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Moraxella Lacunata Endophthalmitis after Intraocular Lens Implantation
Short reports
152
from its position or when it is far from its position with aphakic correction. The common cause of decreased visual acuity is amblyopia, which has to be managed with the appropriate therapy. Sometimes urgent situations like acute glaucoma or posterior dislocations, uveitis etc., call for surgery. A variety of methods have been proposed for lens extraction [5-7]. Each one has advantages and disadvantages. The first is intracapsular lens extraction; this is complicated by vitreous loss and the complications are cystoid macular oedema and retinal detachment. The second method, proposed by J. Barraquer [51, is the aspiration of the soft lens. However, we felt that surgical manipulations in cases with subluxated lenses are difficult. The most recent method is the lensectomy with pars plana approach. The method is frequently complicated with posterior dislocation of the lens, although Charles (1981) maintains that there is no problem with this approach. We consider this method a major intervention, which needs an experienced surgeon, and we believe that in cases such as those described earlier or with dislocation of the lens into the anterior chamber, the cryoextraction of the lens using viscoelastic material to minimize the risk of posterior dislocation is an appropriate procedure. Also, a shallow anterior vitrectomy with an Ocutome system eliminates the possible complication of an intra-cryoextraction procedure. REFERENCES 1 W.C. Booth & L.H. Nadler. Genetic counseling in lenticular abnormalities. In Cataract and Abnormalities of the Lens, edited by J. Bellows, Grune and Stratton, London, 191-206 (1975). 2 H. Cross & A. Jensen. Ocular manifestations in the Marfan syndrome and homocystinuria. Am. J. Ophthalmol., 75, 405 (1973). 3 R. Wilson & R. Ruiz. Bilateral central retinal artery occlusion in homocystinuria. Arch. Ophthalmol., 82, 267 (1969). 4 S.D. McLaren & A. Halasa. Nutritional and metabolic cataract. In Cataract and Abnormalities of the Lens, edited by J. Bellows, Grune and Stratton, London, 255-263 (1975>5 J. Barraquer. Surgery of the dislocated lens. Trans. Am. Acad. Ophthalmol. Otor., 76, 44 (1972). 6 S. Charles. Vitreous Microsurgery. Williams and Wilkins, Baltimore, 33-44 (1981). 7 D. Zuckerman & M. Lahav. A simple method for delivery of a subluxed lens. Am. J. Ophthalmol., 102,537-538 (1986). 8 S.D. Casper, W.J. Simon, B.L. Nelson, H.!. Porter & B.S. Lichtenstein. Familial simple ectopia lentis: A case study. J. Pediatr. Ophthalmol. Strabismus, 22, 227-230 (1985).
Moraxella Lacunata Endophthalmitis after Intraocular Lens Implantation L. COTTICELLI, S. RUSSO, C. COSTAGLIOLA, A. IURA, G. IACCARINO and E. RINALDI Eye Clinic, 1st School of Medicine, University of Naples, Via S. Pansini 5,80131 Napoli, Italy
We report a case of chronic, indolent intraocular inflammation that occurred after extracapsular cataract extraction and posterior chamber intraocular lens implantation. Cultures of intraocular specimens revealed the presence of Moraxella lacunata colonies. Our report emphasizes the need for preoperative attention to potential sources of infection (eyelids, lacrymal system, etc.) and the importance of strict aseptic techniques in the operating room. Keywords: Endophthalmitis; Moraxella lacunata; IOL implantation INTRODUCTION
Acute, subacute or chronic intraocular inflammation can easily occur after extracapsular lens extraction and posterior chamber intraocular lens (IOL) implantation [1-71. This inflammation has been generally attributed to trauma, infections, poor quality intraocular lenses, residual lens cortex and impurities in irritating solutions [2, 3, 8]. Recently, many cases of chronic endophthalmitis induced by low virulence aerobic and/or anaerobic bacteria have been reported [3, 4]. The clinical features described in these patients (low-grade, chronic, sometimes granulomatous intraocular inflammation that is delayed in onset and that occurs in patients who have good vision for a variable period) may represent an emerging new syndrome of which all cataract surgeons should be aware 191. Here we report a case of chronic endophthalmitis induced by Moraxella lacunata after extracapsular lens extraction and IOL implantation. CASE REPORT
A 73-year-old woman had an extracapsular cataract extraction with a posterior chamber lens implant on the right eye in April 1988. The procedure was well tolerated and without complications. PreoperaPlease address all correspondence to: Ernesto Rinaldi MD, PhD, Clinica Oculistica I Facolta, Via S. Pansini, 5, 80131 Napoli, Italy. Eur J Implant Ref Surg, Vol 3, June 1991
