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Bacillus cereus Panophthalmitis Manifesting as an Orbital Cellulitis
Vol. 103, No. 1
Letters to the Journal
for human immunodeficiency virus were 25, 68, and 74 years old. In the 68-year-old and 74-year-old donors the Western Blot confirmed* a human immunodeficiency virus infection. The histories of these patients disclosed that they had had many blood transfusions before death. The first transfusion was in 1983. None of these patients, however, had a history of clinically overt AIDS. Microbiologic work-ups of cultured corneoscleral rims did not prove a bacterial or mycotic contamination in the samples tested. Fungal contamination did occur once in an unopened McCarey-Kaufman medium containing vial be fore the expiration date. Our initial data suggest that increased atten tion must be given to microbiologic and virus work-ups of donors and devices used before corneal grafting, particularly if they pose a potential threat to the general health of the recipient. History-taking for infectious dis eases of a cornea donor is not sufficient; lab oratory evaluation of serum samples for human immunodeficiency virus and HB s Ag is necessary.
References 1. Fujikawa, W. R., Salahuddin, S. Z., Palestine, A. G., Masur, H., Nussenblatt, R. B., and Gallo, R. C : Isolation of HTLV-III from the tears of a patient with AIDS. Lancet 2:529, 1985. 2. Fujikawa, W. R., Salahuddin, S. Z., Ablashi, D., Palestine, A. G., Masur, H., Nussenblatt, R. B., and Gallo, R.C.: HTLV-III in the conjunctival epithe lium of a patient with AIDS. Am. J. Ophthalmol. 100:507, 1985. 3. Salahuddin, S. Z., Palestine, A. G., Heck, E., Ablashi, D., Luckenbach, M., McCulley, J. P., and Nussenblatt, R. B.: Isolation of HTLV-III from the cornea. Am. J. Ophthalmol. 101:149, 1986. 4. Houff, S. A., Burton, R. C., Wilson, R. W., Henson, T. E., London, W. T., Baer, G. M., Anderson, L. J., Winkler, W. G., Madden, D. L., and Sever, J. L.: Human-to-human transmission of rabies virus by corneal transplantation. N. Engl. J. Med. 300:603, 1979. 5. Manuelidis, E. E., Angelo, J. N., and Gorgacz, E. J.: Experimental Creutzfeldt-Jakob disease trans mitted via the eye with infected cornea. N. Engl. J. Med. 296:1334, 1985. 6. Gandhi, S. S., Lamberts, D. W., and Perry, H. D.: Donor to host transmission of disease via corneal transplantation. Surv. Ophthalmol. 25:306, 1981.
105
Bacillus cereus Panophthalmitis Manifesting as an Orbital Ceilulitis Saul Ullman, M.D., Stephen C. Pflugfelder, M.D., Randy Hughes, B.S., and Richard K. Forster, M.D. Bascom Palmer Eye Institute, Department of Oph thalmology, University of Miami School of Medicine. Inquiries to Saul Ullman, M.D., Bascom Palmer Eye Institute, University of Miami School of Medicine, P.O. Box 016880, Miami, FL 33101. Bacillus cereus is an aerobic, gram-positive, spore forming organism that has emerged as one of the most virulent bacteria to affect the eye. We recently treated a patient who had an atypical orbital ceilulitis and posterior scleritis secondary to this organism. A 32-year-old woman had a one-day history of decreased vision, proptosis, and pain in the right eye associated with fevers and chills. She denied a history of trauma, sinus disease, or known malignancies. The patient was a drug abuser who had a positive serum antibody to the human T-cell leukemia-lymphotropic virus type III (HTLV-III). On initial examination the visual acuity was no light perception in the right eye; visual acuity in the left eye was 20/20. There was marked edema and erythema of the right eyelids associated with 10 mm of propto sis and complete ophthalmoplegia (Fig. 1). Slitlamp examination showed diffuse corneal edema without an epithelial defect or infiltrate. Applanation tension was 50 mm Hg and the anterior chamber was formed centrally only. There was no hypopyon. Fundus details could not be visualized secondary to the corneal edema; however, a red reflex was noted.
