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Delayed-Onset Pseudophakic Endophthalmitis
656
May, 1991
AMERICAN JOURNAL OF OPHTHALMOLOGY
v e n t i o n a p p e a r s to b e c r u c i a l for s u r v i v a l o f t h e g l o b e in p o s t t r a u m a t i c C. perfringens endoph thalmitis, the diagnosis and treatment of this infection before exotoxins destroy ocular tissue is difficult s i n c e t h i s o c c u r s r a p i d l y .
References 1. Leavelle, R.: Gas gangrene panophthalmitis. Arch. Ophthalmol. 53:634, 1955. 2. Duke-Elder, S., and MacFaul, P. Α.: Injuries. Mechanical Injuries. In Duke-Elder, S. (ed.): System of Ophthalmology, vol. 14, pt. 1. London, Henry Kimpton, 1972, pp. 4 0 5 - 4 1 0 . 3. Crock, G., Heriot, W. J . , Janakiraman, P., and Winer, J.: Gas gangrene of the eyes and orbits. Br. J. Ophthalmol. 69:143, 1985.
Correspondence Correspondence concerning recent articles or other mate rial published in THE JOURNAL should be submitted within six weeks of publication. Correspondence must be typed double-spaced, on 8V2 χ 11-inch bond paper with IVi-inch margins on all four sides and should be no more than two typewritten pages in length. Every effort will be made to resolve controversies between the correspondents and the authors of the article before publication.
Delayed-Onset Pseudophakie Endophthalmitis EDITOR:
In the a r t i c l e , " D e l a y e d - o n s e t P s e u d o p h a k i e e n d o p h t h a l m i t i s , " b y G . M. Fox, B . C. J o o n d e p h , H. W . F l y n n , J r . , S. C. Pflugfelder, a n d T. J . R o u s s e l ( A m . J . O p h t h a l m o l . 1 1 1 : 1 6 3 , F e b r u a r y 1 9 9 1 ) , ten o f the 19 p a t i e n t s h a d r e c u r r e n c e of c u l t u r e - p o s i t i v e e n d o p h t h a l m i t i s after v i t r e c t o m y with i n j e c t i o n o f s u b c o n j u n c tival a n d i n t r a o c u l a r a n t i b i o t i c s . T h r e e years a g o , we t r e a t e d a p a t i e n t with P s e u d o p h a k i e Propionibacterium acnes e n d o p h t h a l m i t i s o c c u r r i n g 1 8 m o n t h s after c a t a r a c t surgery. H e u n d e r w e n t a total p o s t e r i o r v i t r e c tomy, r e m o v a l of a large p l a q u e on the p o s t e r i or c a p s u l e , i n j e c t i o n o f i n t r a o c u l a r v a n c o m y c i n h y d r o c h l o r i d e (1 m g ) , a n d s u b c o n j u n c t i v a l i n jection of vancomycin hydrochloride (25 mg).
N o i n t r a v e n o u s or p r o l o n g e d t o p i c a l a n t i b i o t i c therapy was used. T h e inflammation initially i m p r o v e d b u t t h e n g r a d u a l l y r e c u r r e d . Two m o n t h s after the initial o p e r a t i o n , the p a t i e n t w a s o n c e again f o u n d to h a v e e n d o p h t h a l m i t i s with a positive culture. He was then admitted to the h o s p i t a l for o n e w e e k o f i n t r a v e n o u s v a n c o m y c i n h y d r o c h l o r i d e t h e r a p y a n d treat ment with topical vancomycin hydrochloride ( 5 0 m g / m l ) every o n e to two h o u r s for two weeks. The inflammation gradually subsided w i t h p r e d n i s o l o n e e y e d r o p s four t i m e s daily, a n d w i t h i n t h r e e m o n t h s all m e d i c a t i o n s w e r e discontinued with no residual inflammation. S i n c e our e x p e r i e n c e w i t h t h i s p a t i e n t , we have t r e a t e d t h r e e o t h e r p a t i e n t s w i t h P s e u d o p h a k i e c u l t u r e - p o s i t i v e P. acnes e n d o p h t h a l m i tis. All p a t i e n t s u n d e r w e n t v i t r e c t o m y w i t h r e m o v a l o f the c e n t r a l p o s t e r i o r c a p s u l e , i n j e c t i o n of i n t r a o c u l a r v a n c o m y c i n h y d r o c h l o r i d e , a n d a r e g i m e n o f five to s e v e n days of i n t r a v e n o u s v a n c o m y c i n h y d r o c h l o r i d e a n d frequent t o p i c a l v a n c o