Risk factors associated with late infection of filtering blebs and endophthalmitis

Late infection of filtering blebs and endophthalmitis are hazardous complications of glaucoma filtering surgery frequently associated with bleb failure and loss of functional vision. To determine possible risk factors for the development of these complications, characteristics of nine eyes of nine patients after filtering surgery in whom late endophthalmitis developed were compared with those in patients who had received a comparable operation at the same time in whom endophthalmitis did not develop. An average of 7.7 +/- 6.2 years (range, 6 months to 18 years) elapsed between the time of the filtering procedure and the initial appearance of endophthalmitis. Factors associated with increased risk were: increased axial length, thin and leaky bleb, conjunctivitis, upper respiratory infection, and the winter season.

Current therapy for bacterial keratitis and bacterial conjunctivitis

Therapy of bacterial keratitis and conjunctivitis requires that antibiotics be administered to eliminate viable bacteria. Only a limited number of ophthalmic antibiotics are commercially available. Although generally adequate for the treatment of bacterial conjunctivitis, the commercial preparations are believed to contain too low a concentration of antibiotic for the treatment of bacterial keratitis. Using products designed for parenteral administration, the ophthalmologist or the pharmacist formulates so-called fortified preparations containing much higher antibiotic concentrations. Because of their limited spectrum of action, two fortified preparations generally are administered concurrently. Topical application is the most effective route of antibiotic administration for treatment of bacterial keratitis. Antibiotics may also be injected periocularly, a method with risk, or intravenously, a method of uncertain efficacy.

Antibacterial effectiveness of ciprofloxacin 0.3% ophthalmic solution in the treatment of bacterial conjunctivitis

Two hundred eighty-eight cases of culture-proven bacterial conjunctivities were evaluated as part of two multicentered, randomized, prospective clinical studies comparing the antibacterial efficacy of topically administered ciprofloxacin 0.3% either with a placebo or with tobramycin 0.3%. In the first study, ciprofloxacin was significantly (P less than .001) more effective than the placebo. It eradicated or reduced the various bacterial pathogens in 93.6% of patients, compared to 59.5% for the placebo. In the second study, ciprofloxacin (94.5%) and tobramycin (91.9%) were equally effective. Topically applied ciprofloxacin eradicated or reduced all isolated bacterial species, attesting to its broad antibacterial spectrum and its potential usefulness in treating external ocular infections.

A review of bacterial keratitis and bacterial conjunctivitis

Bacterial keratitis is an opportunistic infection of the avascular corneal stroma, initiated by a breakdown of the epithelial barrier. Corneal abrasion with infected material, extended-wear contact lenses, eyelid disease, and disorders of the ocular surface are predominant contributing factors. Acute bacterial conjunctivitis occurs when sufficient bacteria are introduced into the fornices to overwhelm normal bacteriostatic and flushing mechanisms. Chronic conjunctivitis is associated with a constant adnexal source of bacteria and resolves when the source is successfully treated. Rapid diagnosis and treatment of bacterial keratitis are essential to limit stromal scarring and minimize visual loss.

Conjunctivitis

Most cases of conjunctivitis are either viral in origin, which makes them extremely contagious and usually self-limited, or bacterial, which usually requires topical antibiotic therapy. Prolonged follicular conjunctivitis should be considered chlamydial in origin and requires systematic antibiotic therapy.

Polymorphonuclear leukocytes and bacterial growth of the normal and mildly inflamed conjunctiva

We examined 304 conjunctiva in 152 subjects by clinical, cytologic, and bacteriologic methods. Bacteriologic samples were evaluated after a 48-hour incubation. Bacterial growth was found in 8 (20.5%) of 39 patients with clinically normal conjunctiva and no polymorphonuclear leukocytes (PMNs), and in 8 (61.5%) of 13 subjects with clinically normal conjunctiva and evidence of PMNs. Bacterial growth also was observed in 4 (40.0%) of 10 patients with clinically mild conjunctivitis and no PMNs, in 10 (24.4%) of 41 patients with clinically mild conjunctivitis and a mixture of inflammatory cells or predominantly lymphocytes, and in 37 (75.5%) of 49 patients with clinically mild conjunctivitis and evidence of PMNs. The presence of PMNs was well correlated with the existence of rapid-growing bacteria.