Fig. 1 (Ullman and associates). Marked swelling and erythema of the right upper and lower eyelids.
106
January, 1987
AMERICAN JOURNAL OF OPHTHALMOLOGY
cal manifestation of this devastating ocular in fection.
References
Fig. 2 (Ullman and associates). Computed tomog raphy (axial view) shows marked proptosis, scleral thickening, and irregular enhancement of orbital structures on the right side.
Standardized echography showed choroidal and scleral thickening and diffuse widening of all orbital structures. No vitreal opacities were noted. Computed tomography showed marked proptosis, diffuse thickening of the sclera, and irregular enhancement of all orbital structures (Fig. 2). The sinuses were normal. Despite intravenous clindamycin, gentamicin, and penicillin a ring-shaped peripheral corneal abscess in association with a central abscess developed, which perforated after one day of treatment. Corneal cultures disclosed B. cereus sensitive to both gentamicin and clinda mycin. After five days of this therapy the prop tosis was decreased and an evisceration was performed. At surgery the vitreous was noted to be clear and the intraocular contents ap peared normal. Cultures of the evisceration specimen disclosed persistent B. cereus. The association of intravenous drug abuse and endogeneous B. cereus infections is well known. 1 3 Tuazon, Hill, and Sheagren 4 have shown it to be the most common bacterial contaminant in the injection paraphernalia of drug addicts. Our patient was unusual in that she initially had the clinical, radiographic, and ultrasonographic appearance of an orbital cellulitis and associated posterior scleritis. This rapidly deteriorated into a panophthalmitis re quiring evisceration. O'Day and coworkers 5 have suggested that the concomitant adminis tration of gentamicin and clindamycin may act synergistically against B. cereus. Despite the rapid institution of this therapy and five days of treatment we were unable to sterilize the intraocular contents or salvage the eye in our patient. This case emphasizes the varied clini
1. Hatem, G., Merritt, J. C , and Cowan, C. J., Jr.: Bacillus cereus panophthalmitis after intravenous her oin. Ann. Ophthalmol. 11:431, 1979. 2. McLane, N. J., and Carroll, D. M: Ocular manifestations of drug abuse. Surv. Ophthalmol. 30:298, 1986. 3. Grossniklaus, H., Bruner, W. E., Frank, K. E., and Purnell, E. W.: Bacillus cereus panophthalmitis appearing as acute glaucoma in a drug addict. Am. J. Ophthalmol. 100:334, 1985. 4. Tuazon, C. U., Hill, R., and Sheagren, J. N.: Microbiologic study of steet heroin and injection paraphernalia. J. Infect. Dis. 129:327, 1974. 5. O'Day, D. M., Smith, R. S., Gregg, C. R., Turnbull, P. C , Head, W. S., Ives, J. A., and Ho, P. C : The problem of bacillus species infection with special emphasis on the virulence of Bacillus cereus. Ophthalmology 88:833, 1981.
Cannulated Subretinal Fluid Aspirator for Vitreoretinal Microsurgery Harry W. Flynn, Jr., M . D . , Mark S. Blumenkranz, M . D . , Jean Marie Parel, Ing. ETS-G., and William G. Lee Bascom Palmer Eye Institute, Department of Oph thalmology, University of Miami School of Medicine. The authors have no commercial, proprietary, or financial interest in the cannulated subretinal fluid aspirator. Inquiries to Harry W. Flynn, Jr., M.D., Bascom Palmer Eye Institute, 900 N.W. 17th St., Miami, FL 33136. Internal drainage of subretinal fluid during vitreoretinal microsurgery is a common tech nique in the management of complex retinal de tachments. Using this technique, subretinal fluid is drained through a pre-existing retinal hole or through an intentionally created retinotomy. A blunt or tapered needle is intro duced through the pars plana and positioned near the retinal break to allow egress of subreti nal fluid out of the eye as air or gas enters the vitreous cavity by a separately placed infusion cannula. 1,2
Letters to the Journal
for human immunodeficiency virus were 25, 68, and 74 years old. In the 68-year-old and 74-year-old donors the Western Blot confirmed* a human immunodeficiency virus infection. The histories of these patients disclosed that they had had many blood transfusions before death. The first transfusion was in 1983. None of these patients, however, had a history of clinically overt AIDS. Microbiologic work-ups of cultured corneoscleral rims did not prove a bacterial or mycotic contamination in the samples tested. Fungal contamination did occur once in an unopened McCarey-Kaufman medium containing vial be fore the expiration date. Our initial data suggest that increased atten tion must be given to microbiologic and virus work-ups of donors and devices used before corneal grafting, particularly if they pose a potential threat to the general health of the recipient. History-taking for infectious dis eases of a cornea donor is not sufficient; lab oratory evaluation of serum samples for human immunodeficiency virus and HB s Ag is necessary.
