Acute endogenous endophthalmitis due to Bartonella henselae.

A 45-year-old man presented with progressively worsening vitreitis of 1 week's duration. Treatment for cat-scratch disease 3 years prior to presentation and persistent vitreitis led to vitrectomy, and analysis of the vitrectomy specimen revealed inflammatory cells and necrotic debris; polymerase-chain-reaction analysis of the vitreous fluid sample, done by use of a novel heminested protocol, demonstrated the presence of Bartonella henselae DNA. Treatment with doxycycline led to improvement in the intraocular inflammation but resulted in a poor visual outcome.

Revised diagnostic criteria for Vogt-Koyanagi-Harada disease: report of an international committee on nomenclature.

PURPOSE: To present revised criteria for the diagnosis of Vogt-Koyanagi-Harada disease, a chronic, bilateral, granulomatous ocular and multisystem inflammatory condition of unknown cause. METHODS: Diagnostic criteria and nomenclature were subjects of discussion at the First International Workshop on Vogt-Koyanagi-Harada Disease on October 19-21, 1999, at the University of California, Los Angeles, Conference Center, Lake Arrowhead, California. A committee appointed by the workshop participants was charged with drafting revised criteria for Vogt-Koyanagi-Harada disease, based on discussions held during the conference. This article is the consensus committee report. RESULTS: New criteria, taking into account the multisystem nature of Vogt-Koyanagi-Harada disease, with allowance for the different ocular findings present in the early and late stages of the disease, were formulated and agreed upon by the committee. These criteria are based on additional knowledge and experience of experts in the field and are believed to reflect disease features more fully than previously published criteria. CONCLUSIONS: The revised definition of Vogt-Koyanagi-Harada disease, with expanded diagnostic criteria, will facilitate performance of studies involving homogeneous populations of patients, at various stages of disease, that address unanswered questions regarding treatment and disease mechanisms.

Tissue plasminogen activator to treat impending pupillary block glaucoma in patients with acute fibrinous HLA-B27 positive iridocyclitis.

PURPOSE: To report the use of intracameral tissue plasminogen activator to dissolve fibrinous membranes and break posterior synechiae in patients with acute HLA-B27-positive iridocyclitis with impending pupillary block. METHODS: Two patients with severe acute fibrinous iridocyclitis and seclusio pupillae were identified. Because of the concern of impending pupillary block, intracameral tissue plasminogen activator (12.5 microg in 0.1 ml, Activase; Genentech, Inc, South San Francisco, California) was injected with a 25-gauge needle through the corneal limbus. RESULTS: Both patients showed complete dissolution of fibrin with disruption of posterior synechiae. There were no adverse events after injection. Neither patient required further invasive intervention, and both fully recovered with medical management. CONCLUSIONS: Intracameral tissue plasminogen activator is a safe and effective agent for patients with severe acute iridocyclitis and pupillary seclusion. Patients with clinical signs suggestive of impending pupillary block glaucoma may be considered for tissue plasminogen activator injection to avoid the possible need for emergency surgical iridectomy and synechiolysis.

Effect of melanin on traumatic hyphema in rabbits.

OBJECTIVE: To investigate the role of melanin in influencing the clearance of traumatic hyphema and in the incidence of rebleeds following the hyphemas. METHODS: Hyphemas were induced in 30 eyes of New Zealand white albino rabbits using an Nd:YAG laser. A total of 3.75 mg of synthetic melanin suspended in 0.1 mL of balanced salt solution was introduced into the anterior chambers of 16 animals. A total of 0.1 mL of balanced salt solution was injected into 14 control eyes. Hyphema levels were measured by a masked observer (V.D.B.) daily for 15 days. Pairs of animals were sacrificed at 1, 3, 5, 10, and 15 days and the eyes studied histologically. RESULTS: Hyphemas were consistently produced in all eyes with mean+/-SD levels of 1.44+/-0.22 mm and 1.57+/-0.24 mm in the melanin-treated and control eyes, respectively. The clearance of hyphemas in the melanin-treated eyes was significantly prolonged throughout the study (P<.001). The rate of rebleed in the melanin-treated group was 18.8% and in the control group was 7.1% (P<.01). Histologically, both groups showed variable degrees of blood in the anterior chambers and trabecular meshwork. In addition, the melanin-treated eyes showed free melanin, melanin-laden macrophages, and an inflammatory response in the anterior chamber and trabecular meshwork that was greater than that in the control eyes. Melanin-treated eyes with rebleeds showed organized hemorrhage with neovascularization. CONCLUSIONS: The presence of melanin results in a significantly prolonged course of hyphemas and may influence the rate of rebleeds. Occlusion of the trabecular meshwork with melanin-laden macrophages and inflammation may be the mechanisms responsible for these effects. CLINICAL RELEVANCE: The release of melanin into the anterior chamber during ocular trauma may be partly responsible for the susceptibility of darker-pigmented individuals to more serious complications following a traumatic hyphema.

