An uncommon case of brucellosis with ocular presentation / Um caso incomum de brucelose com apresentação ocular

ABSTRACT We report an unusual case of brucellosis presented with headache, diminished vision, papillitis and multiple peripapillary hemorrhages accompanied by subretinal fluid extending up to macula. Diagnosis of brucellosis was made based on positive polymerase chain reaction of cerebrospinal fluid sample for Brucella species DNA, accompanied by a raised titer of anti-brucella antibodies. Patient showed remarkable improvement on triple drug therapy in form of doxycycline, rifampicin and ceftriaxone.

RESUMO Relatamos um caso incomum de brucelose apresentada com cefaleia, visão diminuída, papilite e múltiplas hemorragias peripapilares acompanhadas por fluido sub-retinal, estendendo-se até a mácula. O diagnóstico de brucelose foi feito com base na reação em cadeia da polimerase positiva de amostra de líquido cefalorraquidiano para DNA de espécies de Brucella, acompanhada por um título elevado de anticorpos antibrucela. O paciente apresentou melhora notável com a terapia tripla com drogas na forma de doxiciclina, rifampicina e ceftriaxona.

Endogenous endophthalmitis due to Kingella Kingae infectious endocarditis / Endoftalmite endógena por endocardite infecciosa devido a Kingella Kingae

Abstract This report presents a rare case of endogenous endophthalmitis due to Kingella kingae infectious endocarditis. Endogenous endophthalmitis is a rare condition that has a systemic underlying cause, with hematogenic dissemination of a pathogen that will eventually reach and infect the eye. In this article, we present a case of a 54-year-old woman with fever, chills and decreased visual acuity and pain in the right eye. The slit-lamp exam showed conjunctival injection, anterior chamber reaction with a great amount of fibrinous material obscuring her visual axis. Ultrasound echography revealed profuse exudates and scarce membranous formation in the posterior segment. Blood culture was positive for Kingella kingae, and the patient was treated with intravenous ceftriaxone, along with topic dexamethasone and mydriatic. After 15 days of intravenous antibiotic therapy, the patient exhibited best visual acuity of 20/60. Endogenous endophthalmitis is an ocular emergency that demands quick diagnosis and aggressive intervention in order to preserve vision. Therefore, it is important to recognize its signs and symptoms with no retard.

Resumo O presente relato apresenta um raro caso de endoftalmite endógena por endocardite devido à Kingella kingae. Endoftalmite endógena é uma doença pouco comum com uma causa sistêmica subjacente. A disseminação hematogênica de um microrganismo infeccioso leva à infecção ocular. Nesse artigo, apresentamos o caso de uma mulher com 54 anos, febre, calafrios, baixa da acuidade visual e dor em olho direito. Ao exame na lâmpada de fenda apresentava injeção conjuntival, reação de câmara anterior e acúmulo de fibrina no eixo visual. Ultrassonografia revelou exsudatos profusos e escassa formação membranosa em segmento posterior.A hemocultura foi positiva para Kingella kingae e a paciente foi tratada com ceftriaxone venoso conjuntamente com dexametasona e midriático tópicos. Após 15 dias de terapia antibiótica endovenosa, a paciente apresentou acuidade visual corrigida de 20/60. Endoftalmite endógena é uma emergência ocular que demanda rápido diagnóstico e intervenção agressiva para preservar a visão. Portanto, é importante o reconhecimento precoce dos sinais e sintomas.

Infectious keratitis in southern Brazil: a comparison culture negative and culture positive patients / Ceratite infecciosa no sul do Brasil: comparação entre pacientes com cultura negativa e positiva

Abstract Purpose: To compare clinical-epidemiological profile and treatment outcome between culture negative and culture positive keratitis patients. Methods: Patients with suspected infectious keratitis seen at two ophthalmic hospitals in Curitiba, Brazil, between June 2014 and April 2016, were prospectively studied. Ophthalmological exam with corneal scraping and microbiological tests were performed. Data regarding follow up, surgical interventions and treatment outcome were collected after 12 weeks of the first visit trough medical chart review. From the results of the culture, two groups were formed: culture negative keratitis (CNK) and culture positive keratitis (CPK). Results: According to inclusion criteria 21 patients were classified as culture negative keratitis and 20 patients as culture positive keratitis. The number of patients on antibiotic drops at the first visit was greater in CNK group (90.5% versus 60%; p=0.032). Surgical procedures were necessary in 3 patients (15%) in CNK group and in 7 patients (36,8%) in CPK group (p=0.155). Treatment success was achieved by 85% (17/20) of the patients in CNK group and by 61% (11/18) of the patients in CPK group (p=0.144). There was no significant difference between groups regarding age, gender, place of residence, presence of comorbidities, risk factors for infectious keratitis, duration of symptoms and characteristics of corneal ulcer. Conclusions: Previous treatment with antibiotics correlates with negative culture results. There was no significant difference in treatment outcome between culture negative and culture positive keratitis patients.

