Endophthalmitis caused by the coagulase-negative staphylococci. 1. Disease spectrum and outcome.

PURPOSE: The coagulase-negative staphylococci are the most common causes of postoperative endophthalmitis. This study investigates the variability in the disease spectrum and visual outcome of coagulase-negative staphylococcal endophthalmitis in a large, single-center series. METHODS: Ninety consecutive cases of coagulase-negative staphylococcal endophthalmitis were investigated retrospectively from two time periods, 1978 to 1982 and 1985 to 1987, separated by a transitional period in cataract surgery technique. Using a detailed protocol, inpatient, outpatient, and microbiologic records were analyzed. Six-month visual acuity results were obtained. RESULTS: Diagnosis frequently was delayed, often suspected only after hypopyon development. Thirty-seven percent of patients presented more than 1 week after the inoculating event, and 13% presented after more than 1 month. Variable asymptomatic intervals and gradually worsening inflammatory prodromes are noted. Painless endophthalmitis occurred in 16%. Non-epidermidis infections comprised 28%. With vitrectomy/intraocular antibiotic management, 38% and 68% achieved visual acuities of 20/50 and 20/400, respectively. Overall, 10% of patients developed late retinal detachments. This occurred in only 4% of patients, with endophthalmitis occurring after cataract surgery. CONCLUSION: Ophthalmologists should become familiar with the emerging concepts of delayed-onset, chronic, and often painless endophthalmitis in which the coagulase-negative staphylococci play a prominent role.

Endophthalmitis caused by the coagulase-negative staphylococci. 2. Factors influencing presentation after cataract surgery.

PURPOSE: This study, comprising 60 patients with coagulase-negative staphylococcal endophthalmitis which occurred after cataract surgery, was designed to define the variation in disease presentation and visual outcome and to evaluate statistically the role of the primary surgery and its management. METHODS: An intensive evaluation of microbiological, inpatient, outpatient, and cataract surgery charts was made retrospectively using a standardized protocol. The predictive value of surgical, iatrogenic, and clinical factors was analyzed for their influence on defined aspects of the disease pattern and of the visual results using multiple regression models, via a stepwise technique. RESULTS: There was commonly a significant asymptomatic latent period after cataract surgery. The median diagnostic delay was 7 days; 22% of patients presented after 2 weeks and 12% after 1 month. Symptoms progressed longer than 3 days in 25% of patients. Ten percent had no pain. Clinical variation proved largely unrelated to cataract surgery events and postoperative management; bacterial factors were implicated. Good visual outcome was associated statistically with intensive topical corticosteroid in the symptomatic period, but was negatively associated with operative subconjunctival corticosteroid. CONCLUSIONS: The clinical variation in cases of postoperative coagulase-negative staphylococcal endophthalmitis poses particular problems for diagnosis in the outpatient setting. Surgical and perioperative events (except corticosteroid use) probably can be disregarded in studies of endophthalmitis management.

Microbiology of contact lens-related keratitis.

We reviewed 397 cases of microbial keratitis examined at the Massachusetts Eye and Ear Infirmary, Boston, MA, U.S.A., from January 1982 through December 1985. Of these, 136 cases (34%) were related to contact lens use. Extended-wear contact lenses were used by 107 (79%) of these patients. Cosmetic contact lenses accounted for 59 (44%) of lens-related cases, aphakic contact lenses 44 (32%), and therapeutic (bandage) contact lenses 33 (24%). Fifty-three microbial keratitis cases associated with contact lens wear were culture-positive: 28 (52%) were gram-positive, and 19 (36%) were gram-negative. Mixed cultures, fungi, and Acanthamoeba accounted for two cases (4%) each. Pseudomonas aeruginosa was specifically associated with cosmetic soft contact lens use.

Severe group B streptococcal eye infections in adults.

Group B beta-haemolytic streptococci have not been described as causing invasive eye infection in adults. Our observation of 10 such infections in nine patients indicates that persons with damaged ocular surfaces are especially vulnerable.

Evidence for a feline reservoir for dysgonic fermenter 2 keratitis.

A 78-year-old female developed microbial keratitis from which corneal scrapings grew dysgonic fermenter 2. The infection initially responded poorly to a combination of topical antibiotics and corticosteroids but healed with intensive antibiotic therapy. There was no systemic predisposition to infection, and only feline exposure had occurred. Close association with a cat probably contaminated the eye.

Ocular Capnocytophaga infection in an edentulous, immunocompetent host.

Severe microbial keratitis developed in a 74-year-old women receiving long-term corticosteroids. Corneal smears revealed slender, fusiform gram-negative bacilli, but the lesion continued to worsen despite intensive antibiotic treatment. After several days, Capnocytophaga sputigena was identified on culture. Specific antimicrobial therapy was instituted, supplemented with corneal cryotherapy. There was gradual clinical improvement. However, a sterile corneal melt led to the late loss of the eye. Although Capnocytophaga are gingival organisms and usually implicated as opportunists in severely ill, neutropenic patients with oral ulcerations, our patient was edentulous and without systemic immunosuppression. An increased awareness of Capnocytophaga is justified because of their widespread antibiotic resistance, capnophilic cultural requirements, and unusual microscopic and cultural morphology.

Anaerobic bacterial endophthalmitis.

Eighteen patients with endophthalmitis involving anaerobic bacteria are presented. Endophthalmitis followed cataract surgery in seven patients, penetrating trauma in six, a corneal graft in two, and an infected filtering bleb in two; there was one case of endogenous endophthalmitis. Propionibacterium acnes was the most frequent anaerobe isolated (78% of cases). Thirty-two percent of the patients had polymicrobial infection with mixed aerobic and anaerobic species. Six cases of acute P. acnes endophthalmitis were clinically indistinguishable from other cases of mild to moderately severe endophthalmitis. Four patients presented, after cataract surgery, with chronic, low-grade endophthalmitis of 1 to 15 months' duration, emphasizing that "sterile" endophthalmitis cannot be satisfactory diagnosed clinically. The visual prognosis of treated P. acnes endophthalmitis was often good. Based on principles of anaerobic microbiology, recommendations are made for vitreous collection, transport, and culture.