Progression of diabetic retinopathy after endophthalmitis.

OBJECTIVE: To determine the effect of endophthalmitis on diabetic retinopathy. DESIGN: Noncomparative case series. METHODS: The records of all consecutive patients with endophthalmitis treated between 1992 and 1997 at the Medical College of Wisconsin were retrospectively reviewed. Those patients with diabetes mellitus were analyzed. PARTICIPANTS: From 77 reviewed records, 11 patients (12 eyes; 14%) were identified as diabetics with endophthalmitis and were studied. MAIN OUTCOME MEASURES: Stage of diabetic retinopathy, time to retinopathy progression, and visual acuity. RESULTS: Mean patient age was 68 years, and mean duration of diabetes was 11.7 years. Mean patient follow-up was 17 months. Of the six cases without evidence of retinopathy before the endophthalmitis, none went on to develop retinopathy. Of six eyes with pre-existing nonproliferative retinopathy, four showed evidence of progression within 6 months of the infection. Three developed severe proliferative disease and macular edema, and one developed severe nonproliferative disease. More patients without pre-existing retinopathy achieved a final visual acuity of 20/40 or greater. CONCLUSIONS: Patients with pre-existing diabetic retinopathy may be at increased risk for rapid retinopathy progression and a poorer visual outcome after endophthalmitis. These results support the concept that inflammation may exacerbate diabetic retinopathy.

Ocular manifestations of Whipple disease: an atypical presentation.

A 62-year-old man developed bilateral granulomatous iridocyclitis after uncomplicated cataract surgery. On ophthalmic examination, we found moderate inflammation in the anterior chamber and vitreous, with granular crystalline deposits on the iris, intraocular lens, and capsular bag. Biopsy of the lens capsule and vitreous revealed periodic acid-Schiff-positive, diastase-resistant bacilli consistent with Tropheryma whippelii. Electron microscopy and polymerase chain reaction confirmed the diagnosis of Whipple disease. A jejunal biopsy specimen also revealed T whippelii. Treatment with trimethoprim-sulfamethoxazole, cefixime, rifampin, and doxycycline resulted in improvement of systemic symptoms, but intraocular inflammation persisted. Intraocular inflammation was eventually reduced with the intravenous administration of ceftriaxone sodium.

Intraocular penetration of periocular ketorolac and efficacy in experimental uveitis.

PURPOSE: To determine in rabbits whether periocular injection of ketorolac tromethamine effectively delivers the drug to the eye and, if so, whether this is efficacious in the treatment of experimental uveitis. METHODS: Ketorolac was administered by anterior subconjunctival injection, posterior periocular injection, intramuscular injection, or topical eye drops. The aqueous and vitreous were assayed for ketorolac. Anterior subconjunctival and topical ketorolac were compared to control as well as topical and anterior subconjunctival steroid treatments in uveitis induced by the intravitreal injection of tumor necrosis factor. RESULTS: Anterior subconjunctival injection led to high, though short-lived, levels of drug in the aqueous and vitreous. Posterior periocular injection led to much lower levels. Topical dosing led to relatively low aqueous and undetectable vitreous levels. No ocular levels were detected after intramuscular dosing. All tested antiinflammatory treatments were similarly effective in controlling uveitis. CONCLUSIONS: Anterior subconjunctival injection of ketorolac produced high intraocular concentrations of drug and was beneficial in controlling the inflammation in this animal model of uveitis.

Reduction of macular oedema by acetazolamide in patients with chronic iridocyclitis: a randomised prospective crossover study.