Clinico-bacteriological study of neonatal conjunctivitis

Perinatal risk factors and bacteriological profile of conjunctivitis were studied among 245 newborns delivered at JIPMER Hospital between July 1986 and June 1988. Maternal and neonatal factors like lack of antenatal care, presence of adverse intrapartum factors, operative deliveries, birth asphyxia, pre-maturity and prolonged hospital stay significantly increased the chances of developing conjunctivitis (P less than 0.001). Bacteria were recovered from 163 (66.5%) cases. Staphylococcus was the commonest pathogenic bacteria isolated, followed by Pseudomonas aeruginosa and Klebsiella pneumoniae. Neisseria gonorrhoeae was isolated in only one case. Most of the organisms showed in vitro sensitivity to chloramphenicol, gentamycin and tetracycline. All the cases responded to topical chloramphenicol except three which required systemic antibiotics. No complications were observed. The identification and appropriate management of high risk pregnancies with minimal hospital stay can reduce the incidence of neonatal conjunctivitis.

A 2-year quantitative assessment of Chlamydia trachomatis in a sexually transmitted diseases clinic population by the MicroTrak direct smear immunofluorescence test

The MicroTrak direct smear immunofluorescence test was used to determine the prevalence of Chlamydia trachomatis elementary bodies (EBs) in groups of patients in various clinical categories, most of whom were seen in a clinic for sexually transmitted diseases (STD). Overall, 8138 adequate specimens were tested, of which 14.3% were found to contain chlamydial EBs. Of the samples from patients seen in the STD clinic, over 70% were from women and 14.9% of these were positive, as were 15.7% of those from men. EBs were detected in 27% of samples from infants and in 7.0% of those from adults with conjunctivitis. EBs were detected most often in men with nongonococcal urethritis (40.2%), infants with conjunctivitis (30%) and contacts of chlamydiae-positive patients (24.5%) and least often in 'prostatitis' (2.9%) and patients tested to determine the success of treatment (2.7%). Over 40% of samples from both the male urethra and the cervix contained 10 or fewer EBs, highlighting the importance of recognizing small numbers and the sensitivity required of other detection procedures.

[Incidence of Chlamydia ocular infections in patients with conjunctivitis, at a private clinic of Uberaba, MG]

780 patients with recurrent conjunctival infections or persistent complaints of itching, burning pain, lacrimation and conjunctival hyperemia were subject to conjunctival smear examination for cytology and the presence of inclusion bodies. Two hundred and forty seven (31.7%) showed cytoplamic inclusions; 235 of them were subject to a direct specific immunofluorescency test with 90 (38.3%) positive results. The importance of the clinical manifestations and laboratory methods (direct immunofluorescence and research cytoplasmic inclusions) were considered. The patients are clients of a private clinic and have a moderate to hightor socioeconomic level.

Experimental infection of bulls with a genital isolate of bovine herpesvirus-4 and reactivation of latent virus with dexamethasone

Five 13- to 18-month old Belgian Blue bulls were used in this experiment. Four bulls (Nos. 2, 3, 4 and 5) were inoculated intratesticularly with 10(5) plaque-forming units of bovine herpesvirus-4 (BHV-4) in each testicle (Day 0). The challenge BHV-4 strain was previously isolated from testicle cells of a bull exhibiting orchitis and azoospermia. The fifth bull (No. 1) was used as a control and received the same volume of uninfected cell culture supernatant. For 5 days, beginning on Day 51 post-infection, two bulls (Nos. 4 and 5) and the control bull (No. 1) received 0.1 mg kg-1 of dexamethasone. Unilateral castrations were then performed at regular intervals for viral examination. Treatment with dexamethasone reactivated latent BHV-4, but no clinical signs were observed in treated bulls until the end of the experiment (Day 93). Only Bull 3 showed conjunctivitis and temporary azoospermia. The virus was recovered from various samples showing that: (i) BHV-4 can be present in a latent state in the testicles and mononuclear blood cells; (ii) dexamethasone reactivates the virus; (iii) the virus is excreted by nasal and ocular routes. Each infected bull seroconverted and a booster antibody response appeared after dexamethasone treatment as shown by immunofluorescence. Neutralizing antibodies were detected in each bull by complement-dependent neutralization test with titres higher than those obtained by a classical neutralization test. No booster response of neutralizing antibodies was observed after dexamethasone treatment. The antigenically relevant envelope BHV-4 proteins were identified by Western blotting using sera samples from the animals. DNA restriction endonuclease profiles of viruses reisolated after primary infection and reactivation showed only small differences.

