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ARTICLE
Year : 1965  |  Volume : 13  |  Issue : 2  |  Page : 59-61

Endophthalmitis (Presumably Mycotic)


Department of Ophthalmology, Institute of Post-Graduate Medical Education and Research, Chandigarh, India

Date of Web Publication21-Feb-2008

Correspondence Address:
I S Jain
Department of Ophthalmology, Institute of Post-Graduate Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Jain I S, Paul S D. Endophthalmitis (Presumably Mycotic). Indian J Ophthalmol 1965;13:59-61

How to cite this URL:
Jain I S, Paul S D. Endophthalmitis (Presumably Mycotic). Indian J Ophthalmol [serial online] 1965 [cited 2020 Sep 19];13:59-61. Available from: http://www.ijo.in/text.asp?1965/13/2/59/39215

Incidence of intraocular sepsis being low, even a single case of endoph­thalmitis following surgery is a most dreaded problem.

Amongst a host of other ocular causes responsible for post-operative infections, fungi of late, are posing a serious problem. A fifteen fold statis­tical increase in ocular mycosis after exhibition to the cortico-steroids have been reported by Haggerty and Zim­merman (1958).

It is believed and there is ample evidence both experimental and clini­cal, that use of antibiotics and steroids increase the chances of ocular infec­tions by fungi. Mitsui and Hanubusa (1955) showed a contrast in positive fungus cultures from 18 per cent in patients not using corticosteroids to 67 per cent in those that were using steroids. In a separate experiment with 18 fungus free patients, they found that after three weeks of topical hydro­cortisone exactly 50 per cent eyes had positive culture of fungi.

Fungi can get to the ocular structures in the following ways:-

  1. Entrance from outside: causing fungal conjunctivitis, keratitis, canaliculitis etc.
  2. Spread from infected neighbouring structures, as in cases of fungal dermatitis throat affections etc.
  3. As an embolus through the blood stream.
  4. After perforating injuries or at the time of operations.


It is with this last mode of entrance, that we are concerned here, as it proves disastrous to the eye. Although this complication is rare, it makes as reflect whether our lavish pre and post-operative administration of antibiotics and steroids is really necessary.

We are reporting below two such cases, which followed cataract surgery and both had early exhibition of hydrocortisone post-operatively:


  Report of Cases Top


Case-1.

G. D. 65 years old Hindu female, complained of severe pain, redness and blindness of right eye following cataract surgery four weeks back. Im­mediate post-operative visual result was quite satisfactory and she was dis­charged and advised to use Nebacor­tril eye ointment twice daily. Three weeks from the date of operation she started having pain and slight blurring of vision which gradually kept on increasing.

General Examination.- Patient's gene­ral condition was poor. She was afebrile. There was no evidence of fungus infection elsewhere in the body.

Ocular Examination.- Right Eye. Vision was reduced to perception of light. Projection was present. Ciliary injection was well marked. The cornea was clear, anterior chamber slightly shallow, iris was muddy and a yellow­ish white fluffy exudate was present, just behind the lower pupillary border in the anterior vitreous. The eye ball was tender and the tension normal.

On the slit-lamp a + + anterior chamber flare could be recorded al­though no K. P.'s were seen.

Laboratory Investigations. Total and differential white cell count was normal. E.S.R. was 22 mm. after the first hour. Urine examination, blood-sugar estimation and an X-Ray examination of the chest were normal.

An A.C. puncture, was done and a wet film was prepared. Another slide was prepared from the exudate of the an­terior vitreous. Cultures were done for both bacteria and fungi. The wet smear of vitreous exudate, showed club-shaped and cigar-shaped bodies, suggestive of Candida.

The culture on Sabouraud's medium, however, did not show any growth after three weeks of incubation. The culture was also negative for any bac­teria.

Progress.- She was put on oral Nysta­tin tablets. The eye condition gradually worsened, the exudate increased in size and involved the whole vitreous. Even perception of light was lost.

She was advised enucleation which was refused by the patient.

Case-2. H.R. a Hindu male aged 70 years was operated for cataract in the right eye. An intracapsular extrac­tion was done. No complications occured during surgery. On the eighth post-operative day the patient complained of severe pain and lacri­mation.

Examination of the Eye.- Vision was reduced to perceptive of light. Projection was present. Ciliary injection was mild. Cornea appeared hazy. The anterior chamber showed a yellowish white exudate in the pupillary area. The eye ball was tender. Systemic examination did not reveal anything of significance.

Investigations: The results of examina­tion of urine, total differential white cell count, stools, X-Ray chest and blood-sugar were within normal limits.

Conjunctival Cultures.- No pathogenic organisms were reported before sur­gery and during this episode. The pati­ent was put on chloromycetin 2.5 per cent drops 2 hourly.

The condition, after 48 hours, at least remained the same, if it did not worsen. It was then decided to evacuate the exudate from the pupillary area. During paracentesis a wet film was also made and examined microscopi­cally. The microscopic findings indi­cated spores and spore bearing mycelia suggestive of Sporotrichosis. Smear of the same was negative for bacteria. Culture for the fungi was negative.

The patient was taken off the anti­biotic and put on Nystatin. Despite intensive therapy the eye condition did not show any amelioration. Pati­ent was advised enucleation which he refused.


  Discussion Top


Fungus endophthalmitis presents a very characteristic picture, which has been very well described by Theodore (1961). "It is a subacute process. About two or more weeks post-opera­tively, a small localised exudate is seen in the anterior vitreous adjacent to the pupillary border, followed shortly by transient hypopyion. Later on a severe exudate gradually spreads over the en­tire vitreous face and anterior cham­ber." The cortico-steroids predispose to the development of fungal infections by decreasing the host resistance: and the antibiotics by direct stimulation and/or by suppressing bacteria com­peting for available space. The fungi which infect the eye are mostly found in the soil and air and thus a few prophylactic measures taken in the operation theatre in the form of proper air conditioners and non-circulation of dust, avoidance of glove powders etc. would help in the prevention of fungal contamination. At the time of opera­tion the air injection in the anterior chamber should be sterile. Post-opera­tively it is better not to use neomycin and streptomycin drops, and one should avoid as far as possible the use of cortico-steroids.

After these experiences we wonder if it would not be advantagious, so far as prevention of mycotic endophthal­mitis is concerned, if we revert to the old friend argyrol 10-20 per cent (a silver proteniate) both pre-and post­operatively as antiseptic drops.[3]


  Summary Top


Two cases of fungal endophthalmi­tis are reported, who developed intra­ocular infections after 8-15 days of sur­gery. The evidence of fungal infection was clinched by smear examination of a.c. fluid and of vitreal exudate.

Use of silver preparations such as argyrol is recommended, both pre and post-operatively, to prevent the occur­rence of this dreadful complication.


  Acknowledgment Top


We are grateful to Dr. K. C. Agar­wal, for the bacteriological reports of the wet smears of ac. fluid and vitreal exudate.

 
  References Top

1.
Haggerty T. E. and Zimmerman E. (1958) South. MJ. 51, 153.  Back to cited text no. 1
    
2.
Mitsui Y. and Henabusa J. (1965) Brit. J. of Ophthal. 39, 244.  Back to cited text no. 2
    
3.
Theodore F. H.. Littman M. L. and Almeda E. (1961) AMA Arch-Opht. 66. 163.  Back to cited text no. 3
    




 

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