Pneumococcal Endophthalmitis Associated with Nasolacrimal Obstruction

Pneumococcal Endophthalmitis Associated With Nasolacrimal Obstruction Pedro F. Lopez, M.D., Robert A. Beldavs, M.D., Saeed AI-Ghamdi, M.D., Louis A. Wilson, M.D., Ted H. Wojno, M.D., Paul Sternberg, Jr., M.D., Thomas M. Aaberg, M.D., and H. Michael Lambert, M.D. Pneumococcal endophthalmitis can be a devastating postoperative infection after cataract extraction or penetrating keratoplasty. Streptococcus pneumoniae was isolated as the causative agent in three of the 124 patients (2%) who were treated for endophthalmitis at our institution between 1984 and 1990. Two of the three patients lost light perception in the affected eye. All three patients had previously unrecognized or untreated chronic nasolacrimal obstruction of varying causes. We studied the role of pneumococcal lacrimal conjunctivitis in the pathogenesis of the postoperative pneumococcal endophthalmitis in these patients.

mococcal infection, occurring in only approximately 1.5% of such patients." Recently, we reviewed the records of all the patients with acute postoperative bacterial endophthalmitis after cataract extraction or penetrating keratoplasty who were treated at our institution in the past seven years. In three of the 124 patients with endophthalmitis (2%), S. pneumoniae was isolated as the causative agent. Pneumococcal endophthalmitis was associated with previously untreated chronic ipsilateral nasolacrimal obstruction in all three patients.

STREPTOCOCCUS PNEUMONIAE (pneumococcus) is an infrequent, but often visually devastating cause of acute postoperative endophthalmitis after cataract extraction or penetrating keratoplasty.v" In two large series, pneumococcus was the cause of acute postoperative endophthalmitis in 5% of patients after cataract extraction and in 9% of patients after penetrating keratoplasty.v" Conversely, endophthalmitis is an unusual manifestation of external ocular pneu-

Case 1 An 85-year-old woman had bilateral chronic dacryocystitis. Her ocular history disclosed chronic, intermittent epiphora in both eyes and chronic, open-angle glaucoma that had been treated with timolol maleate 0.5%,twice a day in both eyes, since June 1985. Her medical history disclosed chronic, vitamin B12-responsive, hypochromic, macrocytic anemia; chronic weakness; and arthritis. In 1986, the patient had bilateral ocular pemphigoid with superimposed aminoglycoside toxicity that became manifest during treatment of an indolent corneal ulcer and conjunctivitis. On Oct. 4, 1990, the patient underwent uncomplicated extracapsular cataract extraction and posterior chamber intraocular lens implantation in the right eye. Peri operative antibiotic prophylaxis included intraoperative subconjunctival gentamicin and topical aminoglycosides. Results of a postoperative examination on Oct. 12, 1990, were normal. One day later, on Oct. 13, 1990, the patient awoke in the evening with severe ocular discomfort and visual blurring in the right eye. Examination on Oct. 14, 1990, disclosed findings consistent

Accepted for publication April 2, 1993. From the Department of Ophthalmology, Doheny Eye Institute, University of Southern California School of Medicine, Los Angeles, California (Dr. Lopez); Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia (Drs. Beldavs, Al-Gharndi, Wilson, Wojno, Sternberg, and Aaberg); and Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Waco, Texas (Dr. Lambert). This study was supported in part by Research to Prevent Blindness, Inc., New York, New York; and departmental core grant P30EY06360 from the National Institutes of Health. Reprint requests to Pedro F. Lopez, M.D., Doheny Eye Institute, University of Southern California School of Medicine, 1450 San Pablo St., Los Angeles, CA 90033.