Resumo Objetivo: Comparar os perfis clinico-epidemiológicos e os desfechos entre pacientes com ceratite com cultura positiva e pacientes com ceratite com cultura negativa. Métodos: Pacientes com ceratite infecciosa, atendidos em dois hospitais oftalmológicos em Curitiba, Brasil, entre junho de 2014 e abril de 2016, foram estudados prospectivamente. Exame oftalmológico, raspado de córnea e exames microbiológicos foram realizados no primeiro atendimento. Os dados quanto a seguimento e desfecho foram coletados após 12 semanas do primeiro atendimento através de revisão de prontuário. A partir dos resultados das culturas, dois grupos foram formados: ceratite com cultura negativa e ceratite com cultura positiva. Resultados: Vinte e um pacientes foram classificados como ceratite com cultura negativa e 20 como ceratite com cultura positiva. O número de pacientes em uso de colírio antibiótico no primeiro atendimento foi maior no grupo de cultura negativa (90,5% versus 60%; p=0,032). Sete pacientes (37%) no grupo cultura positiva precisaram de procedimentos cirúrgicos no manejo da ceratite, versus 3 pacientes (15%) do grupo cultura negativa (p=0,155). Oitenta e cinco por cento (17/20) dos pacientes do grupo cultura negativa alcançaram sucesso no tratamento, contra 61% (11/18) dos pacientes no grupo cultura positiva (p=0,144). Não houve diferença entre os grupos quanto a idade, gênero, local de procedência, presença de comorbidades, fatores de risco, duração dos sintomas e características da úlcera de córnea. Conclusão: Tratamento prévio com colírio de antibiótico correlaciona-se com resultados negativos de cultura. Não houve diferença no desfecho após tratamento entre os pacientes com cultura negativa e cultura positiva.

Celulitis orbitaria complicada por absceso subperióstico debido a infección por Streptococcus pyogenes / Orbital cellulitis complicated by subperiosteal abscess due to Streptococcus pyogenes infection

Resumen: Introducción: La celulitis orbitaria es una enfermedad infecciosa muy frecuente en la edad pediátrica que puede provocar el desarrollo de severas complicaciones. Los principales microorganismos involucrados son Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae y Moraxella catarrhalis, que juntos corresponden al 95% de los casos. También se pueden presentar Streptococcus beta hemolíticos y microorganismos anaerobios, que corresponden a menos del 5% de los casos. Se presenta un caso poco frecuente de celulitis orbitaria complicada por absceso subperióstico ocasionado por Streptococcus pyogenes (estreptococo beta hemolítico del grupo A). Caso clínico: Paciente masculino de 9 años de edad con antecedente de trastorno por déficit de atención e hiperactividad desde los 5 años de edad. Inició su padecimiento actual por presentar eritema en canto externo del ojo derecho; posteriormente, aumento de volumen periorbicular con limitación de apertura palpebral, progresión a proptosis, dolor a los movimientos oculares y secreción conjuntival purulenta. Los estudios de imagen subperióstico reportaron absceso y preseptal derecho con celulitis extraocular. Se inició manejo empírico con antibióticos, drenaje quirúrgico y cultivo del material purulento. De este, se aisló Streptococcus pyogenes. Conclusiones: Debido a la implementación de los esquemas de vacunación desde la década de los 90 contra H. influenza y S. pneumoniae, los casos por estos patógenos han disminuido, provocando que nuevas bacterias tomen su lugar como causantes de la infección. La importancia de considerar a S. pyogenes como etiología de celulitis orbitaria radica en la rápida progresión para la formación de abscesos, así como los pocos casos descritos en la literatura.

Abstract: Background: Orbital cellulitis is an infectious disease that is very common in pediatric patients, in which severe complications may develop. Etiological agents related to this disease are Haemophilus influenzae B, Staphylococcus aureus, Streptococcus pneumoniae and Moraxella catarrhalis, which correspond to 95% of cases. Moreover, Streptococcus beta hemolytic and anaerobic microorganisms may also be present corresponding to < 5% of the cases. We present an uncommon case of cellulitis complicated by sub-periosteal abscess caused by Streptococcus pyogenes (Group A beta hemolytic streptococcus). Case report: A 9-year-old male patient with a history of deficit disorder and hyperactivity since 5 years of age. His current condition started with erythema in the external edge of the right eye, increase in peri-orbicular volume with limitation of eyelid opening, progression to proptosis, pain with eye movements and conjunctival purulent discharge. Image studies reported subperiosteal abscess and preseptal right with extraocular cellulitis. The patient started with empirical antibiotic treatment, surgical drainage and culture of purulent material from which Streptococcus pyogenes was isolated. Conclusions: Due to the implementation of vaccination schemes against H. influenza and S. pneumoniae since the 90s, the cases by these pathogens have decreased, causing new bacteria to take place as the cause of the infection. The importance of considering S. pyogenes as an etiology of orbital cellulitis is the rapid progression to abscess formation, and the few cases described in the literature.