Short reports
tively, she applied gentamycin sulphate eye drops to the right eye as prophylaxis. After the operation she received pilocarpine and betamethasone eye drops and a subconjunctival injection of gentamicin sulphate. Ascorbic acid betamethasone-tetracyclinechloramphenicol eye drops, indomethacin and gentamicin sulphate were administered daily during the immediate postoperative period. The first two days after the operation were uneventful. On the third day, the patient presented an acute iridial reaction with corneal oedema, peri keratic infection, hypopyon, presence of small and large white keratic precipitates and exudative material on the anterior surface of the IOL. The patient was prescribed intravenous gentamicin sulphate (80 mg/two times a day) and intramuscular cephazolin (1 g/three times a day). Atropine, tobramicine, chloramphenicol and betamethazone eye drops were applied topically. The inflammation responded well to the therapy and the patient was discharged from hospital 10 days later. The patient was examined twice a week, and 1 month after the onset of treatment the eye was free of inflammation and no further therapy was prescribed. Four months after surgery the eye was still free of inflammation. However, there was a cyclytic membrane on the anterior surface of the IOL together with posterior synechia. A YAG laser discission of the cyclic membrane and the posterior lens capsule was made. The patient was given betamethasonetetracycline--ehloramphenicol eye drops for 5 days and her best corrected visual acuity was 10/20. Funduscopy did not reveal any disorder and the vitreous body was normal and clear. Approximately 1 month after the YAG laser capsulotomy, she returned to our observation because her visual acuity had fallen dramatically. A slit lamp examination revealed hypopyon and the presence of exudative material in the vitreous body (Fig. 1). The fundus was not explorable. A para bulbar injection of gentamycin sulphate and betamethasone was given and systemic and topical therapy similar to that administered 3 days after the operation was started. Despite the therapy, the eye was always inflamed and a yellow fibrous tissue with neovessels appeared in the anterior part of the vitreous body (Fig. 1). At this time we decided to reoperate. An anterior vitrectomy was performed and the IOL removed. The IOL was easily removed after the synechiae were lysed. During vitrectomy, a massive haemorrhage occurred. Once the haemorrhage was arrested the vitrectomy was completed and intraocular and parabulbar gentamicin sulphate was administered post surgery. The material removed underwent microbiological analyses that revealed Moraxella lacunata colonies. Eur J Implant Ref Surg, Vo/3, June 1991
153
Fig. 1 For details see the text
This second postoperative period was uneventful. Two months after the operation the fundus could not be examined because of the fibrous post-haemorrhage condition of the vitreous body. The eye was hypotonic, but without signs of intraocular inflammation, and the visual function was abolished. DISCUSSION
With the increase of intraocular lens implantation, more eyes developing postoperative endophthalmitis are pseudophakic [2]. Extracapsular cataract extraction may be complicated by a uveal reaction induced by surgical trauma, by impurities contained in the irrigation solution and, lastly, by the presence of residual lens material [2, 3, 8]. This inflammation is generally sterile and granulomatous with a typical infiltration of giant cells and fibrous proliferation [10, 11, 12]. The uveitis could also be induced by an immunological reaction activated by the IOL per se and mediated by the complement [13]. These types of inflammation are generally self-limited, although more rarely and in patients suffering from an ineffective functioning of the immunological system, they can become chronic and a phacoantigenic reaction can occur [9, 14]. Postoperative intraocular inflammation may also be caused by infection. Demonstration or isolation of the agent from intraocular material is necessary to establish the diagnosis of infectious endophthalmitis. The more frequent microorganisms involved are Staphylococcus aureus, Propionibacterium acnes, Streptococcus species, Proteus vulgaris, Pseudonwnas aeruginosa and Haenwphilus in{luenzae. Corynebacterium difteriae, Citrobacteriam diversus, Serratia marcescens and Achronwbacterium have also been implicated in infectious endophthalmitis [1-5].