56

Case Reports

©AMERICAN JOURNAL OF OPHTHALMOLOGY

116:56-62,

JULY,

1993

Vol. 116, No. 1

Pneumococcal Endophthalmitis

with postoperative bacterial endophthalmitis and she was referred for treatment. Ocular examination on Oct. 14, 1990, disclosed visual acuity of R.E.: counting fingers and L.E.: 20/200. Intraocular pressure was 28 mm Hg in the right eye and 20 mm Hg in the left eye. External examination of the right eye disclosed marked ciliary injection with copious mucopurulent discharge. A pseudomembrane overlying the right inferior palpebral conjunctiva was present. Symblepharon and moderate filamentary keratitis were also noted in the right eye. Palpation of the right lacrimal sac expressed mucopurulent discharge from the right inferior punctum, indicative of chronic dacryocystitis. Pressure on the left lacrimal sac expressed watery mucoid discharge from the left inferior punctum, indicative of chronic dacryocystitis. Cultures of the punctal discharges were not performed. Slit-lamp biomicroscopy of the right eye disclosed a 2-mm area of microbial sclerokeratitis superiorly, adjacent to the cataract wound. The anterior chamber in the right eye was formed with marked aqueous cell and plasmoid flare and a 2.3-mm hypopyon. A fibrinous prepupillary membrane covered the anterior surface of the intraocular lens and precluded ophthalmoscopy. Echography of the right eye disclosed mild vitreous debris with no evidence of retinal or choroidal detachment. Postoperative bacterial keratitis and endophthalmitis associated with chronic dacryocystitis were diagnosed in the right eye. Diagnostic aqueous paracentesis and vitreous aspiration biopsy, as well as intravitreal injection of vancomycin (1 mg) and amikacin (4(J0 ""$), were performed on Oct. 14, 1990. Subconjunctival vancomycin (25 mg), ceftazidime (100 mg), and dexamethasone (6 mg) were also administered intraoperatively. Hourly, fortified topical vancomycin and amikacin, as well as prednisone acetate (1 % every two hours) and atropine (1 % twice a day), were prescribed for the right eye postoperatively. Postoperatively, intravenous ceftazidime (2 g every eight hours), intravenous amikacin (300 mg every 12 hours, after an initial loading dose), and oral prednisone, 30 mg twice a day, were administered. On Oct. 17, 1990, diagnostic culture of the aqueous disclosed confluent growth of S. pneumoniae. Six colonies of S. pneumoniae were also isolated from the vitreous culture. A preoperative conjunctival culture of the right eye disclosed confluent growth of S. pneumoniae and

57

Serratia marcescens. All the S. pneumoniae isolates from each of the different anatomic locations had identical sensitivities. Topical fortified amikacin and intravenous ceftazidime were discontinued on Oct. 17, 1990, and a ten-day course of oral ciprofloxacin, 750 mg twice a day, was begun. On Oct. 18, 1990, visual acuity in the right eye was light perception. A persistent fibrin prepupillary membrane that extended into the anterior chamber angle was lysed with intracameral recombinant tissue plasminogen activator (12.5 ,...g) and visual acuity improved to hand motions. Mild aqueous filtration from the superior area of sclerokeratitis was noted on Oct. 21, 1992, but no further surgical intervention was recommended. Topical antibiotic therapy was gradually tapered in the right eye with resolution of the endophthalmitis. Dacryocystorhinostomies were performed in both eyes on Nov. 2, 1990, for the associated chronic dacryocystitis. One year later, after YAG capsulotomy, the visual acuity in the right eye improved to 20/50. Case 2 An 87-year-old woman had chronic right nasolacrimal obstruction. Her surgical history disclosed radical sinus surgery of the right maxillary antrum performed in 1950 for chronic sinus infection. In 1955, a right anterior ethmoidectomy, subtotal right dacryocystectomy, and right dacryocystorhinostomy were performed. Postoperatively, right chronic epiphora persisted, but was well tolerated by the patient. The patient's ocular history disclosed intracapsular cataract extraction with peripheral iridectomy in the right eye on Jan. 2, 1977, a scleral-buckling procedure for aphakic rhegmatogenous retinal detachment in the right eye in January 1982, and anterior vitrectomy with secondary anterior chamber intraocular lens implantation in the right eye on April 14, 1987. Visual acuity in the right eye had improved to 20/30 without correction on April 28, 1987. External disease history disclosed an episode of canaliculodacryocystitis of the right conjunctiva in August 1987 that was refractory to topical gentamicin but sensitive to oral amoxicillin (250 mg, four times a day for one week). Persistent right nasolacrimal obstruction was confirmed two months later when fluid irrigated into the right inferior canaliculus refluxed from the right superior canaliculus. The left nasolacrimal system was normal. A repeat right dac-

