- Email: [email protected]
Listeria monocytogenes–induced endogenous endophthalmitis: bioultrasonic findings
storage of sulphated glycosaminoglycans in cell culture and in vivo. Toxicology 1996;110:27–37. 5. Jung H, Reme C. Light-evoked arachidonic acid release in the retina: illuminance/duration dependence and the effects of quinacrine, mellitin and lithium. Graefes Arch Clin Exp Ophthalmol 1994;232:167–175.
Listeria monocytogenes–induced Endogenous Endophthalmitis: Bioultrasonic Findings Carmen Mendez-Hernandez, MD, Julian Garcia-Feijoo, MD, PhD, and Julian Garcia-Sanchez, MD, PhD To report bioultrasonic findings in Listeria monocytogenes–induced endophthalmitis (LMIE) that have not been described previously. DESIGN: Interventional case report. METHODS: To rule out intraocular tumor, ultrasound biomicroscopy was performed in a patient referred for a 2-day history of uveitis with elevated intraocular pressure, dark hypopyon, and pigment dispersion in the anterior chamber. RESULTS: Ultrasound biomicroscopy examination showed increased iris thickness with rarefaction of tissue and irregular echogenicity as well as iris pigment epithelial detachment. A small choroidal detachment was also detected. The anterior chamber and vitreous sample confirmed the LMIE diagnosis. CONCLUSIONS: The detection of both pigment epithelial detachment and changes in the iris tissue could explain why black hypopyon frequently develops in LMIE with significant pigment dispersion in some cases. (Am J Ophthalmol 2004;137:579 –581. © 2004 by Elsevier Inc. All rights reserved.) PURPOSE:
FIGURE 2. (Top) Fluorescein angiogram taken in 2003 of the right fundus, showing progression of a bull’s-eye pattern of retinal pigment epithelial atrophy. (Bottom) Fluorescein angiogram of the left fundus showing a pattern similar to that of the right eye.
in the early 1940s, a heightened awareness of this association may help in explaining certain cases of bull’s-eye maculopathy. Given the apparent rarity of the association, the potential role of idiosyncratic factors in raising the risk of this side effect in certain patients is plausible but speculative. REFERENCES
1. Browning DJ. Hydroxychloroquine and chloroquine retinopathy: screening for drug toxicity. Am J Ophthalmol 2002;133: 649 –656. 2. Zinn KM, Greenseid DZ. Toxicology of the retinal pigment epithelium. Int Ophthalmol Clin 1975;15:147–158. 3. Fleet JC, Turnbull AJ, Bourcier M, Wood RJ. Vitamin D-sensitive and quinacrine-sensitive zinc transport in human intestinal cell line Caco-2. Am J Physiol 1993;264:G1037– G1045. 4. Lullmann-Rauch R, Pods R, von Witzendorff B. The antimalarials quinacrine and chloroquine induce weak lysosomal
VOL. 137, NO. 3
E
NDOGENOUS BACTERIAL ENDOPHTHALMITIS IS A PO-
tentially devastating condition that accounts for 2% to 8% of all the cases of endophthalmitis.1 Most of the cases of Listeria monocytogenes–induced endophthalmitis (LMIE) described in the literature have occurred with an acute fibrinous anterior chamber reaction, keratic precipitates and increased ocular pressure. Characteristically, they develop dark hypopyon and pigment dispersion. For this reason, differential diagnosis with ciliary body melanoma2 must be considered. Ultrasound biomicroscopy (UBM) is an ideal method to analyze the iris and ciliary body.3 In the case we describe, both Accepted for publication Aug 18, 2003. From the Instituto de Investigaciones Oftalmologicas Ramo´ n Castro viejo, Glaucoma Department, Hospital Clinico San Carlos, Guadalajara, Spain. Inquiries to Carmen Mendez-Hernandez, MD, Glaucoma Department, Hospital Clinico San Carlos, C/de Aranjuez 1114, Urbanizacion El Coto, El Casar, 19170 Guadalajara, Spain; e-mail: [email protected]
BRIEF REPORTS
579
FIGURE 1. Left: Iris stromal thickening with irregular echogenicity. Pigment epithelial detachment (arrows). Inflammatory deposits on the zonular fibers and the lens (Right, arrow heads). Right: Detail of the pigment epithelial detachment (arrow).
FIGURE 2. Flat and localized choroidal detachment (arrow).
