Mortality of hospitalized patients with Candida endophthalmitis.

BACKGROUND: Candida is becoming an important nosocomial pathogen as the incidence of hospital-acquired candidemia is rising. Candida endophthalmitis is a good indicator of systemic candidiasis in hospitalized patients. METHODS: Thirteen (17%) of 76 ophthalmologic consultations for Candida endophthalmitis in our institution had positive findings during a 12-month period. We studied these 13 patients with Candida endophthalmitis to evaluate their outcomes. RESULTS: All 13 patients were admitted to a large tertiary care hospital, and 10 (77%) were in an intensive care unit. The overall mortality was 77% for all patients and 80% for the intensive care patients. This mortality was higher than the overall mortality for all patients in the surgical intensive care unit in our institution (17%), as well as the mortality for our patients with candidemia in the surgical intensive care unit (61%). CONCLUSIONS: The strikingly high mortality in our group of patients with Candida endophthalmitis reflects the fact that they are a seriously ill group with multiple risk factors for Candida infection. This information suggests that the presence of Candida endophthalmitis is a good indicator of high mortality in seriously ill patients in intensive care units.

A comparison of peribulbar and retrobulbar anesthesia for vitreoretinal surgical procedures.

OBJECTIVE: To compare the efficacy of retrobulbar and peribulbar anesthetic techniques for vitreoretinal surgical procedures. DESIGN: Prospective, randomized, double-blind study. SETTING: A large university teaching hospital. PARTICIPANTS: One hundred sixteen consecutive patients who were scheduled for vitreoretinal surgical procedures. METHODS: Patients who were undergoing vitreoretinal surgical procedures were divided into four separate groups, depending on the type of surgical procedure planned. Equal numbers of patients in each group of patients who were undergoing a surgical procedure were randomly assigned to either the retrobulbar or peribulbar block-treated group. Anesthesia, akinesia, need for block supplementation, and patient acceptance were measured. RESULTS: Both retrobulbar and peribulbar anesthetic techniques provided equal levels of akinesia and analgesia, with each requiring intraoperative supplementation in 32%. CONCLUSION: Peribulbar block can be expeditiously and efficiently used for a full range of vitreoretinal surgical procedures.

Treatment of postvitrectomy fibrin formation with intraocular tissue plasminogen activator.

Twenty-five micrograms of human recombinant tissue plasminogen activator (tPA) was injected intracamerally into the eyes of three aphakic patients who developed severe intraocular fibrin formation within 24 hours after vitrectomy surgery. Fluid obtained from gas-fluid exchange specimens taken 24 hours after tPA injection was analyzed for tPA by an enzyme-linked immunosorbent assay and a spectrophotometric solid-phase fibrin assay. In each of the three patients, complete fibrin resolution occurred within four hours after the tPA injection. There were no complications associated with the intraocular tPA injections. There was measurable tPA activity 24 hours after the initial injection ranging from 0.23 to 1.4 micrograms. In contrast, tPA was undetectable in gas-fluid exchange specimens obtained from seven patients who did not receive intraocular tPA injections. Intraocular tPA is an effective means of treating postvitrectomy fibrin formation in selected aphakic patients.

Cryopexy of the vitreous base in the management of peripheral uveitis.

We reviewed 27 consecutive eyes with peripheral uveitis and vitreous base neovascularization that had been treated with cryopexy and followed up for a median of 4.5 years. During the follow-up period, 21 eyes (78%) remained quiescent, whereas five eyes (18%) demonstrated intermittent inflammation, although only one of these eyes progressed to a traction retinal detachment. One eye (4%) eventually atrophied; however, this was believed to be a result of the ongoing uveitis rather than the cryopexy. The treated eyes had an average improvement of three lines in Snellen visual acuity. We found that corticosteroid therapy remains the primary treatment modality for active inflammation, and vitreous base cryopexy should be reserved for those cases which are resistant to corticosteroids, and which demonstrate active neovascularization.

Neodymium-YAG transscleral cyclocoagulation in rabbit eyes.