58

AMERICAN JOURNAL OF OPHTHALMOLOGY

ryocystorhinostomy was recommended, but the patient declined surgical intervention. Pseudophakic bullous keratopathy associated with an unstable anterior chamber intraocular lens progressively reduced visual acuity in the right eye to counting fingers. Uncomplicated penetrating keratoplasty and anterior chamber intraocular lens exchange were performed in the right eye on Dec. 5, 1989. Postoperative antibiotic prophylaxis included subconjunctival gentamicin and a topical aminoglycoside. One day postoperatively, visual acuity in the right eye was hand motions and intraocular pressure was 25 mm Hg. Slit-lamp biomicroscopy disclosed a Seidel-negative corneal grafthost junction and moderate graft edema. A formed anterior chamber with moderate aqueous cell and flare and a well-centered anterior chamber intraocular lens were present. Ophthalmoscopy was limited by the lack of media clarity, but results appeared normal. Two days postoperatively, the patient developed severe ocular discomfort, erythema and edema of the eyelids, and visual acuity decreased to light perception in the right eye. Slit-lamp biomicroscopy disclosed marked conjunctival injection with ciliary flush, a formed anterior chamber with marked aqueous cells and plasmoid flare, and a minimal hypopyon. An extensive fibrinous prepupillary membrane obscured the intraocular lens and precluded ophthalmoscopy. Echography of the right eye demonstrated moderate vitreous debris and an attached retina. Postoperative endophthalmitis was diagnosed and repeat penetrating keratoplasty, intraocular lens removal, and diagnostic paracentesis and vitrectomy were performed on Dec. 7, 1989. Intraoperative intravitreal antibiotic injections of vancomycin (1 mg) and gentamicin (100 ILg), each in 0.1 ml of balanced saline solution, were administered. Fortified topical cefazolin and gentamicin were given every 30 minutes. Intravenous cefazolin, 1 g every eight hours, was also administered for five days. Diagnostic aqueous and vitreous cultures grew between ten and 100 colonies of S. pneumoniae, which was estimated to represent a concentration of 10,000 to 100,000 organisms per milliliter. A previous culture of the Dexsol (Chiron Medical Optics, Irvine, California) storage medium of the original donor corneal tissue disclosed no growth after seven days. The patient's antibiotic regimen was gradually tapered over the next several weeks with reso-

July, 1993

lution of the endophthalmitis. Light perception in the right eye was ultimately lost. Case 3 A 77-year-old woman had chronic epiphora in the right eye. Her medical history disclosed chronic sinusitis and postnasal drip. She had no history of previous head trauma, surgery, or irradiation. Small-incision, sutureless cataract extraction with posterior chamber lens implantation was performed through a scleral tunnel incision in the right eye in May 1992 without complication. Perioperative antibiotic prophylaxis included intraoperative subconjunctival gentamicin and a topical aminoglycoside. Postoperatively, visual acuity in the right eye improved from counting fingers on the first postoperative day to 20/60 on the tenth postoperative day. Slit-lamp examination disclosed moderate corneal haze, and mild to moderate aqueous cell and flare on the postoperative visits. On the 13th postoperative day visual acuity decreased to hand motions, the right cornea was more hazy, and a hypopyon developed. She was referred to our institution for treatment of presumed infectious postoperative endophthalmitis in the right eye. On examination, she had visual acuity of only light perception, a total hypopyon, and a superior corneal infiltrate involving one third of the cornea adjacent to an area of superior limbal wound ulceration and scleral tunnel flap necrosis in the right eye. Debridement and suture revision of the necrotic limbal wound and scleral tunnel flap with injection of tissue plasminogen activator into the anterior chamber, and intravitreal amikacin (400 ILg) and vancomycin (1 mg) injection were performed. The cornea was too opaque to permit pars plana vitrectomy. Intraocular fluid was cultured and treatment with topical fortified vancomycin and amikacin was initiated. One day later, a descemetocele formed along the superior cornea of the right eye, and this was reinforced with cyanoacrylate adhesive and a therapeutic bandage lens (Fig. 1). Streptococcus pneumoniae was isolated; treatment with topical amikacin was discontinued and treatment with intravenous penicillin was instituted. Visual acuity in the right eye fluctuated between hand motions and light perception. A long-standing history of chronic right epiphora was elicited, and mucopurulent material was noted through the inferior punctum with compression of the nasolacrimal sac (Fig. 2). The