m y c i n h y d r o c h l o r i d e e y e d r o p s for two w e e k s . T h e i n t r a v e n o u s van c o m y c i n h y d r o c h l o r i d e was i n i t i a l l y given to e a c h p a t i e n t at a d o s a g e o f 1 g e v e r y 1 2 h o u r s . P e a k a n d t r o u g h levels w e r e o b t a i n e d t h r o u g h out the c o u r s e o f t h e r a p y , a n d t h e i n t r a v e n o u s d o s e s w e r e adjusted a c c o r d i n g l y to m a i n t a i n t h e r a p e u t i c b l o o d levels at all t i m e s . N o c a s e s of r e n a l toxicity d e v e l o p e d . The intraocular inflammation resolved total ly in all o f the p a t i e n t s w i t h i n t h r e e m o n t h s o f therapy using topical prednisolone, and the p a t i e n t s are c u r r e n t l y n o t t a k i n g any a n t i i n flammatory medications. We b e l i e v e that s y s t e m i c a n d t o p i c a l v a n c o mycin h y d r o c h l o r i d e t h e r a p y m a y b e n e c e s s a r y to e r a d i c a t e i n f e c t i o n t o t a l l y b y o r g a n i s m s s u c h as P. acnes, a n d this m a y h e l p to e x p l a i n w h y so m a n y o f the p a t i e n t s d e s c r i b e d b y Fox a n d a s s o c i a t e s h a d r e c u r r e n c e o f their e n d o p h thalmitis. M A R K H. H A I M A N N , M . D . HAROLD WEISS, M.D. J O E L A. M I L L E R , M . D .
Southfield,
Michigan
Reply EDITOR:
We r e a d w i t h i n t e r e s t t h e c a s e s o f Propioni bacterium acnes e n d o p h t h a l m i t i s r e p o r t e d b y Drs. H a i m a n n , Weiss, and Miller. We share
May, 1991
AMERICAN JOURNAL OF OPHTHALMOLOGY
v e n t i o n a p p e a r s to b e c r u c i a l for s u r v i v a l o f t h e g l o b e in p o s t t r a u m a t i c C. perfringens endoph thalmitis, the diagnosis and treatment of this infection before exotoxins destroy ocular tissue is difficult s i n c e t h i s o c c u r s r a p i d l y .
References 1. Leavelle, R.: Gas gangrene panophthalmitis. Arch. Ophthalmol. 53:634, 1955. 2. Duke-Elder, S., and MacFaul, P. Α.: Injuries. Mechanical Injuries. In Duke-Elder, S. (ed.): System of Ophthalmology, vol. 14, pt. 1. London, Henry Kimpton, 1972, pp. 4 0 5 - 4 1 0 . 3. Crock, G., Heriot, W. J . , Janakiraman, P., and Winer, J.: Gas gangrene of the eyes and orbits. Br. J. Ophthalmol. 69:143, 1985.
Correspondence Correspondence concerning recent articles or other mate rial published in THE JOURNAL should be submitted within six weeks of publication. Correspondence must be typed double-spaced, on 8V2 χ 11-inch bond paper with IVi-inch margins on all four sides and should be no more than two typewritten pages in length. Every effort will be made to resolve controversies between the correspondents and the authors of the article before publication.
Delayed-Onset Pseudophakie Endophthalmitis EDITOR:
In the a r t i c l e , " D e l a y e d - o n s e t P s e u d o p h a k i e e n d o p h t h a l m i t i s , " b y G . M. Fox, B . C. J o o n d e p h , H. W . F l y n n , J r . , S. C. Pflugfelder, a n d T. J . R o u s s e l ( A m . J . O p h t h a l m o l . 1 1 1 : 1 6 3 , F e b r u a r y 1 9 9 1 ) , ten o f the 19 p a t i e n t s h a d r e c u r r e n c e of c u l t u r e - p o s i t i v e e n d o p h t h a l m i t i s after v i t r e c t o m y with i n j e c t i o n o f s u b c o n j u n c tival a n d i n t r a o c u l a r a n t i b i o t i c s . T h r e e years a g o , we t r e a t e d a p a t i e n t with P s e u d o p h a k i e Propionibacterium acnes e n d o p h t h a l m i t i s o c c u r r i n g 1 8 m o n t h s after c a t a r a c t surgery. H e u n d e r w e n t a total p o s t e r i o r v i t r e c tomy, r e m o v a l of a large p l a q u e on the p o s t e r i or c a p s u l e , i n j e c t i o n o f i n t r a o c u l a r v a n c o m y c i n h y d r o c h l o r i d e (1 m g ) , a n d s u b c o n j u n c t i v a l i n jection of vancomycin hydrochloride (25 mg).