Risk Factors for Fluoroquinolone Resistance in Ocular Cultures

PURPOSE: To identify the risk factors associated with fluoroquinolone resistance in patients undergoing cataract surgery. METHODS: A total of 1,125 patients (1,125 eyes) who underwent cataract surgery at Veterans Health Service Medical Center from May 2011 to July 2012 were enrolled in this study. Conjunctival cultures were obtained from the patients on the day of surgery before instillation of any ophthalmic solutions. The medical records of patients with positive coagulase negative staphylococcus (CNS) and Staphylococcus aureus (S. aureus) cultures were reviewed to determine factors associated with fluoroquinolone resistance. RESULTS: Of 734 CNS and S. aureus cultures, 175 (23.8%) were resistant to ciprofloxacin, levofloxacin, gatifloxacin, or moxifloxacin. Use of fluoroquinolone within 3 months and within 1 year before surgery, topical antibiotic use other than fluoroquinolone, systemic antibiotic use, recent hospitalization, ocular surgery, intravitreal injection and use of eyedrops containing benzalkonium chloride were significantly more frequent in resistant isolates than in susceptible isolates. In multivariable logistic regression analysis, ocular surgery (odds ratio [OR], 8.457), recent hospitalization (OR, 6.646) and use of fluoroquinolone within 3 months before surgery (OR, 4.918) were significant predictors of fluoroquinolone resistance, along with intravitreal injection (OR, 2.976), systemic antibiotic use (OR, 2.665), use of eyedrops containing benzalkonium chloride (OR, 2.323), use of fluoroquinolone within 1 year before surgery (OR, 1.943) and topical antibiotic use other than fluoroquinolone (OR, 1.673). CONCLUSIONS: Recent topical fluoroquinolone use, hospitalization and ocular surgery were significantly associated with fluoroquinolone resistance in CNS and S. aureus isolates from ocular culture.

Sensibilidad antibiótica de bacterias obtenidas de queratitis e infecciones intraoculares en la Fundación Oftalmológica de Santander (FOSCAL), Floridablanca, Colombia / Antibiotic susceptibility patterns of bacteria isolated from keratitis and intraocular infections at Fundación Oftalmológica de Santander (FOSCAL), Floridablanca, Colombia

Introducción. La resistencia bacteriana es crítica para la selección de los antibióticos en el tratamiento de las infecciones, por ello es vital conocer su estado actual en nuestro medio. Objetivo. Determinar la sensibilidad antibiótica bacteriana in vitro obtenida de los cultivos de queratitis e infecciones intraoculares. Materiales y métodos. Se llevó a cabo un estudio retrospectivo en la Fundación Oftalmológica de Santander (FOSCAL), entre junio de 2011 y enero de 2012. Resultados. Se examinaron 92 muestras. Se identificaron 110 bacterias, 27 hongos y 12 amebas de vida libre. Del total de bacterias Gram positivas, 1,1 %, 0 %, 1,1 %, 16,9 %, 29,3 % y 85 % fue resistente a imipenem, moxifloxacina, gatifloxacina, levofloxacina, ciprofloxacina y tobramicina, respectivamente, mientras que la resistencia a estos mismos fármacos se presentó, respectivamente, en 0 %, 8,3 %, 0 %, 0 %, 18,2 % y 27,3 % de las bacterias Gram negativas. Los porcentajes de resistencia de los estafilococos positivos para coagulasa resistentes a la meticilina fueron 0 %, 0 %, 0 %, 7 %, 17 % y 100 %, respectivamente, y los porcentajes de los estafilococos negativos para coagulasa resistentes a la meticilina fueron 3 %, 0 %, 0 %, 24 %, 44 % y 100 %, respectivamente. Los porcentajes de resistencia bacteriana globales (tanto para bacterias Gram positivas como para Gram negativas) a imipenem, moxifloxacina, gatifloxacina, levofloxacina, ciprofloxacina y tobramicina fueron 1 %, 1 %, 1 %, 15,1 %, 28 % y 64,5 %, respectivamente. Conclusiones. Los niveles de resistencia bacteriana para imipenem, moxifloxacina y gatifloxacina fueron menores que para levofloxacina, ciprofloxacina y tobramicina. Los niveles de resistencia para la tobramicina fueron muy altos, lo que pone en duda su utilidad clínica en las infecciones oculares en nuestro medio.