Pneumococcal Endophthalmitis

Vol. 116, No.1

Fig. 1 (Lopez and associates). Case 3. Postoperative external photograph discloses tissue adhesive overlying an area of superior corneoscleral necrosis at the site of the scleral tunnel of the previous cataract incision (arrowheads). A therapeutic bandage contact lens is also present.

left nasolacrimal system was normal. A right dacryocystorhinostomy was recommended. On the day before discharge, a new corneal perforation with iris protrusion was noted superonasally in the right eye. The existing disk of cyanoacrylate adhesive was removed and the entire right cornea was reinforced with a second application of the tissue adhesive. One day later, she was discharged with a treatment regimen of oral cefazolin and fortified vancomycin drops. One month later, light perception was lost and the right eye was subsequently enucleated.

Discussion

The normal human lacrimal system effectively bars ascending pneumococcal colonization and infection from the upper respiratory tract. Streptococcus pneumoniae is a normal commensal in the nasopharynx of 9% to 38% of asymptomatic people.v" Streptococcus pneumoniae, however, is rarely, if ever, isolated from normal, uninfected conjunctiva.P''! The reported prevalence of pneumococci in cultures of normal conjunctiva varies between 0.0% and 0.3%. Obstruction of the nasolacrimal outflow system may result in tear stasis and predispose to ascending colonization and infection of the lacrimal system and conjunctiva by the normal

59

Fig. 2 (Lopez and associates). Case 3. External photograph discloses mucopurulent discharge (arrowheads) expressed from the right lower lacrimal punctum by compressing the lacrimal sac with a cotton-tipped applicator.

nasopharyngeal commensals, particularly pneumococcus.":" Because S. pneumoniae is a facultative or aerotolerant anaerobic organism, reduced oxygen tension without the obstructed nasolacrimal outflow system may further contribute to its preferential microbial overgrowth.P:" In such cases, lacrimal reflux from the obstructed nasolacrimal passages may facilitate conjunctival spread of the pneumococci. The association between chronic nasolacrimal outflow obstruction and ocular pneumococcal infection was well understood in the late 19th and early 20th century.13.16.17 Lacrimal conjunctivitis, in which a chronic catarrhal conjunctivitis resulted from continuous reinfection of the conjunctiva by pneumococci derived from an obstructed lacrimal sac, was well known.P:'" The relationship between pneumococcal keratitis or hypopyon ulcer and chronic dacryocystitis was emphasized by Lundsgard" in 1927. In the latter part of the 20th century, however, pneumococcal endophthalmitis, chronic nasolacrimal outflow obstruction, and lacrimal conjunctivitis have rarely been associated," even in series in which postoperative pneumococcal endophthalmitis was particularly cornmon.v" In contrast, all three patients with acute postoperative pneumococcal endophthalmitis seen at our institution in the past seven years had evidence of preexisting chronic nasolacrimal obstruction and lacrimal conjunctivitis. All three patients had long-standing symptoms of chronic or recurrent epiphora