Transscleral ruby cyclocoagulation has been successfully used to lower intraocular pressure. The recent commercial availability of Nd-YAG lasers with a thermal mode provides a possible alternative by which to perform this procedure. We treated one eye of seven pigmented rabbits using the thermal mode of the Nd-YAG laser. The intraocular pressures were followed up for three months. The treated eyes had significantly lower mean intraocular pressures were followed up for three months. The treated eyes had significantly lower mean intraocular pressures than the untreated contralateral eyes (p less than 0.001). Moreover, the decrease was sustained over the three-month duration of the study. Pathological examination revealed very selective destruction of the ciliary processes, with sparing of the overlying ciliary muscle, sclera, and conjunctiva. The potential value of this mode of therapy for use in patients with glaucoma is discussed.

Bacterial endophthalmitis after suture removal.

We present 3 cases of endophthalmitis following suture removal after cataract surgery. In all cases, prophylactic antibiotics had been used. Treatment included vitreous tap and intravitreal antibiotic injection, with only 1 of the 3 patients regaining good visual acuity. Because povidone-iodine 5% is more effective at decreasing conjunctival bacterial counts than topical antibiotics, we recommend this method of conjunctival preparation before suture removal.

Perfluorodecalin corneal toxicity: five case reports.

Perfluorodecalin is a perfluorocarbon liquid used intraoperatively in retinal detachment repair. It is usually removed at the end of the procedure; however, residual amounts may be retained when poor corneal clarity or intraocular hemorrhage obscures the view. No clinical reports exist on the consequences of retained perfluorodecalin in the anterior segment. We report five cases in which perfluorodecalin was in prolonged contact with the cornea. The period of time for corneal pathology to occur and the role perfluorodecalin played in the etiology of such changes is discussed. A total of 348 patients with retinal detachments in one retinal practice underwent repair using pars plana vitrectomy combined with intraoperative perfluorodecalin between January 1992 and May 1994. Postoperatively, residual perfluorodecalin was observed in the anterior chamber in contact with the corneal endothelium in five patients. The patients were followed clinically for a period of up to 18 months. Four of five patients developed corneal changes from prolonged contact with perfluorodecalin. Corneal edema developed in the area perfluorodecalin-endothelial contact in three of five eyes. The period of perfluorodecalin-endothelial contact before corneal decompensation occurred ranged from 4 to 13 weeks. Two eyes required penetrating keratoplasties for progressive corneal edema. Corneal edema was reversed in one eye after removal of perfluorodecalin from the anterior chamber via multiple paracentesis. One of the remaining eyes developed deep corneal vascularization without edema in the area of perfluorodecalin contact after 12 months. These observations suggest that corneal toxicity may be induced by intraocular perfluorodecalin if it is allowed direct contact with the corneal endothelium for periods as short as 1 month. Some of these changes may be reversible if perfluorodecalin is aspirated from the anterior chamber. Further investigations are required to examine perfluorodecalin-induced corneal toxicity.

Familial parafoveal telangiectasis.

We report two cases of parafoveal telangiectasis encountered in the same family. The patients are father and son. Both patients are healthy. Both presented with small parafoveal telangiectatic vessels, with minimal associated subretinal fluid. There were no other associated conditions. To the best of our knowledge these cases represent the first reported cases of father-to-son transmission of parafoveal telangiectasis.

Bacterial endophthalmitis following extracapsular cataract extraction: recommendations for early detection.

OBJECTIVE: To determine the time between the onset of symptoms of endophthalmitis after cataract extraction and presentation to an ophthalmologist and to determine the spectrum of organisms responsible for postoperative endophthalmitis. DESIGN: Case series. SETTING: Tertiary care vitreoretinal service in Toronto. PATIENTS: Thirty-three patients with early (presentation within 2 weeks of surgery) endophthalmitis following extracapsular cataract extraction and intraocular lens implantation performed between January 1989 and December 1992. OUTCOME MEASURES: Time to presentation to an ophthalmologist, duration of symptoms, culture results. RESULTS: Twenty-two patients (66.7%) were documented to experience identifiable symptoms of endophthalmitis before presentation to their ophthalmologist; the mean time of onset of symptoms was 3.6 (standard deviation [SD] 1.7) days after surgery. Of the 22 patients 16 (72.7%) became symptomatic by the fourth postoperative day, and 21 (95.4%) experienced symptoms by the fifth postoperative day. The mean delay between onset of symptoms and presentation was 1.9 (SD 1.6) days. Bacteria were identified in 27 cases (81.8%), confirmed by culture in 23 cases (69.7%). The organisms were gram-positive in 25 (92.6%) of the 27 cases, and coagulase-negative Staphylococcus predominated. CONCLUSIONS: In our series a considerable delay existed between the development of symptoms of endophthalmitis following extracapsular cataract extraction and clinical diagnosis. This delay could be minimized by scheduling routine postoperative visits at 1 and 4 days following cataract surgery.