Molecular epidemiology and restriction site mapping of adenovirus type 3 genome types

One hundred thirty-eight strains of adenovirus type 3 isolated from patients in the United States, West Germany, and other regions between 1961 and 1984 were analyzed with six restriction endonucleases; 18 genome types were found. BglII was the most discriminative enzyme. Mapping of altered restriction sites was also performed for all six enzymes. The genome types D1 (like the prototype) and D3 prevailed among 45 and 47 strains, respectively. All genome types could be divided into two groups related to D1 or D3. Several clusters of infections by strains with the same genome type were observed. Only hints of differences were found in the pathogenicities of individual genome types. D1 strains were present in the United States and in Europe; group D3 prevailed almost exclusively in the United States.

Presence of anaerobic bacteria in conjunctivitis associated with wearing contact lenses

Ten anaerobic bacterial species were found in conjunctival cultures obtained from six patients who wore contact lenses and developed conjunctivitis. In three instances the anaerobic bacteria were associated with facultative bacteria. The predominant anaerobic isolates were Peptostreptococcus species (three isolates), Bacteroides sp. (two), and Fusobacterium sp. (two). It was the practice of five of the six patients to wet their lenses with saliva. It is recommended that a culture for anaerobes be obtained from any patient who uses contact lenses and develops conjunctivitis.

Lymphogranuloma venereum conjunctivitis with a marginal corneal perforation

The authors have recently treated a case of Parinaud's oculoglandular syndrome due to Chlamydia trachomatis serotype L2, a causative agent of lymphogranuloma venereum (LGV). The ocular manifestations included a mixed papillary-follicular conjunctivitis with fleshy superior limbal lesions in both eyes. A superior marginal corneal perforation requiring a therapeutic corneal graft was present in the right eye. The patient had vaginitis, inguinal lymphadenopathy, a history of Sjögren's syndrome, and seropositivity to human immunodeficiency virus (HIV). The ocular disease resolved completely after 6 weeks of oral tetracycline therapy.

The microbial epidemiology of trachoma

Detailed longitudinal studies of the microbiology of endemic trachoma in field situations have provided useful information concerning the epidemiology of this blinding disease. This knowledge should be of particular value for the further development of diagnostic techniques, and for the design of future trachoma control programs.

Effect of vaccination on feline Chlamydia psittaci infection

Experimental ocular infection of specific-pathogen-free cats with the feline pneumonitis strain of Chlamydia psittaci produced an acute, severe conjunctivitis characterized by blepharospasm, conjunctival hyperemia, chemosis, and ocular discharge. Organisms were recovered from the conjunctiva for several weeks, and persistent genital and gastrointestinal infection also resulted from the ocular infection in some cats. Subcutaneous vaccination with live feline pneumonitis C. psittaci 4 weeks before ocular challenge significantly reduced the severity of the conjunctivitis. However, there was no effect on shedding of organisms from the eye or on the transmission of infection to the gastrointestinal and genital tracts. It is suggested that the acute stage of this ocular disease is caused largely by release of pathogenic antigen(s) from chlamydia-infected conjunctival cells, rather than by a direct cytopathic effect of chlamydial replication. Thus, vaccination with whole live organisms reduced the acute disease in experimentally infected cats but did not prevent shedding of the organism. The implications of these findings are discussed.

