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Endophthalmitis
NOTES, CASES,
Athinon. Fundus examination revealed in both cases a marked blurring of the disc margins with a few small hemorrhages and extensive white exudates. The retinal arteries were partly covered by a white sheath, while the veins were dilated and tortuous. Swelling of the optic disc was moderate (no more than 2.0D.). The cloudy picture resembled turbidity of the hyaloid membrane. Visual acuity was relatively normal. The visual field was slightly constricted, while the blindspot was enlarged. It was concluded that these cases were neither typical optic neuritis, because the visual acuity and visual fields were normal, nor edema of the disc, which has a different appearance. The E E G showed profound disturbance of the rhythm, with spikes and rhythm of medial amplitude. These spikes, almost equal on both sides, were recorded chiefly in the anterior region. The whole clinical picture lead to the conclusion that inflammation of the nerve sheath, and probably of the connective tissue which separates the nerve bundles, was to be blamed. That is to say it was thought that exudative edema of the disc was present without damage of the neuroaxons of the optic nerve. 17 Pindar ou Street. ENDOPHTHALMITIS IN
A CONTACT LENS
JOHN
WEARER
J. W I L D ,
Tucson,
M.D.
Arizona
More contact lenses are being fit and ophthalmologists will be called upon to treat the complications of their wear. The case presented is of a 56-year-old white woman, a bilateral aphake. As a result of contact lens wear she suffered a purulent endophthalmitis resulting in loss of useful vision of the left eye. CASE
REPORT
T h e patient had cataract surgery done elsewhere on her right eye in January, 1959, and the left e y e
INSTRUMENTS
847
F I G . 1 ( W i l d ) . Appearance of left eye on admission, J u l y 27, 1961.
in April, 1959. S h e had small iris prolapses and blebs a l o n g the incision in both eyes. S h e w a s fitted w i t h contact lenses about s i x m o n t h s after surgery and found the vision far superior t o conventional glasses. In early July, 1961, her contact lenses w e r e returned t o the factory for adjustment. E x a m i n a t i o n of the returned lenses s h o w e d n o roughness o r sharpness o f the lens e d g e s or surfaces. S h e had a purulent conjunctivitis during the time the lenses w e r e g o n e w h i c h had cleared by the time the lenses w e r e returned. S h e w o r e the lenses only t w o or three hours daily for five days after their return. O n the s i x t h day, the left e y e w a s m o r e u n c o m fortable and red. S h e w a s seen in the office that afternoon w i t h the bulbar conjunctiva diffusely red and minimal purulent e x u d a t e present. T h e ocular tactile tensions w e r e normal. T h e cornea did not stain and a one-plus flare and cells w e r e seen in the anterior chamber. S h e w a s immediately started on systemic a n d topical Chloromycetin. T h e n e x t m o r n i n g she had a frank purulent endophthalmitis. T h e lids w e r e red and swollen, the conjunctiva red and chemotic. T h e r e w a s pus in the anterior c h a m ber and vitreous. T h e right eye w a s entirely normal. S h e w a s hospitalized that day (fig. 1 ) . Cultures w e r e taken from the conjunctival sac for bacteria and fungus. T h e only o r g a n i s m g r o w n w a s a n o n hemolytic Staph, albus, coagulase negative. S h e w a s placed on topical Chloromycetin, neosporin and steroids. S y s t e m i c penicillin, Chloromycetin and steroids w e r e given. Subconjunctival p o l y m y x i n w a s g i v e n o n the first and third hospital day and a keratocentesis w a s p e r f o r m e d o n the second day. T h e eye gradually improved and she w a s disc h a r g e d on A u g u s t 5th. A t this time the e y e had a flat anterior chamber. T h e vitreous w a s grossly cloudy and bare light perception w a s present. A t the present time the vitreous remains cloudy, bare light perception is present but the anterior c h a m ber h a s reformed. T h e ocular tensions are normal.