N o i n t r a v e n o u s or p r o l o n g e d t o p i c a l a n t i b i o t i c therapy was used. T h e inflammation initially i m p r o v e d b u t t h e n g r a d u a l l y r e c u r r e d . Two m o n t h s after the initial o p e r a t i o n , the p a t i e n t w a s o n c e again f o u n d to h a v e e n d o p h t h a l m i t i s with a positive culture. He was then admitted to the h o s p i t a l for o n e w e e k o f i n t r a v e n o u s v a n c o m y c i n h y d r o c h l o r i d e t h e r a p y a n d treat ment with topical vancomycin hydrochloride ( 5 0 m g / m l ) every o n e to two h o u r s for two weeks. The inflammation gradually subsided w i t h p r e d n i s o l o n e e y e d r o p s four t i m e s daily, a n d w i t h i n t h r e e m o n t h s all m e d i c a t i o n s w e r e discontinued with no residual inflammation. S i n c e our e x p e r i e n c e w i t h t h i s p a t i e n t , we have t r e a t e d t h r e e o t h e r p a t i e n t s w i t h P s e u d o p h a k i e c u l t u r e - p o s i t i v e P. acnes e n d o p h t h a l m i tis. All p a t i e n t s u n d e r w e n t v i t r e c t o m y w i t h r e m o v a l o f the c e n t r a l p o s t e r i o r c a p s u l e , i n j e c t i o n of i n t r a o c u l a r v a n c o m y c i n h y d r o c h l o r i d e , a n d a r e g i m e n o f five to s e v e n days of i n t r a v e n o u s v a n c o m y c i n h y d r o c h l o r i d e a n d frequent t o p i c a l v a n c o m y c i n h y d r o c h l o r i d e e y e d r o p s for two w e e k s . T h e i n t r a v e n o u s van c o m y c i n h y d r o c h l o r i d e was i n i t i a l l y given to e a c h p a t i e n t at a d o s a g e o f 1 g e v e r y 1 2 h o u r s . P e a k a n d t r o u g h levels w e r e o b t a i n e d t h r o u g h out the c o u r s e o f t h e r a p y , a n d t h e i n t r a v e n o u s d o s e s w e r e adjusted a c c o r d i n g l y to m a i n t a i n t h e r a p e u t i c b l o o d levels at all t i m e s . N o c a s e s of r e n a l toxicity d e v e l o p e d . The intraocular inflammation resolved total ly in all o f the p a t i e n t s w i t h i n t h r e e m o n t h s o f therapy using topical prednisolone, and the p a t i e n t s are c u r r e n t l y n o t t a k i n g any a n t i i n flammatory medications. We b e l i e v e that s y s t e m i c a n d t o p i c a l v a n c o mycin h y d r o c h l o r i d e t h e r a p y m a y b e n e c e s s a r y to e r a d i c a t e i n f e c t i o n t o t a l l y b y o r g a n i s m s s u c h as P. acnes, a n d this m a y h e l p to e x p l a i n w h y so m a n y o f the p a t i e n t s d e s c r i b e d b y Fox a n d a s s o c i a t e s h a d r e c u r r e n c e o f their e n d o p h thalmitis. M A R K H. H A I M A N N , M . D . HAROLD WEISS, M.D. J O E L A. M I L L E R , M . D .
Southfield,
Michigan
Reply EDITOR:
We r e a d w i t h i n t e r e s t t h e c a s e s o f Propioni bacterium acnes e n d o p h t h a l m i t i s r e p o r t e d b y Drs. H a i m a n n , Weiss, and Miller. We share