60

AMERICAN JOURNAL OF OPHTIiALMOLOGY

with intermittent symptoms of conjunctivitis. All three patients had reflux of mucoid or mucopurulent punctal discharge after external compression of the lacrimal sac ipsilateral to the eye with pneumococcal endophthalmitis. In one patient (Case 2), previously undetected chronic nasolacrimal obstruction was discovered in the unoperated-on fellow eye. The cause of the chronic nasolacrimal obstruction in each patient varied and included the following: mucous membrane scarring in the nasolacrimal passages secondary to cicatricial pemphigoid (Case 1), previous surgical trauma (Case 2), and idiopathic obstruction or obstruction caused by chronic allergic rhinitis (Case 3). None of the patients in our series had a history of orbital or facial fractures, neoplasm, or craniofacial irradiation. Two distinctive clinical findings were present in some of the eyes with pneumococcal endophthalmitis and lacrimal conjunctivitis. Two of the three eyes developed an area of suppurative keratitis involving the superior cornea adjacent to the limbal cataract incision. The onset of the suppurative keratitis coincided with the postoperative appearance of the pneumococcal endophthalmitis. A somewhat similar occurrence of acute postoperative pneumococcal keratitis, but without associated endophthalmitis, has been described in a patient with pneumococcal lacrimal conjunctivitis after cataract extraction." In such patients, trapping of the infected nasolacrimal reflux or exudate between the conjunctival and the superior area of surgically devitalized corneal epithelium by the postoperative superior conjunctival chemosis may contribute to the development of sclerokeratitis in this location. A similar mechanism has been invoked to explain marginal corneal ulceration in the setting of severe, purulent conjunctivitis with ~-hemolytic streptococcus in a patient with chronic low-grade nasolacrimal duct obstruction." Infectious scleritis and scleral necrosis of either the cataract wound or the associated scleral tunnel flap (Patient 3) was also present in two of the three eyes and was likewise coincident in onset with the pneumococcal endophthalmitis. These findings may be either the result of seeding of the surgically devitalized superior corneoscleral cataract wound intraoperatively or postoperatively by the pneumococcus, as described previously, or by contiguous scleral extension of a superior area of associat-

July, 1993

ed keratitis. Pneumococcal sclerokeratitis after pterygium excision with or without prophylactic postoperative B irradiation has also been recently described." but no association with coexisting pneumococcal lacrimal conjunctivitis was noted. Treatment of the associated corneo scleral complications are an important part of the management of postoperative pneumococcal endophthalmitis with lacrimal conjunctivitis. Concomitant pneumococcal keratitis may be managed with frequent fortified topical antibiotics. With respect to initial antibiotic selection, it is important to consider that many recent ocular isolates of S. pneumoniae have been resistant to aminoglycoside antibiotics. 4,6, IJ ,20-23 All three of our patients had postoperative subconjunctival and topical aminoglycoside prophylaxis before developing pneumococcal endophthalmitis. Vancomycin, a first-generation cephalosporin, or other antibiotic active against aminoglycoside-resistant streptococci may be a preferable prophylactic or therapeutic regimen in this situation. Concomitant systemic therapy with similar antibiotics may also be important in the treatment of associated pneumococcal scleritis and canaliculodacryocystitis, especially because aminoglycosides may be relatively less active in hypoxic and acidic microenvironments such as that found in obstructed nasolacrimal passages or in abcesslike, infected scleral tunnels. Associated pneumococcal scleritis or scleral tunnel flap scleritis may result in areas of manifest corneal or scleral necrosis associated with severe thinning and aqueous filtration (which may be confirmed by a positive Seidel test). These areas may require debridement and treatment with either tissue adhesive and a therapeutic bandage contact lens, or with a scleral patch graft. 2o,21 Treatment of areas of corneoscleral necrosis before perforation becomes evident may not only preserve the structural integrity of the globe, but also reduce the likelihood of recurrent intraocular seeding by pneumococci from adjacent foci of infective sclerokeratitis or from abscesslike collections in the infected scleral tunnel flap. Pneumococcal endophthalmitis is an infrequent cause of postoperative infection that has been reported to occur in two distinct clinical situations. Acute postoperative pneumococcal endophthalmitis may occur after transplantation of infected donor corneal tissue that has

