|Year : 1967 | Volume
| Issue : 1 | Page : 23-25
Endophthalmitis (Presumably mycotic)
IS Jain, SD Paul
Department of Ophthalmology, Institute of Post-Graduate Medical Education and Research, Chandigarh, India
I S Jain
Department of Ophthalmology, Institute of Post-Graduate Medical Education and Research, Chandigarh
|How to cite this article:|
Jain I S, Paul S D. Endophthalmitis (Presumably mycotic). Indian J Ophthalmol 1967;15:23-5
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 Huggerby 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 contast in positive fungus cultures from 18 per cent in patients not using corticosteroids to 67% in those using steroids. In a separate experiment with 18 fungus free patients, they found that after three weeks of topical hydrocortisone exactly 50% of eyes had positive culture of fungi.
Fungi can get to the ocular structures in the following ways:
1. Entrance from outside: causing fungal conjuctivitis, 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 does make us reflect whether lavish pre and postoperative administration of antibotics and steroids are 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|| |
Case - I. G.D. 65 years a 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 was slightly shallow, iris was muddy and a yellowish white fluffy exudate was present, just behind the lower pupillary border, in the anterior vitreous The eyeball was tender and tension was 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. 1st 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 Nystain tablets. The eye condition gradually worsened, the exudate increased in size and involved the whole vitreous. Perception of light was even 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 extraction was done. No complications occurred during surgery. On the eighth post-operative day the patient complained of severe pain and lacrimation.
On examination of the Eye: Vision was reduced to perception 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: Urine examination, total differential white cell count, stools, X-Ray chest showed nothing abnormal and blood-sugar was within normal limits.
Conjunctival Cultures: No pathogenic organisms were reported before surgery and during this episode. The patient was put on chloromycetin 2.5%, drops 2 hourly.
The condition, after 48 hours atleast 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 Myselia suggestive of Sporotrichosis. Smear of the same was negative for any bacteria. Culture for the fungi was negative.
The patient was put off the antibiotics and put on Nystatin. Despite intensive therapy the eye condition did not show any amelioration. Patient was advised enucleation which he refused.
| Discussion|| |
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".
Cortico steroids predispose to the development of fungal infections by decreasing the host resistance: and the antibiotics by direct stimulation and or by supressing the activity of nonpathogenic bacteria competing in the available substance. The fungi which infect the eye are mostly found in the soil and air and thus a few extra 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. Postoperatively it is better not to use neumycin drops 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 advantageous, in the long run if we revert to the old friend argyrol 10-20% (a silver proteinate) both pre and post-operatively as antiseptic drops to prevent endophthalmitis.
| Summary|| |
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 vitreal exudate.
Use of silver preparations such as argyrol is recommended, both pre and post-operatively, to prevent the occurrence of this dreadful complication.
| Acknowledgement|| |
Our thanks are due to Dr. K. C. Agarwal, for the bacteriological reports of the wet smears of the a.c. fluid and vitreal exudate.
| References|| |
|1.||Haggerty. T. E. and Zimmerman. E. (1958) South. M.J.. 51: 153-159. |
|2.||Mitsui Y. and Henahusa J. (1905) Brit. J. of Opthal. 39: 244. |
|3.||Theodore F. H., Littman M. L. and Almeda. E. (1961) AMA Arch-ophth. 66: 163. |