Visual outcome following penetrating globe injuries with retained intraocular foreign bodies.

BACKGROUND: In our institution the occurrence of endophthalmitis related to intraocular foreign bodies has been rare. In this review we analyse the outcome of eyes with retained intraocular foreign bodies presenting to two vitreoretinal surgeons over nearly 7 years. METHODS: Review of the records of 26 patients who presented to two surgeons in a tertiary care vitreoretinal service in Toronto between January 1989 and November 1995. Information documented included mechanism of injury, time from injury to definitive surgery, entry site, presence of vitreous hemorrhage, type of surgery performed, initial and final visual acuity, and development of endophthalmitis. RESULTS: All the injuries occurred in male patients, with a mean age of 36.1 (range 15 to 55) years. Most of the injuries occurred in the workplace, and in most cases (17 [65.4%]) the mechanism of injury was "metal on metal." The entry site was via a perforating wound of the cornea in 16 cases (61.5%). Almost all cases were repaired within 48 hours by means of pars plana vitrectomy. Concurrent lensectomy was required in 18 cases (69.2%) for lens damage at the time of the original injury. Vitreous hemorrhage was present in 22 cases (84.6%). One patient (3.8%) manifested clinically apparent endophthalmitis, which responded to intravitreal antibiotic therapy. Nineteen eyes (73.1%) had a final visual acuity of 6/24 or better. Eyes with coexisting or subsequent retinal detachment had significantly worse vision than those without retinal detachment (p < 0.001). INTERPRETATION: The incidence of endophthalmitis in our series is lower than that in other published series. Prompt definitive treatment was associated with a good prognosis in most cases.

Combined scleral buckle and pars plana vitrectomy as a primary procedure for pseudophakic retinal detachments.

BACKGROUND AND OBJECTIVE: Pseudophakic and aphakic retinal detachments are associated with a lower percentage of successful primary repair with standard scleral buckling surgery, than phakic retinal detachments. The objective of this study was to determine whether a combined scleral buckle and vitrectomy, as a primary procedure, offers any advantage over conventional scleral buckling in primary pseudophakic and aphakic retinal detachments, without proliferative vitreoretinopathy. MATERIALS AND METHODS: This was a prospective, non-randomized clinical study. Ninety-four consecutive pseudophakic and aphakic retinal detachments were included in the study. All patients were operated upon by the same surgeon. Each patient underwent a combined scleral buckle and pars plana vitrectomy with perfluorocarbon injection and air-fluid exchange. Each patient was followed by the operating surgeon for a minimum of 6 months. Patients were followed with respect to anatomic reattachment, visual acuity improvement, and surgical complications. RESULTS: All eyes were anatomically reattached after a single operation. All demonstrated an increase in their visual acuity, and there were no complications attributable to the vitrectomy procedure. CONCLUSIONS: We conclude that such a combined approach to primary pseudophakic and aphakic retinal detachments offers significant benefits to scleral buckling alone. We believe that the improved success rate is a function of vitrectomy contributing to both an improved peripheral visibility, resulting in fewer missed peripheral breaks, and a lower likelihood of proliferative vitreoretinopathy. We recommend this combined surgical approach for all primary pseudophakic and aphakic retinal detachments.

Complications of primary scleral buckling procedures in high myopia.

Repair of retinal detachments in high myopia may be associated with numerous intraoperative complications. Included are complications involved with the drainage of subretinal fluid as well as those arising from thin sclera. Highly myopic eyes tend to be more prone to these complications than less myopic or nonmyopic eyes. A retrospective study of 51 consecutive highly myopic eyes (six diopters (D) or greater) undergoing primary scleral buckling procedures was performed. Intraoperative complications occurred in a total of six eyes (12%). The complications were related to drainage of subretinal fluid in four eyes (8%) and associated with thin sclera in two eyes (4%). Despite the above-noted complications, there was no adverse effect on the final level of visual acuity or on the anatomic status of the retina. In the comparison of the incidence of drainage-related complications with previously published studies not preselected according to refractive status, there appears to be no added risk of complications based on the degree of myopia.