154
Short reports
Many of these microorganisms are common conREFERENCES stituents of the normal flora of the external eye and 1 G.W. Zaidman & B.J. Mondino. Postoperative pseudophakic the 10L could represent a vector by which these bacterial endophthalmitis. Am. J. Ophthalmol., 1982; 218: microorganisms are brought into the eye. In this 93. 2 W.T. Driebe, S. Mandelbaum & R.K Forster et al. Pseudostudy we report a case with culture-positive Moraxphakic endophthalmitis. Diagnosis and Management. Ophella lacunata intraocular infection after extracapsuthalmol., 1986; 442: 93. lar cataract extraction and posterior chamber intra3 D.M. Meisler, A.G. Palestine & D.W. Vastine et al. Chronic Propionibacterium endophthalmitis after extracapsular ocular lens implantation. Moraxella lacunata is a cataract extraction and intraocular lens implantation. Am. Gram-negative, non-spore-forming, aerobe diplobaJ. Ophthalmol., 1986; 102: 733. cillus. It is an organism commonly found in the aero4 T.J. Roussel, W.W. Culbertson & N.S. Jaffe. Chronic postbic flora of the eyelids and conjunctiva, that often operative endophthalmitis associated with Propionibacterium acnes. Arch. Ophthalmol., 1987; 105: 1199. causes subacute or chronic conjunctivitis. Moraxella 5 M. Wenzel & M. Reim. Eine Klassifizierung intraokularer lacunata is an organism of low virulence that has bakteriologischer Befunde nach Linsenimplantation. Klin. been reported to induce postoperative uveitis [15]. Mbl. Augenhreilk., 1988; 193: 589. 6 KL. Piest, M.C. Kincaid, M.R. Tetz, D.J. Apple, W.A. Postoperative bacterial endophthalmitis caused Roberts & F.W. Price Jr. Localized endophthalmitis: a newly by virulent pathogens is usually characterized by a documented cause of toxic lens syndrome. J. Cataract painful, hyperacute and destructive course [16]. On Refract. Surg., 1987; 13: 498. 7 D.J. Apple, M.C. Kincaid, N. Mamalis & R.J. Olson. Intrathe cQntrary, in our patient the uveal reaction ocular Lenses. Evolution, Design, Complications and Patholappeared 3 days after the operation and resembled a ogy. Williams & Wilkins, Baltimore, 1989. 8 H. Sievers & D. von Domarus. Foreign'body reaction against phacoantigenic reaction rather than endophthalmiintraocular lensesAm. J. Ophthalmol., 1984; 97: 743. tis. However, because the nature of the inflamma9 E.R Smith. Inflammation after cataract surgery. Am. J. tion observed seemed to be similar to that induced Ophthalmol., 1986; 102: 788. by low-virulence organisms (i.e. S. epidermidis, P. 10 D.J. Apple, N. Mamalis & R.L. Steinmetz et al. Phacoanaphylactic endophthalmitis associated with extracapsular acnes, etc.), we prescribed antibiotic therapy cataract extraction and posterior chamber intraocular lens. together with a topical steroid treatment. The good Arch. Ophthalmol., 1984; 102: 1528. results obtained were in agreement with our diagno- 11 R.J. Wolter. Cytopathology of intraocular lens implantation. Ophthalmol., 1985; 92: 135. sis. Four months after the operation the patient 12 D. von Domarus, R Burk & H. Sievers. Tissue changes underwent YAG laser treatment both of the cyclytic induced by intraocular lenses. Dev. Ophthalmol., 1984; 91: 95. membrane and of the posterior lens capsule. With the discission of the posterior lens capSUle, residual 13 R.S. Coles. Syndrome toxique des implants intra-oculaires. Bull. Mem. Soc. Fr. Ophthalmol., 1984; 91: 95. lens material and microorganisms flowed into the 14 A.M. Galin, A.W. Tuberville & RS. Dotson. Immunological aspects of intraocular lenses. Inter. Ophthalmol. CUn., 1982; vitreous body inducing a more severe and less trea22: 227. table endophthalmitis. This is in agreement with 15 S. Duke·Elder & E.S. Perkins. Disease of the Uveal Tract. Driebe and coworkers who found that antibiotics System of Ophthalmol. Henry Kimpton, London. IX, 1966; 232. were ineffective in the management of infectious endophthalmitis [2]. In addition our patient con- 16 R.K Foster. Etiology and diagnosis of bacterial