Thirty patients with cystoid macular oedema secondary to chronic iridocyclitis were enrolled in a two period, prospective, randomised, double masked, crossover study that compared sustained release acetazolamide (500 mg twice a day) with a placebo to measure the effects on the reduction of cystoid macular oedema and improvement of visual acuity. All patients were treated for 1 month with either acetazolamide or placebo, received no treatment for 1 month, and were then treated for 1 month with the other medication. Statistically significant improvement in visual acuity was seen at 14 and 28 days in the treated patients. No improvement was seen when patients received placebo. Improved visual acuity was not associated with race or sex. However, younger patients (under age 55 years) were more likely to benefit from treatment. Results of vitreous fluorophotometry, obtained at baseline and 4 weeks, demonstrated an improvement in posterior vitreous penetration ratios and mid vitreous penetration ratios after treatment with acetazolamide but not with placebo.

Topical cyclosporin A in the treatment of anterior segment inflammatory disease.

Topical cyclosporin A was used in the management of 43 patients with a variety of anterior segment inflammatory disorders that had failed corticosteroid treatment. Treatment with topical cyclosporin A ranged from 1 week to 43 months, with a mean treatment period of 13 months. Thirty-five patients (81%) with disorders including high-risk keratoplasty, atopic and vernal keratoconjunctivitis, ligneous conjunctivitis, ulcerative keratitis, and Mooren's ulcer had a beneficial result, with resolution, reduction, or prevention of inflammation. Six patients (14%) with scleritis, ocular cicatricial pemphigoid, or endothelitis showed no clinical improvement. Two patients (5%) had significant ocular discomfort, and the drug had to be discontinued in them. None of the other patients developed local side effects. Twenty-seven of these patients were followed with serial cyclosporin A blood levels and serum creatinine. None of these patients developed measurable drug blood levels or renal toxicity.

Intraocular lens implantation versus no intraocular lens implantation in patients with chronic iridocyclitis and pars planitis. A randomized prospective study.

PURPOSE: The authors studied the safety of intraocular lens (IOL) implantation in patients with uveitis. METHODS: The authors prospectively randomized 26 patients with chronic iridocyclitis (22 patients) or pars planitis (4 patients) to undergo IOL implantation or no IOL implantation at the time of cataract surgery. RESULTS: There was no statistical difference in visual acuity results at 1 year between the two groups. There was a trend toward better visual acuity in patients with chronic iridocyclitis without IOLs. Cocoon-like dense fibrous membranes enveloped the IOL in two patients. CONCLUSION: The authors conclude that IOLs are relatively safe in patients with chronic iridocyclitis but that only a much larger study could determine if the trend toward better visual acuity without an IOL was real.

Preliminary study of a new intraocular method in the diagnosis and treatment of Propionibacterium acnes endophthalmitis following cataract extraction.

Late endophthalmitis, due to Propionibacterium acnes, developed in three patients following uncomplicated extracapsular cataract extraction and posterior chamber intraocular lens (PC-IOL) insertion. Cultures from the capsular bag yielded P. acnes in all three. With topical anesthesia and through an anterior chamber paracentesis, culture specimens were taken from and clindamycin irrigated into the capsular bag. Filtered 100% oxygen was introduced into the anterior chamber in two; the third also received an injection of gentamicin and dexamethasone into the capsular bag. After treatment, two patients received oral antibiotics; one received hyperbaric oxygen therapy. Visual acuity was improved and inflammation reduced in all three. However, after treatment, ocular toxic effects due to clindamycin were suspected in one. This approach offers several clear advantages, including topical anesthesia, outpatient management, elimination of the need for vitrectomy, and retention of the intraocular lens (IOL).

Quadruple therapy for ocular toxoplasmosis.

Between Dec. 1, 1973, and May 30, 1989, 36 patients (37 eyes) with ocular toxoplasmosis seen at a uveitis clinic received quadruple therapy (pyrimethamine, trisulfapyrimidines, clindamycin and prednisone). The criteria for quadruple therapy were active lesions involving or threatening the macula or the optic disc, or a visual acuity of 20/70 or worse due to vitreous opacification caused by active inflammation. All but four of the cases showed improved vision. A total of 54% of the cases responded favourably within 2 weeks after the start of treatment, and 81% responded within 3 weeks. Patients took pyrimethamine for 1 to 2 weeks and received trisulfapyrimidines and clindamycin for 3 weeks, with a tapering course of orally given prednisone. The only complication was skin rash secondary to trisulfapyrimidine therapy, in four cases. None of the patients manifested diarrhea, pseudomembranous colitis or bone marrow suppression. The length of follow-up ranged from 1 month to 15.5 years. There were seven recurrences in five patients, five of which responded to a second course of quadruple therapy.