Vol. 116, No.1

61

Pneumococcal Endophthalmitis

been preserved in a storage medium that contains only gentamicin antimicrobial prophylaxis. 22,23,24 In the one patient in our series who developed acute pneumococcal endophthalmitis after penetrating keratoplasty, culture of the donor corneal storage medium disclosed no evidence of microbial contamination. The other two patients in this series developed acute postoperative pneumococcal endophthalmitis, after either sutured or sutureless extracapsular cataract extraction with posterior chamber intraocular lens implantation. The second clinical situation in which postoperative pneumococcal endophthalmitis appears to be relatively common is in late-onset filtering bleb infections that may occur months or years after trabeculectomy." Possibly, the late-onset pneumococcal endophthalmitis in some of the previously described patients may have been caused by subclinical pneumococcal lacrimal conjunctivitis associated with cryptic chronic nasolacrimal obstruction. Our findings suggest that all patients with pneumococcal endophthalmitis after intraocular procedures should have a careful external ocular and lacrimal system examination to exclude nasolacrimal obstruction and lacrimal conjunctivitis. If nasolacrimal obstruction is detected in association with postoperative endophthalmitis, inclusion in the therapeutic regimen of both topical and systemic antibiotics active against gram-positive cocci, such as vancomycin or a first-generation cephalosporin, may be considered to reduce the risk of ocular reinfection by microbial pathogens from the obstructed lacrimal system. Once there has been a marked therapeutic response to the endophthalmitis regimen and the structural integrity of the globe is deemed adequate, surgical correction of the obstructed nasolacrimal drainage system abnormalities may be undertaken. The external ocular and lacrimal drainage system of the fellow eye should be similarly examined and prophylactically treated before performing intraocular procedures in the affected eye. Careful routine examination of the external ocular and lacrimal drainage system before intraocular procedures may identify individuals at risk for postoperative pneumococcal infection. Surgical correction of obstructed nasolacrimal drainage passages should be performed before elective intraocular procedures to minimize the risk of postoperative endophthalmitis.

The absence of nasolacrimal or punctal reflux and the absence of microbial growth on conjunctival cultures may be useful in confirming resolution of pneumococcal lacrimal conjunctivitis before intraocular procedures in selected patients.

References 1. Leveille, A. 5., McMullan, F. D., and Cavanagh, H. D.: Endophthalmitis following penetrating keratoplasty. Ophthalmology 90:388, 1983. 2. Guss, R. B., Koenig,S., De La Pena, W., Marx, M., and Kaufman, H. E.: Endophthalmitis after penetrating keratoplasty. Am. J. Ophthalmol. 95:651, 1983. 3. Salvanet-Bouccara, A., Dubayle, P., Forestier, F., Dublanchet, A., Antiphon, P., and Lafaix, c.: Endophthalmies post-operatoires a pneumocoques. J. Fr. Ophtalmol. 7:535, 1984. 4. Jones,S., Cohen, E. J., Arentsen, J. J., and Laibson, P. R.: Ocular streptococcal infections. Cornea 7:295, 1988. 5. Verbraeken, H., and Rysselaere, M.: Bacteriological study of 92 cases of proven infectious endophthalmitis treated with pars plana vitrectomy. Ophthalmologica 203:17,1991. 6. Mao, L. K., Flynn, H. W., Jr., Miller, D., and Pflugfelder, S. C.! Endophthalmitis caused by streptococcal species. Arch. Ophthalmol. 110:798, 1992. 7. Okumoto, M., and Smolin, G.: Pneumococcal infections of the eye. Am. J. Ophthalmol. 77:346, 1974. 8. Dowling, J. N., Sheehe, P. R., and Feldman, H. A.: Pharyngeal pneumococcal acquisitions in "normal" families. A longitudinal study. J. Infect. Dis. 124:9, 1971. 9. Hendley, J. 0., Sande, M. A., Stewart, P. M., and Gwaltney, J. M., [r.: Spread of Streptococcus pneumoniae in families. I. Carriage rates and distribution of types. J. Infect. Dis. 132:55, 1975. 10. Seal, D. V., Barrett, S. P., and McGill, J.1.: Aetiology and treatment of acute bacterial infection of the external eye. Br. J. Ophthalmol. 66:357, 1982. 11. Mahajan, V. M.: Acute bacterial infections of the eye. Their aetiology and treatment. Br. J. Ophthalmol. 67:191, 1983. 12. Seal, D. V.: Bacterial classification and diagnosis. Trans. Ophthalmol. Soc. V. K. 105:32, 1986. 13. Lundsgard, K. K. K.: The Doyne Memorial lecture. Pneumococcus in connection with ophthalmology. Trans. Ophthalmol. Soc. V. K. 47:294,1927. 14. Mahajan, V. M., Bareja, V., Prakash, K., and Chose. 5.: Pneumococci in ocular disease of children and their treatment. Ann. Trop. Paediatr. 7:270, 1987.