580
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
MARCH 2004
pigment epithelial detachment and changes in the iris tissue can be detected with the UBM. A 62-year-old man with no significant ocular history was referred for a decreased vision, redness, and pain in his left eye of 2-day duration, with poor response to topical corticoid treatment. The patient had undergone extended supraglottic laryngectomy and local radiotherapy sessions for epidermoid carcinoma with lymphoganglionar metastasis 2 years before. Two months after surgery, he developed laryngeal perichondritis that required oral corticosteroid treatment (60 mg/day) for 1 year. On examination, he presented visual acuity of light perception and uveitis with elevated intraocular pressure (IOP ⬎ 50 mm Hg) with dark hypopyon and pigment dispersion in the anterior chamber. A UBM examination was performed to rule out an intraocular tumor (UBM-840, 50 MHz; Zeiss-Humphrey; Palo Alto, California, USA).4 It showed an increase of iris thickness with rarefaction of the tissue and irregular echogenicity as well as an iris pigment epithelial detachment (Figure 1). A small choroidal detachment was also detected (Figure 2). Vitrectomy was indicated, but the patient rejected treatment. The suspicion of an endophthalmitis led to the washing of the anterior chamber and intravitreal injection of vancomycin (1 mg/0.1 ml). Because this patient was allergic to penicillin, treatment with oral ciprofloxacin (750 mg twice a day), and topical vancomycin (50 mg/ml) was initiated, and the patient improved significantly. The anterior chamber and vitreous sample confirmed the diagnosis of LMIE. The patient required two more intravitreal injections of vancomycin (3 and 6 days after the first injection). He has continued with outpatient visits, presenting intumescent cataract and diffuse corneal edema, and a visual acuity of hand movements in the examination performed 8 months postdiagnosis. There have been no significant changes, and hypertensive uveitis has not been detected during the follow-up. No treatment has been necessary to control IOP. In this case, UBM allowed us to detect an iris pigment epithelial detachment related to LMIE, which has not been described previously, supporting the hypothesis provided by Eliot.2 He suggested the possibility that some feature unique to LMIE causes iris necrosis with pigment dispersion and a progressive black hypopyon. In fact, thickening of the iris and free melanin pigment in preparations of aqueous aspirate was observed in one patient.2 Iris pigment epithelial detachment and rarefaction of the iris tissue detected in this patient supports this theory and could explain why black hypopyon frequently develops in this type of endophthalmitis with significant pigment dispersion in some cases. In contrast to other bacterial endophthalmitis that usually occur with normal or low IOP, LMIE occurs with high IOP. This pigment dispersion and dark hypopyon may be responsible for the IOP increase because of obstruction of the trabecular mesh. In fact, the iris necrosis may have been responsible for the VOL. 137, NO. 3
pigment epithelial detachment found in this case and could be related to both the pigment dispersion and dark hypopyon. On the other hand, the choroidal detachment detected was small in size, so that it may have been insufficient to counteract the IOP increase caused by the pigment dispersion in the anterior chamber. REFERENCES
1. Betriu C, Fuentemilla S, Me´ ndez R, Picazo J, Garcı´a Sa´ nchez J. Endophthalmitis caused by Listeria monocytogenes. J Clin Microbiol 2001;39:2742–2744. 2. Eliott D, O’Brien T, Green R, Jampel H, Goldberg M. Elevated intraocular pressure, pigment dispersion and dark hypopyon in endogenous endophthalmitis from Listeria monocytogenes. Surv Ophthalmol 1992;37:117–124. 3. Pavlin CJ, Harasiewicz K, Sherar MD, Foster FS. Clinical use of ultrasound biomicroscopy. Ophthalmology 1991;96:287– 295. 4. Garcı´a-Feijoo´ J, Martı´n-Carbajo M, Benitez del Castillo JM, Garcı´a-Sa´ nchez J. Orbital cup: a device to facilitate ultrasound biomicroscopic examination of pars plana and peripheral retina. Arch Ophthalmol 1997;115:1475– 1476.
A Prospective, Pilot Study of Treatment of Amblyopia in Children 10 to <18 Years Old Pediatric Eye Disease Investigator Group* PURPOSE: To determine whether amblyopia can be successfully treated in older children and adolescents. DESIGN: Prospective, single group treatment trial. METHODS: Sixty-six amblyopic patients aged 10 to <18 years with amblyopic eye acuity of 20/40 to 20/160 were treated with daily patching (>2 hours a day) combined with at least 1 hour of near activities. Visual acuity was measured before and after 2 months of prescribed treatment. RESULTS: Visual acuity improved 2 or more lines from baseline in 18 (27%) of the 66 patients (95% confidence interval, 17%– 40%), and the improvement appeared similar in 10- to <14-year-olds and 14- to <18-yearolds. CONCLUSIONS: Amblyopia treatment can improve visual acuity in older children and adolescents. A randomized controlled trial is needed to determine if there is an upper age limit for which amblyopia treatment is successful.