References 1. Fujikawa, W. R., Salahuddin, S. Z., Palestine, A. G., Masur, H., Nussenblatt, R. B., and Gallo, R. C : Isolation of HTLV-III from the tears of a patient with AIDS. Lancet 2:529, 1985. 2. Fujikawa, W. R., Salahuddin, S. Z., Ablashi, D., Palestine, A. G., Masur, H., Nussenblatt, R. B., and Gallo, R.C.: HTLV-III in the conjunctival epithe lium of a patient with AIDS. Am. J. Ophthalmol. 100:507, 1985. 3. Salahuddin, S. Z., Palestine, A. G., Heck, E., Ablashi, D., Luckenbach, M., McCulley, J. P., and Nussenblatt, R. B.: Isolation of HTLV-III from the cornea. Am. J. Ophthalmol. 101:149, 1986. 4. Houff, S. A., Burton, R. C., Wilson, R. W., Henson, T. E., London, W. T., Baer, G. M., Anderson, L. J., Winkler, W. G., Madden, D. L., and Sever, J. L.: Human-to-human transmission of rabies virus by corneal transplantation. N. Engl. J. Med. 300:603, 1979. 5. Manuelidis, E. E., Angelo, J. N., and Gorgacz, E. J.: Experimental Creutzfeldt-Jakob disease trans mitted via the eye with infected cornea. N. Engl. J. Med. 296:1334, 1985. 6. Gandhi, S. S., Lamberts, D. W., and Perry, H. D.: Donor to host transmission of disease via corneal transplantation. Surv. Ophthalmol. 25:306, 1981.
105
Bacillus cereus Panophthalmitis Manifesting as an Orbital Ceilulitis Saul Ullman, M.D., Stephen C. Pflugfelder, M.D., Randy Hughes, B.S., and Richard K. Forster, M.D. Bascom Palmer Eye Institute, Department of Oph thalmology, University of Miami School of Medicine. Inquiries to Saul Ullman, M.D., Bascom Palmer Eye Institute, University of Miami School of Medicine, P.O. Box 016880, Miami, FL 33101. Bacillus cereus is an aerobic, gram-positive, spore forming organism that has emerged as one of the most virulent bacteria to affect the eye. We recently treated a patient who had an atypical orbital ceilulitis and posterior scleritis secondary to this organism. A 32-year-old woman had a one-day history of decreased vision, proptosis, and pain in the right eye associated with fevers and chills. She denied a history of trauma, sinus disease, or known malignancies. The patient was a drug abuser who had a positive serum antibody to the human T-cell leukemia-lymphotropic virus type III (HTLV-III). On initial examination the visual acuity was no light perception in the right eye; visual acuity in the left eye was 20/20. There was marked edema and erythema of the right eyelids associated with 10 mm of propto sis and complete ophthalmoplegia (Fig. 1). Slitlamp examination showed diffuse corneal edema without an epithelial defect or infiltrate. Applanation tension was 50 mm Hg and the anterior chamber was formed centrally only. There was no hypopyon. Fundus details could not be visualized secondary to the corneal edema; however, a red reflex was noted.