62

AMERICAN JOURNAL OF OPHTHALMOLOGY

15. Austrain, R.: Pneumococci. In Davis, B. D., Dulbecco, R., Eisen, H. N., and Ginsber, H. S. (eds.): Microbiology, Including Immunology and Molecular Genetics, ed. 4. New York, J. B. Lippincott Co., 1990, pp.515-524. 16. Duke-Elder, S.: Diseases of the outer eye. Conjunctiva. In System of Ophthalmology, vol. 8, part 1. St. Louis, C. V. Mosby, 1965, pp. 163-166. 17. Duke-Elder, S., and MacFaul, P. A.: The ocular adnexa. Lacrimal, orbital and para-orbital diseases. In Duke-Elder, S. (ed.); System of Ophthalmology, vol. 13, part 2. St. Louis, C. V. Mosby, 1974, pp. 710-711. 18. Van-Bijsterveld, O. P., and Klaassen-Broekema, N.: Lacrimal conjunctivitis. Bull. Soc. BeIge Ophthalmol. 238:61, 1990. 19. Kim, H. B., and Ostler, H. B.: Marginal corneal ulcer due to beta-streptococcus. Arch. Ophthalmol. 95:454,1977. 20. Farrell, P. L. R., and Smith, R. E.: Bacterial corneoscleritis complicating pterygium excision.

July, 1993

Am. J. OphthalmoI. 107:515, 1989. 21. Altman, A. J., Cohen, E. J., Berger, S. T., and Mondino, B. J.: Scleritis and Streptococcus pneumaniae. Cornea 10:341, 1991. 22. Lindquist, T. D., Weber, K., Spika, J., and Facklam, R.: Gentamicin-resistant streptococcal endophthalmitis after keratoplasty (correspondence). Cornea 9:88, 1990. 23. Jones, M., Middaugh, J., Benjamin, R., Werner, S. B., and Lyman, D.O.: Pneumococcal endophthalmitis after ocular surgery-Alaska, California. MMWR 39:71, 1990. 24. Shaw, E. L., and Aquavella, J. V.: Pneumococcal endophthalmitis following grafting of corneal tissue from a (cadaver) kidney donor. Ann. Ophthalmol. 9:435, 1977. 25. Mandelbaum, S., Forster, R. K., Gelender, H., and Culbertson, W.: Late onset endophthalmitis associated with filtering blebs. Ophthalmology 92:964, 1985.

OPHTHALMIC MINIATURE

Have you ever considered the latent possibilities for dramatic situations in short sight? You know how your glasses cloud over when you come into a warm room out of the cold? Well, imagine your hero in such a position. He has been waiting outside the murderer's den preparatory to dashing in and saving the heroine. He dashes in. "Hands up, you scoundrels," he cries. And then his glasses get all misty, and there he is, temporarily blind, with a full-size desperado backing away and measuring the distance in order to hand him one with a pickaxe. P. G. Wodehouse, "Spectacles of Fate," from The Uncollected Wodehouse, D. A. Jansen, editor New York, New York, International Polygonics, Ltd., 1992, p. 21