Introduction: Bacterial resistance is critical for the selection of antibiotics in the treatment of infections, so it is vital to know its current status in our geographical area. Objective: To determine in vitro antibiotic susceptibility of bacterial isolates obtained from keratitis and intraocular infections. Materials and methods: A retrospective study of microbiological tests in Fundación Oftalmológica de Santander (FOSCAL) was carried out between June, 2011, and January, 2012. Results: A total of 92 samples were examined and 110 bacteria, 27 fungi and 12 free-living amoebae were identified. Polymicrobial infections constituted 50% of the total; 1.1%, 0%, 1.1%, 16.9%, 29.3% and 85% of Gram-positive bacteria were resistant to imipenem, moxifloxacin, gatifloxacin, levofloxacin, ciprofloxacin and tobramycin, respectively, while 0%, 8.3%, 0%, 0%, 18.2% and 27.3% of Gram-negative bacteria were resistant to imipenem, moxifloxacin, gatifloxacin, levofloxacin, ciprofloxacin and tobramycin, respectively. For methicillin-resistant coagulase-positive staphylococci, resistance percentages to imipenem, moxifloxacin, gatifloxacin, levofloxacin, ciprofloxacin and tobramycin were 0%, 0%, 0%, 7%, 17% and 100%, respectively. For methicillin-resistant coagulase-negative staphylococci, resistance percentages to imipenem, moxifloxacin, gatifloxacin, levofloxacin, ciprofloxacin and tobramycin were 3%, 0%, 0%, 24%, 44% and 100%, respectively. Overall bacterial resistance to imipenem, moxifloxacin, gatifloxacin, levofloxacin, ciprofloxacin and tobramycin, for both Gram-positive and Gram-negative, was 1%, 1%, 1%, 15.1%, 28% and 64.5%, respectively. Conclusions: The levels of bacterial resistance to imipenem, moxifloxacin and gatifloxacin were lower than for levofloxacin, ciprofloxacin and tobramycin. The levels of resistance to tobramycin were very high, which calls into question its usefulness in this region of our country.

Evaluation of conjunctival bacterial flora in patients with Stevens-Johnson Syndrome

OBJECTIVE: To determine the conjunctival bacterial flora present in patients with Stevens-Johnson syndrome. METHODS: A prospective study of the conjunctival bacterial flora was performed in 41 eyes of 22 patients with Stevens-Johnson syndrome. The information gathered included the patient's sex and age, the duration of disease, the cause of Stevens-Johnson syndrome, and treatments. Scrapings of the inferior conjunctival fornix were performed in both eyes. Fourteen days before scraping, the patients were asked to interrupt all topical medication and start using 0.5% nonpreserved methylcellulose. The microbiological evaluation included microorganism identification and determination of antibiotic sensitivity. RESULTS: Of 22 patients (41 eyes), 14 (64%) were females, and eight (36%) were males. The mean age was 33.2 years, and the mean duration of disease was 15.6 years. Visual acuity ranged from light perception to 20/25 (1.57 logMar). The treatment received by most patients consisted of tear substitutes, topical antibiotics, and contact lenses. Bacterial identification was positive in 39 eyes (95%) and negative in two eyes (5%). Gram-positive cocci accounted for 55.5% of the microorganisms, whereas gram-positive bacilli and gram-negative bacilli accounted for 19% and 25.5%, respectively. Half of the patients (54%) had multiple bacterial species in their flora, and only one bacterial species was identified in the other half. Resistant bacteria were isolated from four eyes. The antibiotic sensitivity results for the Streptococcus group showed the lowest sensitivity and the highest microbial resistance identified. CONCLUSION: Patients with Stevens-Johnson syndrome have a diverse conjunctival flora that includes many pathogenic species. .

Antibiotic resistance and molecular characterization of ophthalmic Staphylococcus pseudintermedius isolates from dogs

The prevalence, virulence potential, and antibiotic resistance of ophthalmic Staphylococcus pseudintermedius (SP) isolated from dogs were examined. Sixty-seven Staphylococcus species were isolated from ophthalmic samples and surveyed for species-specific sequences in the Staphylococcus intermedius group (SIG) nuclease gene (SInuc), exfoliative toxin gene for SIG (siet), and antibiotic resistance genes (blaZ and mecA). PCR-restriction fragment length polymorphism analysis of the pta gene was also performed. Fifty isolates were identified as SIG strains, all of which were found to be SP. The blaZ gene was detected in 42 of the 50 SP strains and mecA gene was observed in 18 of the 50 SP strains. The 50 SP strains were most susceptible to amoxicillin/clavulanic acid (94%) and chlorampenicol (70%), and highly resistant to tetracycline (94%) and penicillin (92%). It was also found that 16 (88.9%) mecA-positive SP strains were resistant to oxacillin, tetracycline and penicillin. All mecA-positive SP were resistant to more than four of the eight tested antibiotics and therefore considered SP with multi-drug resistance (MDR). Our results indicate a high prevalence of antibiotic resistance genes in ophthalmic SP along with a close relationship between MDR SP strains and the mecA gene. Based on our findings, judicious administration of antibiotics to companion dogs is necessary.

Prevalence and antibiotic susceptibility of methicillin-resistant Staphylococcus aureus in ocular infections / Prevalência e suscetibilidade antibiótica de Staphylococcus aureus resistente à meticilina em infecções oculares

