Lens loop-iris spatula.
single handle facilitates delivery of the lens nucleus during planned extracapsular surgery. The stainless steel instrument (Figure) consists of a 6 x 7-mm ultrathin blade lens loop (modified Gills/Welsh-type) at one end attached by a round knurled handle, 88 mm in length, to a 12-mm angled, round-tipped spatula (Cleasbytype) on the opposite end. The lens loop may be used to express or slide the nucleus. If the nucleus becomes trapped, the spatula end may be used to impale the nucleus or rotate it out of the eye under direct visualization.
Bacillus cereus Panophthalmitis
Appearing as Acute Glaucoma in a Drug Addict Hans Grossniklaus, M.D., William E. Bruner, M.D., K. Ellen Frank, M.D., and Edward W. Purnell, M.D. Division of Ophthalmology, University Hospitals of Cleveland, and Case Western Reserve University. This study was supported in part by the Ohio Lions Research Foundation.
Fig. 1 (Grossniklaus and associates). Ultrasonographic B-scan shows diffuse uveal thickening and uveal effusion (arrowhead). uveal thickening. The diagnosis was uveal effusion with displacement of the lens-iris diaphragm causing secondary angle-closure glaucoma. The patient was treated with topical prednisolone acetate 1 % and systemic prednisone. The next day he had left periorbital edema, a markedly chemotic left eye, and an anterior chamber hypopyon (Fig. 2). Anterior chamber and vitreous aspirates grew B. cereus. The patient admitted intravenous drug abuse. He was treated with intravitreal, topical, and systemic gentamicin sulfate and systemic chloramphenicol but his condition failed to improve and after three days required evisceration. Our patient was remarkably similar to the first patient described by Young and associates." Both were young male intravenous drug abusers who were treated for acute glaucoma in the left eye and who proved to have B. cereus panophthalmitis within 24 hours. We believe that early B. cereus panophthalmitis must be
Inquiries to William E. Bruner, M.D., 1611 S. Green Rd., Cleveland, OH 44121.
Endogenous Bacillus cereus panophthalmitis may result from intravenously administered drugs in drug addicts.P We recently examined a patient who had acute glaucoma as the initial manifestation of B. cereus panophthalmitis. He later admitted to being a drug abuser. This 27-year-old man had had acute pain in the left eye for eight hours. The intraocular pressure was 52 mm Hg. The angle was closed and the cornea was hazy. He was treated initially with topical pilocarpine hydrochloride 2%, oral glycerin, and intravenous mannitol. His intraocular pressure decreased to 32 mm Hg after one hour but the eye remained painful. B-scan ultrasonography (Fig. 1) showed diffuse
Fig. 2 (Grossniklaus and associates). Marked chemosis and hypopyon in the left eye the morning after admission.
Vol. 100, No.2
Letters To The Journal
considered in the differential diagnosis of acute monocular glaucoma in intravenous drug abusers.
References 1. Bouza, E., Grant,S., Jordan, C., Yook, R. H., and Sulit, H. L.: Bacillus cereus endogenous panophthalmitis. Arch. Ophthalmol. 97:498, 1979. 2. Hatem, G., Merritt, J. c.. and Cowan, C. L.: Bacillus cereus panophthalmitis after intravenous heroin. Ann. Ophthalmol. 11:431, 1979. 3. Young, E. J., Wallace, R. J., Ericson, C. D., Harris, R. A., and Clarridge, J.: Panophthalmitis due to Bacillus cereus. Arch. Intern. Med. 140:559, 1980.
Anaerobic Peptostreptococcal Keratitis Richard A. Eiferman, M.D., Lynn L. Ogden, M.D., and James Snyder, Ph.D. University of Louisville (R.A.E.), the Jewish Hospital (L.L.O), and Kosair-Childrens Hospital 0.5.). Inquiries to Richard A. Eiferman, M .. D., Department of Ophthalmology, University of Louisoille School of Medicine, 301 E. Muhammad Ali Blvd., Louisville, KY 40202.
An 83-year-old woman underwent a penetrating keratoplasty for pseudophakic bullous keratopathy. Five months postoperatively she developed a white, filamentous midstromal infiltrate without evidence of internal or external inflammation. Cultures and scrapings on two occasions were negative and the filaments
Fig. 1 (Eiferman, Ogden, and Snyder). Slit-lamp photograph demonstrating filamentous midstromal infiltrates.
335
eventually invaded the visual axis (Fig. 1) despite multiple antibiotics. A 9.5-mm penetrating keratoplasty completely removed the involved donor button. The specimen was bisected; one-half was sent for light and electron microscopy and the other half was immediately placed on anaerobic and aerobic media. All cultures except the ones placed on strict anaerobic media were negative. A choppedmeat broth grew a pure culture of Pepiostrepiococcus. Light microscopy disclosed deep stromal cords of bacteria without concomitant inflammation and a totally intact corneal epithelium. Brown-Bren stains showed a massive collection of confluent gram-positive cocci (Fig. 2); this was confirmed by electron microscopy. Peptostreptococcus is a rare cause of ocular disease and has been reported in anaerobic sites such as brain abscesses! and the vitreous cavity.v" One previously reported case of a corneal ulcer caused by Peptostreptococcus did not resemble this case. 4 Meisler and associates" reported a similar clinical pattern caused by Streptococcus viridans. This facultative aerobe and the anaerobic Pepiostreptococcus are both capable of inducing a refractory infectious keratitis. In our case, the correct diagnosis was only obtained when the specimen was placed in a tissue grinder and immediately placed on anaerobic media to minimize exposure to oxygen. Although thioglycolate broth can support anaerobic growth, fastidious obligate organisms will only grow in chopped-meat- or carbohydrate-enriched media or "laked' blood agar. As Perry, Brinser, and Kolodner" emphasized, ophthalmologists should be cognizant of corneal disease caused by anaerobic infections. Proper culture technique using tissue fragments in the appropriate media is essential.
Fig. 2 (Eiferman, Ogden, and Snyder). Confluent midstromal cocci without surrounding inflammation (hematoxylin and eosin, x 100).