Fig. 1 (Ullman and associates). Marked swelling and erythema of the right upper and lower eyelids.
106
January, 1987
AMERICAN JOURNAL OF OPHTHALMOLOGY
cal manifestation of this devastating ocular in fection.
References
Fig. 2 (Ullman and associates). Computed tomog raphy (axial view) shows marked proptosis, scleral thickening, and irregular enhancement of orbital structures on the right side.
Standardized echography showed choroidal and scleral thickening and diffuse widening of all orbital structures. No vitreal opacities were noted. Computed tomography showed marked proptosis, diffuse thickening of the sclera, and irregular enhancement of all orbital structures (Fig. 2). The sinuses were normal. Despite intravenous clindamycin, gentamicin, and penicillin a ring-shaped peripheral corneal abscess in association with a central abscess developed, which perforated after one day of treatment. Corneal cultures disclosed B. cereus sensitive to both gentamicin and clinda mycin. After five days of this therapy the prop tosis was decreased and an evisceration was performed. At surgery the vitreous was noted to be clear and the intraocular contents ap peared normal. Cultures of the evisceration specimen disclosed persistent B. cereus. The association of intravenous drug abuse and endogeneous B. cereus infections is well known. 1 3 Tuazon, Hill, and Sheagren 4 have shown it to be the most common bacterial contaminant in the injection paraphernalia of drug addicts. Our patient was unusual in that she initially had the clinical, radiographic, and ultrasonographic appearance of an orbital cellulitis and associated posterior scleritis. This rapidly deteriorated into a panophthalmitis re quiring evisceration. O'Day and coworkers 5 have suggested that the concomitant adminis tration of gentamicin and clindamycin may act synergistically against B. cereus. Despite the rapid institution of this therapy and five days of treatment we were unable to sterilize the intraocular contents or salvage the eye in our patient. This case emphasizes the varied clini
1. Hatem, G., Merritt, J. C , and Cowan, C. J., Jr.: Bacillus cereus panophthalmitis after intravenous her oin. Ann. Ophthalmol. 11:431, 1979. 2. McLane, N. J., and Carroll, D. M: Ocular manifestations of drug abuse. Surv. Ophthalmol. 30:298, 1986. 3. Grossniklaus, H., Bruner, W. E., Frank, K. E., and Purnell, E. W.: Bacillus cereus panophthalmitis appearing as acute glaucoma in a drug addict. Am. J. Ophthalmol. 100:334, 1985. 4. Tuazon, C. U., Hill, R., and Sheagren, J. N.: Microbiologic study of steet heroin and injection paraphernalia. J. Infect. Dis. 129:327, 1974. 5. O'Day, D. M., Smith, R. S., Gregg, C. R., Turnbull, P. C , Head, W. S., Ives, J. A., and Ho, P. C : The problem of bacillus species infection with special emphasis on the virulence of Bacillus cereus. Ophthalmology 88:833, 1981.
Cannulated Subretinal Fluid Aspirator for Vitreoretinal Microsurgery Harry W. Flynn, Jr., M . D . , Mark S. Blumenkranz, M . D . , Jean Marie Parel, Ing. ETS-G., and William G. Lee Bascom Palmer Eye Institute, Department of Oph thalmology, University of Miami School of Medicine. The authors have no commercial, proprietary, or financial interest in the cannulated subretinal fluid aspirator. Inquiries to Harry W. Flynn, Jr., M.D., Bascom Palmer Eye Institute, 900 N.W. 17th St., Miami, FL 33136. Internal drainage of subretinal fluid during vitreoretinal microsurgery is a common tech nique in the management of complex retinal de tachments. Using this technique, subretinal fluid is drained through a pre-existing retinal hole or through an intentionally created retinotomy. A blunt or tapered needle is intro duced through the pars plana and positioned near the retinal break to allow egress of subreti nal fluid out of the eye as air or gas enters the vitreous cavity by a separately placed infusion cannula. 1,2