PURPOSE: To study the prevalence of methicillin-resistant Staphylococcus aureus among S. aureus ocular infections in a tertiary health center in Brazil and compare antibiotic susceptibility patterns between MRSA and methicillin-susceptible S. aureus isolates. METHODS: Electronic records from the ocular microbiology laboratory of the Universidade Federal de São Paulo were retrospectively reviewed. During a 10-year period (between January 2000 and December 2009) all conjunctivitis, keratitis, and endophthalmitis cases with a positive culture for S. aureus were identified. Antibiotic susceptibility was determined using the Kirby-Bauer disk diffusion method. RESULTS: Five hundred sixty-six S. aureus isolates were identified; of those, 56 (9.9%) were resistant to methicillin. Throughout the 10-year period, Staphylococcus aureus showed a significant increasing trend from 7.55% to 16.18% among overall S. aurues infections (p=0.001) and from 3.7% to 13.16% in conjunctivitis (p=0.001). Conversely, we did not observe the same trend among those with keratitis (p=0.38). Staphylococcus aureus isolates showed higher resistance rates to tobramycin, gentamicin, ciprofloxacin, gatifloxacin, and moxifloxacin when compared with S. aureus isolates (p< 0.001). All cases were susceptible to vancomycin. CONCLUSION: We observed an increasing trend in the overall prevalence of Staphylococcus aureus ocular infections and statistically significant higher resistance rates to commonly used antibiotics compared to Staphylococcus aureus. Our data supports the need for constant bacterial surveillance and should be taken into consideration before initiating empiric treatment of ocular infections.

OBJETIVO: Estudar a prevalência do Staphylococcus aureus resistente à meticilina nas infecções oculares causadas por S. aureus em um centro de saúde terciário no Brasil e comparar o perfil de suscetibilidade antimicrobiana entre as cepas de Staphylococcus aureus resistente à meticilina e S. aureus susceptível à meticilina MÉTODOS: Foi realizada uma análise retrospectiva dos arquivos do laboratório de microbiologia ocular da Universidade Federal de São Paulo e selecionados todos os casos de conjuntivite, ceratite e endoftalmite com cultivo positivo para S. aureus, durante um período de 10 anos (entre janeiro de 2000 e dezembro de 2009). Foi avaliada a prevalência de Staphylococcus aureus resistente à meticilina e comparado o perfil de susceptibilidade antimicrobiano dos Staphylococcus aureus resistente à meticilina e S. aureus susceptível à meticilina. RESULTADOS: Quinhentos e sessenta e seis isolados de S. aureus foram identificados. Desses, 56 (9,9%) apresentaram resistência à meticilina. Durante o período de 10 anos estudado, Staphylococcus aureus resistente à meticilina mostrou uma tendência significante de aumento de 7,6% para 16,2% entre as infecções oculares causadas por S. aureus em geral (p=0,001) e de 3,7% para 13,2% nas conjuntivites (p=0,001). A mesma tendência não foi observada entre as amostras de ceratite (p=0,38). Os isolados de Staphylococcus aureus resistente à meticilina mostraram maiores taxas de resistência à tobramicina, gentamicina, ciprofloxacino, gatifloxacino e moxifloxacino em comparação com os isolados de S. aureus susceptível à meticilina (p<0,001). Todos os casos foram susceptíveis à vancomicina. CONCLUSÃO:Foi observada uma tendência de aumento na prevalência do Staphylococcus aureus resistente à meticilina nas infecções oculares causadas por S. aureus, bem como taxas de resistência significantemente maiores aos antibióticos comumente utilizados na prática oftalmológica. Nossos dados alertam para a necessidade de constante vigilância de resistência bacteriana a antimicrobianos e devem ser considerados na eleição do tratamento empírico das infecções oculares.

Efeito terapêutico do crosslinking corneal na ceratite infecciosa / Therapeutic effect of corneal crosslinking on infectious keratitis

OBJETIVO: Avaliar o efeito do crosslinking (CXL) no tratamento de ceratite infecciosa, resistente ao tratamento clínico, e investigar a relação com o agente etiológico. MÉTODOS: Foram incluídos 11 pacientes com diagnóstico de ceratite infecciosa de etiologia bacteriana (sete olhos) e fúngica (quatro olhos) na Fundação Altino Ventura (FAV) no período de outubro de 2011 a maio de 2012. Os pacientes incluídos estavam em uso de colírios há pelo menos sete dias e não apresentavam melhora da infecção. Estes foram avaliados antes da realização do CXL e no período pós-operatório até cicatrização da úlcera. Para realização do CXL foram instiladas gotas de riboflavina a 0,1% e dextrano a 20%, a cada cinco minutos em um período de 30 minutos antes do procedimento, e durante a aplicação da luz ultravioleta A (UVA). A córnea foi exposta à UVA com comprimento de onda de 370ηm ± 5ηm e uma irradiância de 3mW/cm2. RESULTADOS: Os pacientes com infecção bacteriana obtiveram cura do processo infeccioso após o CXL e nenhum paciente com ceratite fúngica apresentou cicatrização. Observou-se associação significante (p = 0,003) entre o agente etiológico e a cicatrização. CONCLUSÃO: O CXL mostrou-se eficaz no tratamento da ceratite bacteriana resistente ao tratamento clínico, evitando a realização de transplante tectônico. Em relação à ceratite fúngica, este procedimento não influenciou na melhora do processo infeccioso.