848
NOTES, CASES, DISCUSSION
I feel that the contact lens partially eroded through one of the conjunctival blebs. The iris then acted as a wick for organisms present in the conjunctival sac to be introduced into the eye. The purulent conjunctivitis of the week before, plus the patient's habit of using saliva as a wetting agent suggest a large bacterial population in the conjunctival sac. The use of contact lenses in eyes with conjunctival blebs, the habit of using saliva as a wetting agent and the wearing of contact lenses in the presence of infection in or about the eye are dangerous practices. 607 North 4th Avenue.
CATARACT EXTRACTION* I N A CASE OF B U P H T H A L M O S JOHN
D.
R O S C O E J.
GUNDZIK,
M.D.
KENNEDY,
M.D.
AND J A M E S H.
MAYER,
Cleveland,
M.D.
Ohio
Cataract extraction in patients who have buphthalmos is rare ; no cases could be found in the indexed literature of the last 44 years. W e are reporting a case that we believe is significant because it illustrates that untreated buphthalmos does not invariably terminate in blindness and that partial arrest is possible. Cataract extraction can be successfully performed in such cases. REPORT OF A
INSTRUMENTS In December, 1940, because of e x t r e m e pain and tenderness the patient underwent enucleation of the right e y e at another hospital. Examination at that time revealed that his vision w a s : O . D , 2 0 / 2 0 0 ; O.S., 2 0 / 7 0 with correction. T h e right globe w a s stony hard with an enlarged, hazy cornea. T h e l e f t eye had an enlarged cornea ( 1 6 m m . in diame t e r ) with normal intraocular pressure to finger palpation. Fundus examination of the right eye w a s impossible because of corneal edema. E x a m i n a t i o n of the -left eye showed clear media ; the disc w a s normal except for severe excavation. V i s u a l fields showed peripheral constriction consistent with glaucoma. One year later, in December, 1941, he w a s e x amined in the Department of Ophthalmology at the Cleveland Clinic. A t that time examination showed the f o l l o w i n g : O . D . had been enucleated. Vision, O.S., 2 0 / 1 0 0 without correction; 2 0 / 7 0 with correction, tension ( S c h i ^ t z ) O.S., 16/10 w t , 6.0 m m . H g . F i g u r e 1 s h o w s the visual field. L e f t eye. Corneal diameter 16 m m . Small vertical hyalinized breaks in Descemet's membrane temporal to pupil. A n t e r i o r chamber deep, iris normal, pupil round, reacted to light but not to accommodation. F u n d u s : media clear. D i s c : round, flat, pale, with sharp scleral margins, narrow nerve zone, deep cut but n o displacement of vessels. Macula, periphery, and vessels w e r e normal. W h e n first examined at St. V i n c e n t Charity H o s pital o n M a r c h 22, 1955, vision w a s : O.S., 7/200 with correction. Intraocular pressure ( S c h l i t z ) O . S . 18 mm. H g . L i g h t fields s h o w e d e x t r e m e constriction. Fundus, O.S., revealed dense, immature nuclear sclerosis w i t h a g o o d red fundus reflex, but details w e r e not visible. Cataract extraction w a s not recommended. D u r i n g the f o l l o w i n g years, ocular tensions remained normal. I n 1960, fundus e x a m i nation revealed a dense mature cataract. T h e patient w a s advised to have cataract extraction and w a s also informed of the possibility of an unsatisfactory result. O n March 28, 1961, the patient underwent a c o m bined intracapsular cataract extraction with cornN a m e : w.CDate: February,
1941
..
20/70 T e
CASE
W . C , a 68-year-old white man, w a s first e x a m ined in the Department of Ophthalmology, St. V i n cent Charity Hospital, o n March 22, 1955. H e had poor vision with constricted fields in both e y e s since early childhood. A t the age of seven years, an accidental puncture wound of the right globe caused the loss of vision in the right eye. T h e family, consisting of mother, father, three brothers and one sister, w a s free of ocular disease except that the sister had esotropia. T h e grandparents had no ocular disease.
T..t Object.
* F r o m the Departments of Ophthalmology, T h e Cleveland Clinic Foundation and St. Vincent Charity Hospital.
UO/IOOO Cooperation good F i g . 1 (Gundzik, Kennedy, and M a y e r ) . S h o w s the central visual field w h e n first e x a m i n e d at the Cleveland Clinic.
