Intraocular candidiasis in patients with candidemia. Clinical implications derived from a prospective multicenter study.

PURPOSE: Intraocular infection caused by Candida species can have devastating visual consequences. With the emergence of Candida as a major nosocomial pathogen, the authors investigated the prevalence of ocular lesions in patients with candidemia and evaluated risk factors for eye involvement. METHODS: This study is a prospective, multicentered, observational design. One hundred eighteen patients with candidemia were evaluated by the infectious disease service and received indirect ophthalmologic examination within 72 hours of a reported positive blood culture. Ocular findings were classified on the basis of objective, pre-determined criteria. Candida chorioretinitis was defined as the presence of focal, white, infiltrative chorioretinal lesions without vitreal involvement. Candida endophthalmitis was defined as chorioretinitis with extension into the vitreous or intravitreal "fluff balls." RESULTS: In contrast to previous studies of patients with candidemia citing prevalence rates of endophthalmitis approaching 40%, no patients were shown to have endophthalmitis. Candida chorioretinitis was seen in 9% of the patients, all of whom received antifungal agents. The observation that chorioretinitis never progressed to endophthalmitis suggests that systemic antifungal agents provided adequate ocular therapy. Risk factors for Candida chorioretinitis include fungemia with Candida albicans (versus nonalbicans species), multiple positive blood cultures, visual symptoms, and immunosuppression. Twenty percent of patients had nonspecific ocular lesions not directly related to infection. CONCLUSION: Patients with candidemia who have the risk factors noted above warrant formal ophthalmologic examination.

Empiric treatment of endophthalmitis. Are aminoglycosides necessary?

OBJECTIVE: To reevaluate the necessity of empiric gram-negative therapy for postoperative endophthalmitis based on the recognition of aminoglycoside-induced toxic effects. METHODS: A review of 162 cases of culture-positive bacterial endophthalmitis to determine bacterial prevalence, antibiotic susceptibilities, and laboratory staining results of intraocular material. RESULTS: One hundred fifty (93%) gram-positive and 12 (7%) gram-negative isolates. All the gram-positive bacteria were susceptible to vancomycin hydrochloride; and gram-negative bacteria were susceptible to gentamicin sulfate, amikacin sulfate, and ceftazidime sodium. Bacterial rods were observed on smear of intraocular material in 10 gram-negative cases submitted for examination. CONCLUSION: Vancomycin is an appropriate single agent if laboratory studies rule out gram-negative infection. In the absence of laboratory support, an aminoglycoside (possible toxic effects) or another gram-negative antibiotic (possibly ceftazidime) should also be administered.

Vitreous cultures in suspected endophthalmitis. Biopsy or vitrectomy?

BACKGROUND: Isolation of bacteria from vitreous biopsy often guides therapy in suspected endophthalmitis. Therapeutic vitrectomy provides an additional source of culture material. The authors compared the ability of these two techniques to isolate organisms from patients with acute endophthalmitis. METHODS: In a large ophthalmic microbiology laboratory during a 4-year period, the authors analyzed 206 microbial culture results from patients with suspected endophthalmitis. RESULTS: Two hundred six cases were evaluated. While cultures of vitreous biopsy specimens obtained using a needle and syringe were positive in 91 (53.8%) of 169 patients, culturing the contents of the vitrectomy cassettes produced positive cultures in 29 (74.8%) of 39 patients. Both techniques were performed on 23 patients. Vitreous biopsy allowed isolation of the causative organism in 43% of these patients, whereas vitrectomy was 76% successful. Both comparisons were significant at the P < 0.01 level. No positive vitreous biopsy cultures had associated negative vitrectomy cultures. CONCLUSION: Culturing the contents of the vitrectomy cassette significantly increases the likelihood of obtaining a positive culture compared with merely culturing a vitreous biopsy.

Broad-spectrum Möbius syndrome associated with a 1;11 chromosome translocation.

The authors report a case of Möbius syndrome with Poland syndrome, cleft palate, dextrocardia, mandibular hypoplasia, and multiple areas of diffuse brain volume loss. Karyotype demonstrated a t(1;11)(p22;p13) translocation in the patient and his phenotypically normal father and brother. This case extends the spectrum of congenital disorders that are associated with Möbius syndrome and raises the possibility of genetic heterogeneity for the Möbius disorder.