Accepted for publication Aug 18, 2003. InternetAdvance publication at ajo.com August 28, 2003. *A listing of the Writing Committee and the investigators who participated in the study appears at the end of the article. Supported by a cooperative agreement from the National Eye Institute grant EY11751. Inquiries to Raymond T. Krakes, MSPH, PEDIG Coordinating Center, Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647.
BRIEF REPORTS
581
Listeria monocytogenes–induced Endogenous Endophthalmitis: Bioultrasonic Findings Carmen Mendez-Hernandez, MD, Julian Garcia-Feijoo, MD, PhD, and Julian Garcia-Sanchez, MD, PhD To report bioultrasonic findings in Listeria monocytogenes–induced endophthalmitis (LMIE) that have not been described previously. DESIGN: Interventional case report. METHODS: To rule out intraocular tumor, ultrasound biomicroscopy was performed in a patient referred for a 2-day history of uveitis with elevated intraocular pressure, dark hypopyon, and pigment dispersion in the anterior chamber. RESULTS: Ultrasound biomicroscopy examination showed increased iris thickness with rarefaction of tissue and irregular echogenicity as well as iris pigment epithelial detachment. A small choroidal detachment was also detected. The anterior chamber and vitreous sample confirmed the LMIE diagnosis. CONCLUSIONS: The detection of both pigment epithelial detachment and changes in the iris tissue could explain why black hypopyon frequently develops in LMIE with significant pigment dispersion in some cases. (Am J Ophthalmol 2004;137:579 –581. © 2004 by Elsevier Inc. All rights reserved.) PURPOSE:
FIGURE 2. (Top) Fluorescein angiogram taken in 2003 of the right fundus, showing progression of a bull’s-eye pattern of retinal pigment epithelial atrophy. (Bottom) Fluorescein angiogram of the left fundus showing a pattern similar to that of the right eye.
in the early 1940s, a heightened awareness of this association may help in explaining certain cases of bull’s-eye maculopathy. Given the apparent rarity of the association, the potential role of idiosyncratic factors in raising the risk of this side effect in certain patients is plausible but speculative. REFERENCES
1. Browning DJ. Hydroxychloroquine and chloroquine retinopathy: screening for drug toxicity. Am J Ophthalmol 2002;133: 649 –656. 2. Zinn KM, Greenseid DZ. Toxicology of the retinal pigment epithelium. Int Ophthalmol Clin 1975;15:147–158. 3. Fleet JC, Turnbull AJ, Bourcier M, Wood RJ. Vitamin D-sensitive and quinacrine-sensitive zinc transport in human intestinal cell line Caco-2. Am J Physiol 1993;264:G1037– G1045. 4. Lullmann-Rauch R, Pods R, von Witzendorff B. The antimalarials quinacrine and chloroquine induce weak lysosomal
VOL. 137, NO. 3
E
NDOGENOUS BACTERIAL ENDOPHTHALMITIS IS A PO-
tentially devastating condition that accounts for 2% to 8% of all the cases of endophthalmitis.1 Most of the cases of Listeria monocytogenes–induced endophthalmitis (LMIE) described in the literature have occurred with an acute fibrinous anterior chamber reaction, keratic precipitates and increased ocular pressure. Characteristically, they develop dark hypopyon and pigment dispersion. For this reason, differential diagnosis with ciliary body melanoma2 must be considered. Ultrasound biomicroscopy (UBM) is an ideal method to analyze the iris and ciliary body.3 In the case we describe, both Accepted for publication Aug 18, 2003. From the Instituto de Investigaciones Oftalmologicas Ramo´ n Castro viejo, Glaucoma Department, Hospital Clinico San Carlos, Guadalajara, Spain. Inquiries to Carmen Mendez-Hernandez, MD, Glaucoma Department, Hospital Clinico San Carlos, C/de Aranjuez 1114, Urbanizacion El Coto, El Casar, 19170 Guadalajara, Spain; e-mail: [email protected]
BRIEF REPORTS
579
FIGURE 1. Left: Iris stromal thickening with irregular echogenicity. Pigment epithelial detachment (arrows). Inflammatory deposits on the zonular fibers and the lens (Right, arrow heads). Right: Detail of the pigment epithelial detachment (arrow).
FIGURE 2. Flat and localized choroidal detachment (arrow).