PURPOSE: To evaluate the effect of corneal crosslinking (CXL) in the treatment of infectious keratitis resistant to medical treatment, and investigate the relation with the CXL outcome to the etiologic agent. METHODS: The study included 11 patients who were diagnosed with bacterial (seven eyes) or fungal keratitis (four eyes) at Altino Ventura Foundation from october 2011 to may 2012. All patients were using antibiotic eye drops for at least 7 days and have had no infection improvement. Patients were evaluated prior to CXL and the postoperative period until healing of the keratitis. For CXL, eyes were first instilled with a solution containing 0.1% riboflavin and 20% dextran for 30 min at a 5-minutes interval. Riboflavin-soaked eyes were then irradiated with UVA light (370ηm ± 5ηm) at 3mW/cm2 for 30 minutes. RESULTS: Eyes with bacterial infection exhibited improvement of infectious symptoms after CXL whereas eyes with fungal keratitis showed no improvement. Thus, there was a statistically significant correlation (p = 0.003) between the etiologic agent and the effectiveness of healing. CONCLUSION: CXL was effective in the treatment of bacterial keratitis resistant to clinical treatment, eliminating the need for surgery. However, CXL was not effective in managing fungal keratitis.

Antibiotic resistance in ocular bacterial pathogens.

Bacterial infections of the eye are common and ophthalmologists are spoilt for choice with a variety of antibiotics available in the market. Antibiotics can be administered in the eye by a number of routes; topical, subconjunctival, subtenon and intraocular. Apart from a gamut of eye drops available, ophthalmologists also have the option of preparing fortified eye drops from parenteral formulations, thereby, achieving high concentrations; often much above the minimum inhibitory concentration (MIC), of antibiotics in ocular tissues during therapy. Antibiotic resistance among ocular pathogens is increasing in parallel with the increase seen over the years in bacteria associated with systemic infections. Although it is believed that the rise in resistant ocular bacterial isolates is linked to the rise in resistant systemic pathogens, recent evidence has correlated the emergence of resistant bacteria in the eye to prior topical antibiotic therapy. One would like to believe that either of these contributes to the emergence of resistance to antibiotics among ocular pathogens. Until recently, ocular pathogens resistant to fluoroquinolones have been minimal but the pattern is currently alarming. The new 8-fluoroquinolone on the scene-besifloxacin, is developed exclusively for ophthalmic use and it is hoped that it will escape the selective pressure for resistance because of lack of systemic use. In addition to development of new antibacterial agents, the strategies to halt or control further development of resistant ocular pathogens should always include judicious use of antibiotics in the treatment of human, animal or plant diseases.

Sífilis ocular: Presentación de diez casos y revisión de la literatura / Ocular syphilis: Ten new cases and review of the literature

Introduction: Ocular manifestations in patients with syphilis may involve almost any of the structures of the eye. Objectives: To describe ten new cases of syphilis with eye involvement and to briefly discuss the management and therapy of such condition. Material and Methods: Ten cases were retrospectively studied over 13 years. Demographic factors, ophthalmologic examination, and laboratory tests were assessed. Results: Seven of the 10 cases were male and 3 were female. The mean age of patients was 39,7 years. Disease presentation included: panuveitis (6 patients), optic neuritis (3), retinal vasculitis (1) and Argyll-Robertson pupil (1). Cerebrospinal fluid VDRL test was positive in 6 patients and 3 patients were HIV (+). Conclusions: Syphilis is able to display diverse ophthalmologic manifestations. Not in all the cases the CSF-VDRL test was positive. Antitreponemal therapy generates a fast and effective response in the affected patients.

Introducción: Las manifestaciones oculares de los pacientes con sífilis pueden comprometer cualquiera de las estructuras del ojo. Objetivos: Describir diez nuevos casos de sífilis con compromiso ocular y realizar una breve discusión de su manejo y tratamiento. Pacientes y Métodos: Se estudiaron, de forma retrospectiva, diez casos en un período de 13 años. Se evaluaron factores demográficos, exámenes oftalmológico y de laboratorio. Resultados: De los diez casos, 7 eran hombres y 3 mujeres. El promedio de edad fue de 39,7 años. Las presentaciones fueron: panuveítis (n: 6), neuritis óptica (n: 3), vasculitis retinal (n: 1) y pupila de Argyll-Robertson (n: 1). Se obtuvo VDRL (+) en líquido cefalorraquídeo en 6 pacientes y serología para VIH (+) en 3 pacientes. Conclusiones: La sífilis puede producir variadas manifestaciones oftalmológicas. No en todos los casos el VDRL resultó positivo en el LCR. El tratamiento anti-treponémico produce una rápida y efectiva respuesta en los pacientes afectados.

Etiology and antibacterial susceptibility pattern of community-acquired bacterial ocular infections in a tertiary eye care hospital in south India.