postoperative endophthalmitis. Ophthalmol., 1978; 85: 320. firms the difficulty of differentiating between a ph acoantigenic reaction and infectious endophthalmitis induced by low-virulence organisms. It has been Received April 1990 demonstrated that the two entities can be present at the same time [9] and that sterile uveitis can be activated by microorganisms that promote hypersensitivity to the lens proteins or to 10L constituents [3]. The diagnosis of infectious endophthalmiAPPENDIX tis is supported by the finding of organisms in cultures of intraocular specimens. However, cultureEditorial Question negative cases do not exclude the organisms that cause the inflammation. In fact, not all laboratories routinely employ cultures that isolate these low-virulence organisms. In conclusion this report serves to emphasize the Question need for preoperative attention to potential sources of infection (e.g. eyelids, lacrimal system) and the importance of strict aseptic technique in the operat- Is there any role today for preoperative cultures from eyes which no longer have a routine procedure? ingroom. Eur J Implant Ref Surg, Vol 3, June 1991
Short reports
155
Answer
Routine preoperative cultures are expensive and time consuming and, moreover, given the very low
Eur J Implant Ref Surg. Vol 3. June 1991
incidence of endophthalmitis induced by extracapsular lens extraction and intraocular lens implantation, these methods are not justified on a costbenefit basis.
152
from its position or when it is far from its position with aphakic correction. The common cause of decreased visual acuity is amblyopia, which has to be managed with the appropriate therapy. Sometimes urgent situations like acute glaucoma or posterior dislocations, uveitis etc., call for surgery. A variety of methods have been proposed for lens extraction [5-7]. Each one has advantages and disadvantages. The first is intracapsular lens extraction; this is complicated by vitreous loss and the complications are cystoid macular oedema and retinal detachment. The second method, proposed by J. Barraquer [51, is the aspiration of the soft lens. However, we felt that surgical manipulations in cases with subluxated lenses are difficult. The most recent method is the lensectomy with pars plana approach. The method is frequently complicated with posterior dislocation of the lens, although Charles (1981) maintains that there is no problem with this approach. We consider this method a major intervention, which needs an experienced surgeon, and we believe that in cases such as those described earlier or with dislocation of the lens into the anterior chamber, the cryoextraction of the lens using viscoelastic material to minimize the risk of posterior dislocation is an appropriate procedure. Also, a shallow anterior vitrectomy with an Ocutome system eliminates the possible complication of an intra-cryoextraction procedure. REFERENCES 1 W.C. Booth & L.H. Nadler. Genetic counseling in lenticular abnormalities. In Cataract and Abnormalities of the Lens, edited by J. Bellows, Grune and Stratton, London, 191-206 (1975). 2 H. Cross & A. Jensen. Ocular manifestations in the Marfan syndrome and homocystinuria. Am. J. Ophthalmol., 75, 405 (1973). 3 R. Wilson & R. Ruiz. Bilateral central retinal artery occlusion in homocystinuria. Arch. Ophthalmol., 82, 267 (1969). 4 S.D. McLaren & A. Halasa. Nutritional and metabolic cataract. In Cataract and Abnormalities of the Lens, edited by J. Bellows, Grune and Stratton, London, 255-263 (1975>5 J. Barraquer. Surgery of the dislocated lens. Trans. Am. Acad. Ophthalmol. Otor., 76, 44 (1972). 6 S. Charles. Vitreous Microsurgery. Williams and Wilkins, Baltimore, 33-44 (1981). 7 D. Zuckerman & M. Lahav. A simple method for delivery of a subluxed lens. Am. J. Ophthalmol., 102,537-538 (1986). 8 S.D. Casper, W.J. Simon, B.L. Nelson, H.!. Porter & B.S. Lichtenstein. Familial simple ectopia lentis: A case study. J. Pediatr. Ophthalmol. Strabismus, 22, 227-230 (1985).