Brazilian purpuric fever: epidemic purpura fulminans associated with antecedent purulent conjunctivitis. Brazilian Purpuric Fever Study Group

In late 1984, 10 children in a small, rural town in Brazil had high fever associated with vomiting and abdominal pain. Within 12-48 h of the onset of fever, purpura developed associated with vascular collapse and peripheral necrosis. All 10 children died. Cerebrospinal fluid examinations did not suggest meningitis and, when done, tests were negative for Neisseria meningitidis. Other culture, serological, and necropsy examinations did not reveal a cause. Case-finding uncovered another cluster of similar illness in children in a second town and sporadic cases in five other cities. Two case-control studies demonstrated that children who became ill were significantly more likely than control children to have had conjunctivitis during the month before illness. This conjunctivitis was purulent, preceded the onset of more severe disease by 3-15 days, and had resolved before fever began. Although no conjunctival cultures were obtained from case-children, Haemophilus aegyptius was the most common pathogen isolated from other conjunctival cultures during the epidemic. This organism was also isolated from a non-aseptic skin scraping from 1 case child. A 25-megadalton plasmid distinguished the H aegyptius isolates epidemiologically associated with illness from other Brazilian conjunctival isolates. Brazilian purpuric fever is a newly recognized syndrome of epidemic purpura fulminans associated with antecedent purulent conjunctivitis, possibly caused by H aegyptius.

Neisseria meningitidis conjunctivitis in children

We examined two children from the same family who had purulent conjunctivitis. Isolates of Neisseria species were obtained from eye cultures and Gram stain of conjunctival scrapings disclosed many gram-negative intracellular diplococci. Colony structure and growth characteristics of the organism with subsequent carbohydrate fermentation tests and serotyping were consistent with Neisseria meningitidis Group B. The patients had no neurologic signs or symptoms. Results of laboratory investigations and blood cultures were normal. Early diagnosis is mandatory and aggressive systemic therapy with appropriate antibiotics may prevent ocular, neurologic, or systemic complications.

Value and cost effectiveness of double culture tests for diagnosis of ocular viral and chlamydial infections

Swabbings from the eyes of 4132 patients attending ophthalmic casualty and outpatients clinics were tested for chlamydiae, adenovirus, and herpes simplex virus. Laboratory isolation tests gave positive results for one of these three agents in 696 (16.8%) cases. When a positive isolation was obtained, only 341 (49%) agreed with the clinical diagnosis while 355 (51%) either had no definite diagnosis marked on the request card or had been clinically diagnosed incorrectly. Routine testing of ocular specimens for all likely organisms can enable the correct treatment to be started sooner than doing one test at each visit, thereby reducing the number of times the patient has to visit the clinic and the expenses involved.

The clinical characteristics and course of adult gonococcal conjunctivitis

We studied 21 cases of adult conjunctivitis caused by Neisseria gonorrhoeae, confirmed by either Gram's stain or culture, that were seen between 1972 and 1986. The patients, typically young men, had irritation or pain, a copious purulent discharge, and marked conjunctival inflammation. Keratitis, anterior chamber inflammation, periocular edema and tenderness, gaze restriction, and preauricular lymphadenopathy were common. All patients were hospitalized and treated with high doses of parenterally administered antibiotics. Two patients had severe ulcerative keratitis at initial examination, which ultimately resulted in light-perception visual acuity, despite antibiotic therapy and keratoplasty. In the remainder of the patients, corneal involvement was milder and transient, and treatment with parenteral penicillin and topical antibiotics was uniformly effective in reversing the course of the infection and preventing significant visual loss. Careful ophthalmologic and microbiologic monitoring is suggested to prevent possible complications caused by penicillin-resistant strains.

Postgonococcal conjunctivitis due to Chlamydia trachomatis

We describe a case in which Chlamydia trachomatis was the etiologic agent of postgonococcal conjunctivitis in an adolescent female. This case report demonstrates the need for considering C. trachomatis as the cause of persistent or recurrent conjunctivitis in a sexually active patient. Clinicians should be aware of the possibility of concurrent infections with Neisseria gonorrhoeae and C. trachomatis and should treat the patient accordingly.