Aims: To identify the etiology, incidence and prevalence of ocular bacterial infections, and to assess the in vitro susceptibility of these ocular bacterial isolates to commonly used antibiotics. Materials and Methods: Retrospective analysis of consecutive samples submitted for microbiological evaluation from patients who were clinically diagnosed with ocular infections and were treated at a tertiary eye care referral center in South India between January 2002 and December 2007. Results: A total of 4417 ocular samples was submitted for microbiological evaluation, of which 2599 (58.8%) had bacterial growth, 456 (10.3%) had fungal growth, 15 (0.34%) had acanthamoebic growth, 14 (0.32%) had mixed microbial growth and the remaining 1333 (30.2%) had negative growth. The rate of culture-positivity was found to be 88% (P < 0.001) in eyelids’ infection, 70% in conjunctival, 69% in lacrimal apparatus, 67.4% in corneal, 51.6% in intraocular tissues, 42.9% in orbital and 39.2% in scleral infections. The most common bacterial species isolated were Staphylococcus aureus (26.69%) followed by Streptococcus pneumoniae (22.14%). Sta. aureus was more prevalent more in eyelid infections (51.22%; P = 0.001) coagulase-negative staphylococci in endophthalmitis (53.1%; P = 0.001), Str. pneumoniae in lacrimal apparatus and corneal infections (64.19%; P = 0.001), Corynebacterium species in blepharitis and conjunctivitis (71%; P = 0.001), Pseudomonas aeruginosa in keratitis and dacryocystitis (66.5%; P = 0.001), Haemophilus species in dacryocystitis and conjunctivitis (66.7%; P = 0.001), Moraxella lacunata in blepharitis (54.17%; P = 0.001) and Moraxella catarrhalis in dacryocystitis (63.83%; P = 0.001). The largest number of gram-positive isolates was susceptible to moxifloxacin (98.7%) and vancomycin (97.9%), and gram-negative isolates to amikacin (93.5%) and gatifloxacin (92.7%). Conclusions: Gram-positive cocci were the most frequent bacteria isolated from ocular infections and were sensitive to moxifloxacin and vancomycin, while gram-negative isolates were more sensitive to amikacin and gatifloxacin.

Syphilitic retinitis and panuveitis simulating acute retinal necrosis: case report / Retinite e panuveíte por sífilis simulando necrose aguda de retina: relato de caso

Retinitis and panuveitis in immunocompetent patients is a rare and sight-threatening disease, of difficult diagnosis. A case of a 31-year-old male who presented with unilateral placoid retinitis and panuveitis, unsuccessfully treated as acute retinal necrosis, that in fact was syphilis, with neurosyphilis and excellent response to treatment is reported.

Retinite com panuveíte em pacientes imunocompetentes é um condição rara e ameaçadora para a visão, e de difícil diagnóstico. É relatado um caso de um paciente do sexo masculino com 31 anos de idade, que se apresentou com retinite em placas e panuveíte, inicialmente tratado sem sucesso como necrose aguda de retina, que na verdade era um caso de sífilis ocular, com afecção do sistema nervoso central e ótima resposta ao tratamento sistêmico para sífilis.

Disseminated orbital actinomycetoma: A case report.

Mycetoma is a chronic granulomatous infection. Lower extremities are commonly involved. A 20-year-old male came with complaints of multiple sinuses on scalp, left eyelid swelling with a sinus and dystopia, since one year. On examination there was relative proptosis in left eye of 2 mm. Computed tomography scan showed soft tissue swelling of the pre-septal area of the left upper eyelid with orbital involvement. Magnetic resonance imaging showed increased left orbital volume and evident dystopia. Microbiology testing of the erosive scalp and lid lesions showed genus Nocardia, suggestive of actinomycetoma. This case is presented as it shows an unusual involvement of the orbit.

Contact lens-associated microbial keratitis / Ceratites microbianas relacionadas a lente de contato

PURPOSE: Contact lens-associated microbial keratitis is a severe condition with sight-threatening potential and increasing incidence. Information regarding the etiological agents is essential in guiding management and may vary geographically. The aim of this study was to analyze the microbiological results of corneal scrapings collected from patients presenting with contact lens-associated microbial keratitis. METHODS: Retrospective analysis of the records of all patients who were clinically diagnosed with contact lens-associated microbial keratitis and had corneal scrapings sent to the Laboratory of Ocular Microbiology, UNIFESP/EPM during a 5-year period from January 2002 to December 2007. RESULTS: The etiological agent was identified in 239 patients. Bacterial isolates accounted for 166 (69.46 percent) cases, Acanthamoeba for 95 (39.75 percent) cases and fungi for 4 (1.67 percent) cases. Among the bacterial infections, coagulase-negative Staphylococcus was demonstrated in 74 cases, while Pseudomonas spp was found in 32 patients. All coagulase negative Staphylococcus and Pseudomonas were susceptible to ciprofloxacin and ofloxacin. Resistance to gentamicin was documented in a single case of Pseudomonas. Fourth-generation flouoroquinolone resistance was not observed among Pseudomonas cases. CONCLUSION: Coagulase-negative Staphylococcus was the most frequent isolate, and such data must be considered when determining empiric treatment. Second-generation fluoroquinolones ciprofloxacin and ofloxacin and fourth-generation fluoroquinolones moxifloxacin and gatifloxacin showed a good antibacterial profile and therefore could be good options for initial management.

