One should be highly suspicious of herpesvirus involvement in the pathogenesis of unknown uveitis and herpes simplex virus, in particular, in PosnerSchlossman syndrome. Viral and host immune sys tems seem to play key roles in the clinical expression of these ocular diseases. Further studies are necessary to confirm these observations in a large patient series. REFERENCES 1. Posner A, Schlossman A. Syndrome of unilateral recurrent attacks of glaucoma with cyclitis symptoms. Arch Ophthalmol 1948;39:517-35. 2. Bloch-Michel E, Dussaix E, Cerqueti P, Patarin D. Possible role of cytomegalovirus infection in the etiology of the Posner-Schlossman syndrome. Int Ophthalmol 1987;11:95-6. 3. Tanaka Y, Harino S, Hara J. Cellular immunity as judged by varicella skin test in Posner-Schlossman syndrome patients. Folia Jpn 1985;36:972-6. 4. Ohashi Y, Yamamoto S, Nishida K, Okamoto S, Kinoshita S, Hayashi K, et al. Demonstration of herpes simplex virus DNA in idiopathic corneal endotheliopathy. Am J Ophthalmol 1991;112:419-23. 5. Yamamoto S, Shimomura Y, Kinoshita S, Nishida K, Yamamoto R, Tano Y. Detection of herpes simplex virus DNA in human tear film by the polymerase chain reaction. Am J Ophthalmol 1994;117:160-3. 6. Boerman RH, Arnoldus EPJ, Raap AK, Bloem BR, Verhey M, van Gemert G, et al. Polymerase chain reaction and viral culture techniques to detect HSV in small volumes of cerebrospinal fluid; an experimental mouse encephalitis study. J Virol Methods 1989;25:189-98.
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CANTHAMOEBA KERAT1TIS USUALLY OCCURS IN
wearers of soft contact lens and probably results from a combination of corneal epithelial trauma and contaminated contact lens cleaning solutions.1 Fusar ium species cause disease after agricultural trauma to the cornea and are a common fungal isolate in temperate areas. The external eye is constantly ex posed to Acanthamoeba and Fusarium, opportunistic pathogens that are ubiquitous in the environment. If keratitis develops from these organisms, a compro mised ocular surface may be present. We studied a case of Acanthamoeba and Fusarium keratitis eight years after radial keratotomy. A 39-year-old man was referred to us for examina tion of a corneal ulcer in the right eye. His history disclosed bilateral eight-incision radial keratotomy eight years previously. He stated he woke up three days before initial examination with a foreign body sensation and redness in the right eye. He did not wear contact lenses and denied any history of trauma to the eye. He attempted to soothe the eye by rinsing it with tap water; however, the symptoms worsened and he sought medical attention. His ophthalmolo gist noted a corneal ulcer and prescribed topical ciprofloxacin, 3 mg/ml every hour. No improvement
Infection After Radial Keratotomy Joseph R. Gussler, M.D., Darlene Miller, M.S., Mark Jaffe, M.D., and Eduardo C. Alfonso, M.D. PURPOSE/METHODS: Eight years after eightincision radial keratotomy, a corneal ulcer devel oped around the inferotemporal incision in an otherwise healthy 39-year-old man. There was no history of corneal trauma or contact lens wear. RESULTS/CONCLUSIONS: Both Fusarium and Acanthamoeba organisms were eventually isolated from the ulcer. A therapeutic keratoplasty was performed. Inferotemporal incisions may be predis posed to epithelial breakdown and infection many years after radial keratotomy. Department of Ophthalmology, Bascom Palmer Eye Institute. Inquiries to Eduardo C. Alfonso, M.D., Bascom Palmer Eye Institute, P.O. Box 016880, Miami, FL 33101; fax: (305) 326-6337.
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Fig. 1 (Gussler and associates). Central, full-thickness corneal infiltrate of the right eye with hypopyon. Cul tures grew both Acanthamoeba and Fusarium organ isms. Infiltrate began around the inferotemporal keratot omy incision.
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Fig. 2 (Gussler and associates). One week after therapeu tic penetrating keratoplasty in the right eye, there is no sign of infection or rejection. Before trephination, inter rupted sutures were placed in the peripheral keratotomy incisions to prevent gaping.
was noted over the next 24 hours, and he was referred to the Bascom Palmer Eye Institute. Uncorrected visual acuity in the right eye was 20/60 and pinhole visual acuity was 20/30. Slit-lamp examination showed an eight-incision radial keratotomy pattern with a small, fluffy infiltrate straddling the inferotemporal incision. There was mild cell and flare in the anterior chamber; the left eye showed a well-healed eight-incision radial keratotomy pattern. A microbial infection was suspected and smears and cultures were obtained. Treatment of the right eye commenced with topical vancomycin hydrochloride, 50 mg/ml, and tobramycin, 9 mg/ml drops, every hour. Both smears and cultures were negative, and the infiltrate began to enlarge. Six days after initial examination a ringshaped infiltrate appeared that embraced all of the keratotomy incisions and a hypopyon developed (Fig. 1). A second set of smears and cultures for atypical bacteria {Mycobacterium, Nocardia, Streptomyces), fungi, and Acanthamoeba were obtained. The infil trate continued to enlarge despite the antibiotics, and a third scraping was performed 12 days after initial examination specifically for amebae. The smears were negative but cultures grew Acanthamoeba. Nineteen days after initial examination, treatment of the right
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eye was changed to topical propamidine, 1 mg/ml, and polyhexamethylene biguanide, 0.2 mg/ml every hour, but the infiltrate did not respond. Visual acuity had decreased to hand motions and pain was severe 20 days after initial examination. A therapeutic penetrating keratoplasty was per formed on the right eye 21 days after initial examina tion and the patient's corneal button demonstrated many septate hyphae penetrating Descemet's mem brane. A few amebic cysts were present in the stroma; however, the anterior chamber exudate was laden with amebae. Intraoperative cultures grew both Acan thamoeba and Fusarium organisms. Postoperatively, the right eye was maintained on topical propamidine and prednisolone acetate for two months; prednisolone acetate and artificial tears were used during the next eight months. There was no sign of infection recurrence for 16 months and best-corrected visual acuity is 20/20 (Fig. 2). Although most patients who undergo radial kera totomy enjoy excellent vision, the potential for com plications exists.2 Healing is never complete and both early and late cases of infectious keratitis have been well documented.3 Our report of opportunistic kerati tis should not be unexpected, as these organisms depend on a compromised corneal surface to become established. Our patient may have had wound irregu larity around the inferotemporal keratotomy incision. The ameba may have been introduced by means of the tap water. The Fusarium organism may have invaded the cornea secondarily. As in other cases of amebic and fungal keratitis, clinical evidence must be great and multiple scrapings or corneal biopsy, or both, are often required for diagnosis. Patients should be informed of the potential risks of radial keratoto my, especially of sight-threatening infections. REFERENCES 1. Moore MB, McCulley JP, Luckenbach M, Gelender H, Newton C, McDonald MB, et al. Acanthamoeba keratitis associated with soft contact lenses. Am J Ophthalmol 1985;100:396-403. 2. Rashid ER, Waring GO. Complications of radial and trans verse keratotomy. Surv Ophthalmol 1989;34:73-106. 3. Matoba AY, Torres J, Wilhelmus KR, Hamill MB, Jones DB. Bacterial keratitis after radial keratotomy. Ophthalmology 1989;96:1171-5.
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