Moraxella Lacunata Endophthalmitis after Intraocular Lens Implantation L. COTTICELLI, S. RUSSO, C. COSTAGLIOLA, A. IURA, G. IACCARINO and E. RINALDI Eye Clinic, 1st School of Medicine, University of Naples, Via S. Pansini 5,80131 Napoli, Italy
We report a case of chronic, indolent intraocular inflammation that occurred after extracapsular cataract extraction and posterior chamber intraocular lens implantation. Cultures of intraocular specimens revealed the presence of Moraxella lacunata colonies. Our report emphasizes the need for preoperative attention to potential sources of infection (eyelids, lacrymal system, etc.) and the importance of strict aseptic techniques in the operating room. Keywords: Endophthalmitis; Moraxella lacunata; IOL implantation INTRODUCTION
Acute, subacute or chronic intraocular inflammation can easily occur after extracapsular lens extraction and posterior chamber intraocular lens (IOL) implantation [1-71. This inflammation has been generally attributed to trauma, infections, poor quality intraocular lenses, residual lens cortex and impurities in irritating solutions [2, 3, 8]. Recently, many cases of chronic endophthalmitis induced by low virulence aerobic and/or anaerobic bacteria have been reported [3, 4]. The clinical features described in these patients (low-grade, chronic, sometimes granulomatous intraocular inflammation that is delayed in onset and that occurs in patients who have good vision for a variable period) may represent an emerging new syndrome of which all cataract surgeons should be aware 191. Here we report a case of chronic endophthalmitis induced by Moraxella lacunata after extracapsular lens extraction and IOL implantation. CASE REPORT
A 73-year-old woman had an extracapsular cataract extraction with a posterior chamber lens implant on the right eye in April 1988. The procedure was well tolerated and without complications. PreoperaPlease address all correspondence to: Ernesto Rinaldi MD, PhD, Clinica Oculistica I Facolta, Via S. Pansini, 5, 80131 Napoli, Italy. Eur J Implant Ref Surg, Vol 3, June 1991
Short reports
tively, she applied gentamycin sulphate eye drops to the right eye as prophylaxis. After the operation she received pilocarpine and betamethasone eye drops and a subconjunctival injection of gentamicin sulphate. Ascorbic acid betamethasone-tetracyclinechloramphenicol eye drops, indomethacin and gentamicin sulphate were administered daily during the immediate postoperative period. The first two days after the operation were uneventful. On the third day, the patient presented an acute iridial reaction with corneal oedema, peri keratic infection, hypopyon, presence of small and large white keratic precipitates and exudative material on the anterior surface of the IOL. The patient was prescribed intravenous gentamicin sulphate (80 mg/two times a day) and intramuscular cephazolin (1 g/three times a day). Atropine, tobramicine, chloramphenicol and betamethazone eye drops were applied topically. The inflammation responded well to the therapy and the patient was discharged from hospital 10 days later. The patient was examined twice a week, and 1 month after the onset of treatment the eye was free of inflammation and no further therapy was prescribed. Four months after surgery the eye was still free of inflammation. However, there was a cyclytic membrane on the anterior surface of the IOL together with posterior synechia. A YAG laser discission of the cyclic membrane and the posterior lens capsule was made. The patient was given betamethasonetetracycline--ehloramphenicol eye drops for 5 days and her best corrected visual acuity was 10/20. Funduscopy did not reveal any disorder and the vitreous body was normal and clear. Approximately 1 month after the YAG laser capsulotomy, she returned to our observation because her visual acuity had fallen dramatically. A slit lamp examination revealed hypopyon and the presence of exudative material in the vitreous body (Fig. 1). The fundus was not explorable. A