-T?''°°°
CP
7 ft
Athinon. Fundus examination revealed in both cases a marked blurring of the disc margins with a few small hemorrhages and extensive white exudates. The retinal arteries were partly covered by a white sheath, while the veins were dilated and tortuous. Swelling of the optic disc was moderate (no more than 2.0D.). The cloudy picture resembled turbidity of the hyaloid membrane. Visual acuity was relatively normal. The visual field was slightly constricted, while the blindspot was enlarged. It was concluded that these cases were neither typical optic neuritis, because the visual acuity and visual fields were normal, nor edema of the disc, which has a different appearance. The E E G showed profound disturbance of the rhythm, with spikes and rhythm of medial amplitude. These spikes, almost equal on both sides, were recorded chiefly in the anterior region. The whole clinical picture lead to the conclusion that inflammation of the nerve sheath, and probably of the connective tissue which separates the nerve bundles, was to be blamed. That is to say it was thought that exudative edema of the disc was present without damage of the neuroaxons of the optic nerve. 17 Pindar ou Street. ENDOPHTHALMITIS IN
A CONTACT LENS
JOHN
WEARER
J. W I L D ,
Tucson,
M.D.
Arizona
More contact lenses are being fit and ophthalmologists will be called upon to treat the complications of their wear. The case presented is of a 56-year-old white woman, a bilateral aphake. As a result of contact lens wear she suffered a purulent endophthalmitis resulting in loss of useful vision of the left eye. CASE
REPORT
T h e patient had cataract surgery done elsewhere on her right eye in January, 1959, and the left e y e
INSTRUMENTS
847
F I G . 1 ( W i l d ) . Appearance of left eye on admission, J u l y 27, 1961.
in April, 1959. S h e had small iris prolapses and blebs a l o n g the incision in both eyes. S h e w a s fitted w i t h contact lenses about s i x m o n t h s after surgery and found the vision far superior t o conventional glasses. In early July, 1961, her contact lenses w e r e returned t o the factory for adjustment. E x a m i n a t i o n of the returned lenses s h o w e d n o roughness o r sharpness o f the lens e d g e s or surfaces. S h e had a purulent conjunctivitis during the time the lenses w e r e g o n e w h i c h had cleared by the time the lenses w e r e returned. S h e w o r e the lenses only t w o or three hours daily for five days after their return. O n the s i x t h day, the left e y e w a s m o r e u n c o m fortable and red. S h e w a s seen in the office that afternoon w i t h the bulbar conjunctiva diffusely red and minimal purulent e x u d a t e present. T h e ocular tactile tensions w e r e normal. T h e cornea did not stain and a one-plus flare and cells w e r e seen in the anterior chamber. S h e w a s immediately started on systemic a n d topical Chloromycetin. T h e n e x t m o r n i n g she had a frank purulent endophthalmitis. T h e lids w e r e red and swollen, the conjunctiva red and chemotic. T h e r e w a s pus in the anterior c h a m ber and vitreous. T h e right eye w a s entirely normal. S h e w a s hospitalized that day (fig. 1 ) . Cultures w e r e taken from the conjunctival sac for bacteria and fungus. T h e only o r g a n i s m g r o w n w a s a n o n hemolytic Staph, albus, coagulase negative. S h e w a s placed on topical Chloromycetin, neosporin and steroids. S y s t e m i c penicillin, Chloromycetin and steroids w e r e given. Subconjunctival p o l y m y x i n w a s g i v e n o n the first and third hospital day and a keratocentesis w a s p e r f o r m e d o n the second day. T h e eye gradually improved and she w a s disc h a r g e d on A u g u s t 5th. A t this time the e y e had a flat anterior chamber. T h e vitreous w a s grossly cloudy and bare light perception w a s present. A t the present time the vitreous remains cloudy, bare light perception is present but the anterior c h a m ber h a s reformed. T h e ocular tensions are normal.