OBJETIVO: A ceratite microbiana associada ao uso de lente de contato é uma condição clínica grave, com risco de perda visual e cuja incidência vem aumentando progressivamente. Os principais agentes etiológicos podem variar geograficamente e informações referentes aos agentes causais são essenciais para tratamento apropriado. Este estudo se propõe a analisar os resultados microbiológicos de raspados de córnea coletados de pacientes usuários de lente de contato com quadro de ceratite microbiana. MÉTODOS: Foi realizada análise retrospectiva de todos os estudos microbiológicos de pacientes usuários de lente de contato com diagnóstico clínico de ceratite microbiana que tiveram material corneal enviado para o Laboratório de Microbiologia Ocular UNIFESP durante o período de 5 anos de janeiro de 2002 a dezembro de 2007. RESULTADOS: Dos 239 pacientes em que foi possível identificação, o agente era bactéria em 166 (69,46 por cento), Acanthamoeba em 95 (39,75 por cento) e fungo em 4 (1,67 por cento). Staphylococcus coagulase negativo foi encontrado em 74 casos, dos quais todos eram sensíveis tanto a ciprofloxacino quanto a ofloxacino. Dois casos de resistência a quinolonas de quarta geração (gatifloxacino e moxifloxacino) foram identificados entre os casos de Staphylococcus coagulase negativo. Pseudomonas spp foi isolada em 32 pacientes, dos quais todos eram sensíveis a quinolonas de segunda geração (ciprofloxacino e ofloxacino) e de quarta geração. Foi encontrado um único caso de Pseudomonas resistente a gentamicina. CONCLUSÃO: Staphylococcus coagulase negativo foi isolado em um número de casos superior a Pseudomonas, o agente tradicionalmente considerado o principal de ceratites microbianas associadas ao uso de lente de contato. Aminoglicosídeos, fluorquinolonas de segunda e de quarta geração apresentaram um perfil antibiótico satisfatório para o tratamento empírico de ceratites microbianas em usuários de lente de contato.

Intracanalicular antibiotics may obviate the need for surgical management of chronic suppurative canaliculitis.

Chronic suppurative lacrimal canaliculitis is an important cause of ocular surface discomfort. Treatment with topical antibiotics is often inadequate and surgical treatment by canaliculotomy and canalicular curettage has been the mainstay of treatment in the past. The role of canalicular antibiotic irrigation has been inadequately studied. We report the clinical features, microbiological profile and treatment outcome in a series of 12 patients with suppurative lacrimal canaliculitis. Two patients had Actinomyces infection, five had Nocardia infection and seven patients had polymicrobial infection. Three patients had resolution of canaliculitis on combination broad-spectrum topical antibiotic therapy using ciprofloxacin and fortified cefazolin. In nine patients, topical antibiotic therapy was combined with canalicular irrigation using fortified cefazolin. All patients had excellent resolution of canaliculitis without the need for surgical treatment. Availability of broad-spectrum antibiotics and canalicular irrigation may offer an alternative to surgery in the management of suppurative lacrimal canaliculitis.

Bartonelosis ocular: Reporte de tres casos / Ocular bartonellosis: Report of three clinical cases

The characteristic clinical presentation of cat scratch disease is subacute regional lymphadenopathy; nevertheless, 5-25 percent of Bartonella henselcie infections may present an atypical or systemic form, with potential eye involvement. We describe three clinical cases of ocular bartonellosis in two adolescents and one young adult, who had close contact with cats; all of them presented persistent fever ranging from 15 to 21 days, and two of them developed a sudden unilateral loss of visual acuity associated with optic neuritis. The other patient presented retinal choroiditis and unilateral retinal microgranulomas, with normal visual acuity. Patients received macrolides as sole antimicrobial or in association with rifampin, and one patient was additionally treated with systemic corticoids. The outcome was favorable in two patients; one patient developed a permanent visual deficit. Ocular bartonellosis must be suspected in patients with close contact to cats or with cat scratches whom develop persistent fever and sudden loss of visual acuity.

La enfermedad por arañazo de gato se manifiesta típicamente como una linfadenopatía regional sub-aguda; sin embargo, 5 a 25 por ciento de los pacientes infectados por Bartonella henselae desarrollan formas atípicas o sistémicas de la enfermedad, pudiendo evolucionar con compromiso ocular. Consideramos de interés describir las características clínicas, tratamiento y evolución de tres pacientes con bartonelosis ocular, dos adolescentes y un adulto joven, que tenían antecedentes de contacto y/o rasguño por gatos. Todos cursaron con síndrome febril prolongado, con 15 a 21 días de duración, asociado a pérdida súbita de la agudeza visual unilateral en dos casos, cuya fondoscopia reveló neuritis óptica. El otro paciente presentó retino-coroiditis y microgranulomas retiñíanos, con agudeza visual conservada. Todos recibieron tratamiento antimicrobiano con macrólidos solos o asociados a rifam-picina y uno recibió además corticosteroides sisté-micos. La evolución fue satisfactoria en dos, quedando un paciente con déficit visual permanente. Recomendamos sospechar bartonelosis ocular en pacientes con antecedentes de contacto y/o rasguños por gatos, que cursan con un síndrome febril prolongado y/o disminución súbita de la agudeza visual.