Prospective evaluation of external ocular microbial growth and aqueous humor contamination during cataract surgery.

PURPOSE: To analyze the route of aqueous humor contamination leading to the development of postoperative endophthalmitis. SETTING: Department of Ophthalmology, University of Helsinki, Finland. METHODS: Forty-nine eyes of 49 patients (31 having phacoemulsification and 18 extracapsular cataract extraction [ECCE]) participated in the study. Four bacterial cultures were taken: preoperative conjunctival swab, lid margin culture, intraoperative lacrimal lake sample, and immediate postoperative anterior chamber fluid sample. RESULTS: Preoperative lid margin cultures were positive in 59.2% of eyes, conjunctival cultures in 69.4%, and lacrimal lake cultures in 24.9%. Four aqueous humor samples (8.2%) showed bacterial growth in the anterior chamber aspirate: 3 in the phacoemulsification and 1 in the ECCE group. The bacteria isolated in this study, Staphylococcus epidermidis and Propionibacterium acnes (2 positive isolates each) were sensitive to the preoperative topical antibiotics used. No aqueous humor sample or any from other locations showed gram-negative microbe growth. The most frequently recovered microbes in all samples collected from the 3 other sources were S epidermidis and other coagulase-negative staphylococcus species, followed by P acnes and other propionibacterium species. Staphylococcus aureus, and diptheroids. CONCLUSION: The ocular surface significantly contributed to the transmission of microbes into the eye during cataract surgery. These microbes could not be eradicated by topical preoperative antibiotics. However, no patient developed postoperative endophthalmitis. Natural defense mechanisms appear to fend off a minor inoculum with these microbes of relatively low pathogenicity.

Diagnosis and management of pigmentary glaucoma.

Pigment dispersion syndrome and pigmentary glaucoma affect typically young, myopic persons. Iridozonular contact causes pigment dispersion and obstruction of the trabecular meshwork. Accumulation of pigment may result in transient elevation of intraocular pressure or irreparable damage to the meshwork accompanied by uncontrolled glaucoma. In the reviewed publications the transition from pigment dispersion syndrome to pigmentary glaucoma was found to be 20%. The main risk factors for the transition were ocular hypertension and myopia. Dapiprazole, an alpha-adrenergic blocking agent, was found to be effective in treating pigmentary glaucoma and in preventing pressure spikes after exercise. Dapiprazole causes miosis without affecting accommodation. Yttrium aluminum garnet laser iridotomy reduced the incidence of ocular hypertension in pigment dispersion syndrome, although the effect was less pronounced in persons older than 40 years of age. Lattice degeneration was found in 33.3% of the eyes with pigment dispersion syndrome.

A randomized, prospective study on the use of sodium hyaluronate (Healon) in trabeculectomy.

The effect of injecting sodium hyaluronate (Healon) before fistulization in trabeculectomy was investigated in a prospective, randomized study of 107 consecutive eyes. Fifty-two eyes were operated on with the viscoelastic and 55 without. An early postoperative intraocular pressure (IOP) peak of 21 mm Hg or more occurred in 27% of the study eyes versus 17% of the control eyes, an insignificant difference. The mean peak IOPs of the study and the control eyes did not differ significantly (29.8 +/- 9.0 mm Hg versus 32.7 +/- 10.2 mm Hg), nor did the mean IOPs and the need for glaucoma medications 1 month after surgery. Shallow/flat anterior chamber and choroidal detachment were equally frequent in both groups, but hyphema occurred significantly more often in the study group (40%) than in the control group (18%).

Long-term follow up of argon laser trabeculoplasty in pigmentary glaucoma.

Nine eyes in nine patients with pigmentary glaucoma were treated with argon laser trabeculoplasty (ALT). The mean age of the patients at the time of treatment was 35 years (range, 25 to 46 years); the mean follow up after treatment was 5.5 years. The initial pressure-lowering effect of ALT was 53% (15.3 mm Hg), ie, from a preoperative mean of 29.0 mm Hg to a postoperative mean of 13.7 mm Hg the day after ALT. However, the initial response to ALT wore off in 3 months, after which the intraocular pressure settled at a level 14% (4 mm Hg) lower than before treatment. The rate of failure (ie, unstable glaucoma after treatment) was 11%.

Corneal endothelium in pigmentary glaucoma and pigment dispersion syndrome.

Corneal endothelial cell density was determined in 64 eyes (32 patients) with pigmentary glaucoma and in 18 eyes (9 persons) with pigment dispersion syndrome without glaucoma. Twenty-eight healthy eyes served as controls. The glaucomas were stabilized with topical treatment or following laser trabeculoplasty or filtration surgery. The mean duration of the glaucoma was 7.6 years (SD 6.1 years) subsequent to diagnosis. Neither in the glaucomatous, nor in the pigment dispersion syndrome eyes, could any statistically significant difference in cell density be noted compared to the control series. Within the glaucoma group pressure level, topical treatment, laser trabeculoplasty and trabeculectomy did not have any statistically significant effect on cell counts. Distinct pleomorphism and polymegatism of the endothelial cells were observed in the study groups. The endothelial cell density decreased linearly with age.

Immune functions and the prognosis of patients with solid tumours.

The immune competence of 169 patients with solid malignant tumours was assessed before initiation of radiotherapy or chemotherapy and followed during the course of the disease. The data of years 1974-1984 were collected and subjected to an analysis in order to evaluate their prognostic significance. The number of leucocytes and lymphocytes in the peripheral blood, the percentage or absolute number of E-rosette forming cells or EAC-rosette forming cells or serum immunoglobulin levels did not show any association with the prognosis. Lymphocyte proliferative responses to PHA, Con A and PPD as studied before initiation of the treatment did not correlate with recurrence or final prognosis of the disease, except that the responses to PPD were slightly lower in patients with recurrence of gynaecological cancer, melanoma or gastrointestinal cancer than in their respective control patients. In the values observed after the first treatment course a low response to PPD was associated with poor prognosis in patients with melanoma or gastrointestinal cancer. At the time of recurrent disease the PPD response showed an association with a poor final outcome in patients with gastrointestinal malignancy. Of the responses assessed less than 3 months before death due to cancer, only in patients with breast cancer were low Con A responses seen; in all patient groups the PHA responses decreased in the terminal patients. The results do not support the idea that the methods currently available should be routinely used in the follow-up of cancer patients; rather, they indicate the need to seek new methods for this purpose.

Laser trabeculoplasty in open angle glaucoma.

Laser trabeculoplasty was performed in 72 patients (81 eyes) with open angle glaucoma. A positive correlation between pre-laser pressure level and pressure reduction was found. In 23 eyes with POAG and an average pre-treatment pressure of 26.4 mmHg, post-laser IOP 6 months later was 21.6 (18% reduction) and 1 year later 21.8 mmHg (17% reduction). In 24 eyes with CG and an average pre-treatment pressure of 32.9 mmHg, post-laser IOP 6 months later was 23.8 mmHg (28% reduction) and 1 year later 22.8 mmHg (31% reduction). All eyes needed additional medical therapy for glaucoma control, and 8 eyes had to be operated. Three eyes had complications. One eye had a pressure rise on the 2nd post-operative day, and two eyes had a haemorrhage from the chamber angle.