848
NOTES, CASES, DISCUSSION
I feel that the contact lens partially eroded through one of the conjunctival blebs. The iris then acted as a wick for organisms present in the conjunctival sac to be introduced into the eye. The purulent conjunctivitis of the week before, plus the patient's habit of using saliva as a wetting agent suggest a large bacterial population in the conjunctival sac. The use of contact lenses in eyes with conjunctival blebs, the habit of using saliva as a wetting agent and the wearing of contact lenses in the presence of infection in or about the eye are dangerous practices. 607 North 4th Avenue.
CATARACT EXTRACTION* I N A CASE OF B U P H T H A L M O S JOHN
D.
R O S C O E J.
GUNDZIK,
M.D.
KENNEDY,
M.D.
AND J A M E S H.
MAYER,
Cleveland,
M.D.
Ohio
Cataract extraction in patients who have buphthalmos is rare ; no cases could be found in the indexed literature of the last 44 years. W e are reporting a case that we believe is significant because it illustrates that untreated buphthalmos does not invariably terminate in blindness and that partial arrest is possible. Cataract extraction can be successfully performed in such cases. REPORT OF A
INSTRUMENTS In December, 1940, because of e x t r e m e pain and tenderness the patient underwent enucleation of the right e y e at another hospital. Examination at that time revealed that his vision w a s : O . D , 2 0 / 2 0 0 ; O.S., 2 0 / 7 0 with correction. T h e right globe w a s stony hard with an enlarged, hazy cornea. T h e l e f t eye had an enlarged cornea ( 1 6 m m . in diame t e r ) with normal intraocular pressure to finger palpation. Fundus examination of the right eye w a s impossible because of corneal edema. E x a m i n a t i o n of the -left eye showed clear media ; the disc w a s normal except for severe excavation. V i s u a l fields showed peripheral constriction consistent with glaucoma. One year later, in December, 1941, he w a s e x amined in the Department of Ophthalmology at the Cleveland Clinic. A t that time examination showed the f o l l o w i n g : O . D . had been enucleated. Vision, O.S., 2 0 / 1 0 0 without correction; 2 0 / 7 0 with correction, tension ( S c h i ^ t z ) O.S., 16/10 w t , 6.0 m m . H g . F i g u r e 1 s h o w s the visual field. L e f t eye. Corneal diameter 16 m m . Small vertical hyalinized breaks in Descemet's membrane temporal to pupil. A n t e r i o r chamber deep, iris normal, pupil round, reacted to light but not to accommodation. F u n d u s : media clear. D i s c : round, flat, pale, with sharp scleral margins, narrow nerve zone, deep cut but n o displacement of vessels. Macula, periphery, and vessels w e r e normal. W h e n first examined at St. V i n c e n t Charity H o s pital o n M a r c h 22, 1955, vision w a s : O.S., 7/200 with correction. Intraocular pressure ( S c h l i t z ) O . S . 18 mm. H g . L i g h t fields s h o w e d e x t r e m e constriction. Fundus, O.S., revealed dense, immature nuclear sclerosis w i t h a g o o d red fundus reflex, but details w e r e not visible. Cataract extraction w a s not recommended. D u r i n g the f o l l o w i n g years, ocular tensions remained normal. I n 1960, fundus e x a m i nation revealed a dense mature cataract. T h e patient w a s advised to have cataract extraction and w a s also informed of the possibility of an unsatisfactory result. O n March 28, 1961, the patient underwent a c o m bined intracapsular cataract extraction with cornN a m e : w.CDate: February,
1941
..
20/70 T e
CASE
W . C , a 68-year-old white man, w a s first e x a m ined in the Department of Ophthalmology, St. V i n cent Charity Hospital, o n March 22, 1955. H e had poor vision with constricted fields in both e y e s since early childhood. A t the age of seven years, an accidental puncture wound of the right globe caused the loss of vision in the right eye. T h e family, consisting of mother, father, three brothers and one sister, w a s free of ocular disease except that the sister had esotropia. T h e grandparents had no ocular disease.
T..t Object.
* F r o m the Departments of Ophthalmology, T h e Cleveland Clinic Foundation and St. Vincent Charity Hospital.
UO/IOOO Cooperation good F i g . 1 (Gundzik, Kennedy, and M a y e r ) . S h o w s the central visual field w h e n first e x a m i n e d at the Cleveland Clinic.
-T?''°°°
CP
7 ft