580
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
MARCH 2004
pigment epithelial detachment and changes in the iris tissue can be detected with the UBM. A 62-year-old man with no significant ocular history was referred for a decreased vision, redness, and pain in his left eye of 2-day duration, with poor response to topical corticoid treatment. The patient had undergone extended supraglottic laryngectomy and local radiotherapy sessions for epidermoid carcinoma with lymphoganglionar metastasis 2 years before. Two months after surgery, he developed laryngeal perichondritis that required oral corticosteroid treatment (60 mg/day) for 1 year. On examination, he presented visual acuity of light perception and uveitis with elevated intraocular pressure (IOP ⬎ 50 mm Hg) with dark hypopyon and pigment dispersion in the anterior chamber. A UBM examination was performed to rule out an intraocular tumor (UBM-840, 50 MHz; Zeiss-Humphrey; Palo Alto, California, USA).4 It showed an increase of iris thickness with rarefaction of the tissue and irregular echogenicity as well as an iris pigment epithelial detachment (Figure 1). A small choroidal detachment was also detected (Figure 2). Vitrectomy was indicated, but the patient rejected treatment. The suspicion of an endophthalmitis led to the washing of the anterior chamber and intravitreal injection of vancomycin (1 mg/0.1 ml). Because this patient was allergic to penicillin, treatment with oral ciprofloxacin (750 mg twice a day), and topical vancomycin (50 mg/ml) was initiated, and the patient improved significantly. The anterior chamber and vitreous sample confirmed the diagnosis of LMIE. The patient required two more intravitreal injections of vancomycin (3 and 6 days after the first injection). He has continued with outpatient visits, presenting intumescent cataract and diffuse corneal edema, and a visual acuity of hand movements in the examination performed 8 months postdiagnosis. There have been no significant changes, and hypertensive uveitis has not been detected during the follow-up. No treatment has been necessary to control IOP. In this case, UBM allowed us to detect an iris pigment epithelial detachment related to LMIE, which has not been described previously, supporting the hypothesis provided by Eliot.2 He suggested the possibility that some feature unique to LMIE causes iris necrosis with pigment dispersion and a progressive black hypopyon. In fact, thickening of the iris and free melanin pigment in preparations of aqueous aspirate was observed in one patient.2 Iris pigment epithelial detachment and rarefaction of the iris tissue detected in this patient supports this theory and could explain why black hypopyon frequently develops in this type of endophthalmitis with significant pigment dispersion in some cases. In contrast to other bacterial endophthalmitis that usually occur with normal or low IOP, LMIE occurs with high IOP. This pigment dispersion and dark hypopyon may be responsible for the IOP increase because of obstruction of the trabecular mesh. In fact, the iris necrosis may have been responsible for the VOL. 137, NO. 3
pigment epithelial detachment found in this case and could be related to both the pigment dispersion and dark hypopyon. On the other hand, the choroidal detachment detected was small in size, so that it may have been insufficient to counteract the IOP increase caused by the pigment dispersion in the anterior chamber. REFERENCES
1. Betriu C, Fuentemilla S, Me´ ndez R, Picazo J, Garcı´a Sa´ nchez J. Endophthalmitis caused by Listeria monocytogenes. J Clin Microbiol 2001;39:2742–2744. 2. Eliott D, O’Brien T, Green R, Jampel H, Goldberg M. Elevated intraocular pressure, pigment dispersion and dark hypopyon in endogenous endophthalmitis from Listeria monocytogenes. Surv Ophthalmol 1992;37:117–124. 3. Pavlin CJ, Harasiewicz K, Sherar MD, Foster FS. Clinical use of ultrasound biomicroscopy. Ophthalmology 1991;96:287– 295. 4. Garcı´a-Feijoo´ J, Martı´n-Carbajo M, Benitez del Castillo JM, Garcı´a-Sa´ nchez J. Orbital cup: a device to facilitate ultrasound biomicroscopic examination of pars plana and peripheral retina. Arch Ophthalmol 1997;115:1475– 1476.
A Prospective, Pilot Study of Treatment of Amblyopia in Children 10 to <18 Years Old Pediatric Eye Disease Investigator Group* PURPOSE: To determine whether amblyopia can be successfully treated in older children and adolescents. DESIGN: Prospective, single group treatment trial. METHODS: Sixty-six amblyopic patients aged 10 to <18 years with amblyopic eye acuity of 20/40 to 20/160 were treated with daily patching (>2 hours a day) combined with at least 1 hour of near activities. Visual acuity was measured before and after 2 months of prescribed treatment. RESULTS: Visual acuity improved 2 or more lines from baseline in 18 (27%) of the 66 patients (95% confidence interval, 17%– 40%), and the improvement appeared similar in 10- to <14-year-olds and 14- to <18-yearolds. CONCLUSIONS: Amblyopia treatment can improve visual acuity in older children and adolescents. A randomized controlled trial is needed to determine if there is an upper age limit for which amblyopia treatment is successful.
Accepted for publication Aug 18, 2003. InternetAdvance publication at ajo.com August 28, 2003. *A listing of the Writing Committee and the investigators who participated in the study appears at the end of the article. Supported by a cooperative agreement from the National Eye Institute grant EY11751. Inquiries to Raymond T. Krakes, MSPH, PEDIG Coordinating Center, Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647.
BRIEF REPORTS
581