para bulbar injection of gentamycin sulphate and betamethasone was given and systemic and topical therapy similar to that administered 3 days after the operation was started. Despite the therapy, the eye was always inflamed and a yellow fibrous tissue with neovessels appeared in the anterior part of the vitreous body (Fig. 1). At this time we decided to reoperate. An anterior vitrectomy was performed and the IOL removed. The IOL was easily removed after the synechiae were lysed. During vitrectomy, a massive haemorrhage occurred. Once the haemorrhage was arrested the vitrectomy was completed and intraocular and parabulbar gentamicin sulphate was administered post surgery. The material removed underwent microbiological analyses that revealed Moraxella lacunata colonies. Eur J Implant Ref Surg, Vo/3, June 1991
153
Fig. 1 For details see the text
This second postoperative period was uneventful. Two months after the operation the fundus could not be examined because of the fibrous post-haemorrhage condition of the vitreous body. The eye was hypotonic, but without signs of intraocular inflammation, and the visual function was abolished. DISCUSSION
With the increase of intraocular lens implantation, more eyes developing postoperative endophthalmitis are pseudophakic [2]. Extracapsular cataract extraction may be complicated by a uveal reaction induced by surgical trauma, by impurities contained in the irrigation solution and, lastly, by the presence of residual lens material [2, 3, 8]. This inflammation is generally sterile and granulomatous with a typical infiltration of giant cells and fibrous proliferation [10, 11, 12]. The uveitis could also be induced by an immunological reaction activated by the IOL per se and mediated by the complement [13]. These types of inflammation are generally self-limited, although more rarely and in patients suffering from an ineffective functioning of the immunological system, they can become chronic and a phacoantigenic reaction can occur [9, 14]. Postoperative intraocular inflammation may also be caused by infection. Demonstration or isolation of the agent from intraocular material is necessary to establish the diagnosis of infectious endophthalmitis. The more frequent microorganisms involved are Staphylococcus aureus, Propionibacterium acnes, Streptococcus species, Proteus vulgaris, Pseudonwnas aeruginosa and Haenwphilus in{luenzae. Corynebacterium difteriae, Citrobacteriam diversus, Serratia marcescens and Achronwbacterium have also been implicated in infectious endophthalmitis [1-5].
154
Short reports
Many of these microorganisms are common conREFERENCES stituents of the normal flora of the external eye and 1 G.W. Zaidman & B.J. Mondino. Postoperative pseudophakic the 10L could represent a vector by which these bacterial endophthalmitis. Am. J. Ophthalmol., 1982; 218: microorganisms are brought into the eye. In this 93. 2 W.T. Driebe, S. Mandelbaum & R.K Forster et al. Pseudostudy we report a case with culture-positive Moraxphakic endophthalmitis. Diagnosis and Management. Ophella lacunata intraocular infection after extracapsuthalmol., 1986; 442: 93. lar cataract extraction and posterior chamber intra3 D.M. Meisler, A.G. Palestine & D.W. Vastine et al. Chronic Propionibacterium endophthalmitis after extracapsular ocular lens implantation. Moraxella lacunata is a cataract extraction and intraocular lens implantation. Am. Gram-negative, non-spore-forming, aerobe diplobaJ. Ophthalmol., 1986; 102: 733. cillus. It is an organism commonly found in the aero4 T.J. Roussel, W.W. Culbertson & N.S. Jaffe. Chronic postbic flora of the eyelids and conjunctiva, that often operative endophthalmitis associated with Propionibacterium acnes. Arch. Ophthalmol., 1987; 105: 1199. causes subacute or chronic conjunctivitis. Moraxella 5 M. Wenzel & M. Reim. Eine Klassifizierung intraokularer lacunata is an organism of low virulence that has bakteriologischer Befunde nach Linsenimplantation. Klin. been reported to induce postoperative uveitis [15]. Mbl. Augenhreilk., 1988; 193: 589. 