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ARTICLE
Year : 1967  |  Volume : 15  |  Issue : 1  |  Page : 23-25

Endophthalmitis (Presumably mycotic)


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

Date of Web Publication18-Jan-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 1967;15:23-5

How to cite this URL:
Jain I S, Paul S D. Endophthalmitis (Presumably mycotic). Indian J Ophthalmol [serial online] 1967 [cited 2020 Dec 3];15:23-5. Available from: https://www.ijo.in/text.asp?1967/15/1/23/38674

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 Top


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 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".

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 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 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 Top


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.[3]

 
  References Top

1.
Haggerty. T. E. and Zimmerman. E. (1958) South. M.J.. 51: 153-159.  Back to cited text no. 1
    
2.
Mitsui Y. and Henahusa J. (1905) Brit. J. of Opthal. 39: 244.  Back to cited text no. 2
    
3.
Theodore F. H., Littman M. L. and Almeda. E. (1961) AMA Arch-ophth. 66: 163.  Back to cited text no. 3
    




 

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Report of Cases
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Summary
Acknowledgement
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