6 KL. Piest, M.C. Kincaid, M.R. Tetz, D.J. Apple, W.A. Postoperative bacterial endophthalmitis caused Roberts & F.W. Price Jr. Localized endophthalmitis: a newly by virulent pathogens is usually characterized by a documented cause of toxic lens syndrome. J. Cataract painful, hyperacute and destructive course [16]. On Refract. Surg., 1987; 13: 498. 7 D.J. Apple, M.C. Kincaid, N. Mamalis & R.J. Olson. Intrathe cQntrary, in our patient the uveal reaction ocular Lenses. Evolution, Design, Complications and Patholappeared 3 days after the operation and resembled a ogy. Williams & Wilkins, Baltimore, 1989. 8 H. Sievers & D. von Domarus. Foreign'body reaction against phacoantigenic reaction rather than endophthalmiintraocular lensesAm. J. Ophthalmol., 1984; 97: 743. tis. However, because the nature of the inflamma9 E.R Smith. Inflammation after cataract surgery. Am. J. tion observed seemed to be similar to that induced Ophthalmol., 1986; 102: 788. by low-virulence organisms (i.e. S. epidermidis, P. 10 D.J. Apple, N. Mamalis & R.L. Steinmetz et al. Phacoanaphylactic endophthalmitis associated with extracapsular acnes, etc.), we prescribed antibiotic therapy cataract extraction and posterior chamber intraocular lens. together with a topical steroid treatment. The good Arch. Ophthalmol., 1984; 102: 1528. results obtained were in agreement with our diagno- 11 R.J. Wolter. Cytopathology of intraocular lens implantation. Ophthalmol., 1985; 92: 135. sis. Four months after the operation the patient 12 D. von Domarus, R Burk & H. Sievers. Tissue changes underwent YAG laser treatment both of the cyclytic induced by intraocular lenses. Dev. Ophthalmol., 1984; 91: 95. membrane and of the posterior lens capsule. With the discission of the posterior lens capSUle, residual 13 R.S. Coles. Syndrome toxique des implants intra-oculaires. Bull. Mem. Soc. Fr. Ophthalmol., 1984; 91: 95. lens material and microorganisms flowed into the 14 A.M. Galin, A.W. Tuberville & RS. Dotson. Immunological aspects of intraocular lenses. Inter. Ophthalmol. CUn., 1982; vitreous body inducing a more severe and less trea22: 227. table endophthalmitis. This is in agreement with 15 S. Duke·Elder & E.S. Perkins. Disease of the Uveal Tract. Driebe and coworkers who found that antibiotics System of Ophthalmol. Henry Kimpton, London. IX, 1966; 232. were ineffective in the management of infectious endophthalmitis [2]. In addition our patient con- 16 R.K Foster. Etiology and diagnosis of bacterial postoperative endophthalmitis. Ophthalmol., 1978; 85: 320. firms the difficulty of differentiating between a ph acoantigenic reaction and infectious endophthalmitis induced by low-virulence organisms. It has been Received April 1990 demonstrated that the two entities can be present at the same time [9] and that sterile uveitis can be activated by microorganisms that promote hypersensitivity to the lens proteins or to 10L constituents [3]. The diagnosis of infectious endophthalmiAPPENDIX tis is supported by the finding of organisms in cultures of intraocular specimens. However, cultureEditorial Question negative cases do not exclude the organisms that cause the inflammation. In fact, not all laboratories routinely employ cultures that isolate these low-virulence organisms. In conclusion this report serves to emphasize the Question need for preoperative attention to potential sources of infection (e.g. eyelids, lacrimal system) and the importance of strict aseptic technique in the operat- Is there any role today for preoperative cultures from eyes which no longer have a routine procedure? ingroom. Eur J Implant Ref Surg, Vol 3, June 1991
Short reports
155
Answer
Routine preoperative cultures are expensive and time consuming and, moreover, given the very low
Eur J Implant Ref Surg. Vol 3. June 1991
incidence of endophthalmitis induced by extracapsular lens extraction and intraocular lens implantation, these methods are not justified on a costbenefit basis.