Comparative Evaluation of the Short-Term Bactericidal Potential of a Steroid-Antibiotic Combination versus Steroid in the Treatment of Chronic Bacterial Blepharitis and Conjunctivitis

The effects of four days' treatment with topical Maxitrol (neomycin sulphate 3500 IU/mL, polymyxin-B sulphate 6000 IU/mL with dexamethasone 0.1%) were compared with those of Maxidex (dexamethasone 0.1% alone) in a double-masked study in 111 patients with bacterial blepharitis or conjunctivitis, 95 of whom were evaluable for efficacy. The majority of patients (N = 80) had chronic blepharitis. Maxitrol treatment resulted in a significantly greater reduction (90%) in bacterial counts and bacterial eradication (50%) compared with Maxidex (34% and 17% respectively). Maxitrol treatment also produced a significantly greater reduction in conjunctival discharge than did Maxidex, while the treatments were equally effective in alleviating other ocular signs and symptoms. It was concluded that use of a fixed dose combination steroid-antibiotic product was more effective for bacterial control and therapeutic efficacy in the treatment of chronic blepharitis and conjunctivitis patients than treatment with steroid alone. However, in the long-term treatment of chronic blepharitis the well-known toxic problems of neomycin sulphate have to be taken into account.

Slime Production by Coagulase-Negative Staphylococci Isolated in Chronic Blepharitis

Background

The purpose of the study was to determine the impact of slime-producing strains of coagulase-negative staphylococci (CNS) on non-ulcerative blepharitis. Formerly considered harmless organisms, CNS are now recognised as opportunistic pathogens. Although these microorganisms are a component of normal conjunctival flora, they often produce the typical signs and symptoms of chronic staphylococcal blepharoconjunctivitis. Certain strains produce a polysaccharide extracellular material called “slime”. Slime production is considered to be associated with the virulence of the organism.

Methods

Swabs were taken from the lids of 38 eyes of 19 patients with chronic non-ulcerative blepharitis and cultured for CNS. A group of 42 normal control eyes were similarly sampled. The strains of CNS isolated from 26 eyes (68.4%) of the patients with blepharitis and 25 eyes (59.5%) of the normal subjects were studied for slime layer production.

Results

No significant difference was found between normal subjects and patients in the incidence of slime producing CNS strains from the conjunctiva. The antibiotic sensitivity profiles of the slime-producing strains were no different from the slime-negative isolates in the blepharitis (p=0.85) and normal group (p=0.25).

Conclusions

Our data suggest that slime production by CNS does not play a significant role in the pathogenesis of staphylococcal blepharitis.

Ciprofloxacin Ophthalmic Solution in the Treatment of Conjunctivitis and Blepharitis: A Comparison with Fusidic Acid

The efficacy and safety of ciprofloxacin ophthalmic solution (0.3%) and fusidic acid gel (1%) were compared in the treatment of bacterial conjunctivitis and blepharitis in a randomized, open, parallel group study. Thirty-nine patients, 21 treated with ciprofloxacin solution and 18 treated with fusidic acid gel, were culture-positive on admission and were evaluable for efficacy. At the end of a 7-day treatment, the infecting organism was eradicated in 81% of those treated with ciprofloxacin and 72% of those treated with fusidic acid gel. There was clinical cure or improvement in 95% and 89% respectively. The clinical cure rate appeared to be higher with ciprofloxacin than fusidic acid (62% compared with 28%) but this was related to the higher proportion of patients with acute conjunctivitis in the ciprofloxacin group. Two patients using ciprofloxacin had mild discomfort and stinging on instillation and one given fusidic acid had moderate edema and discomfort; the latter patient stopped treatment. Topical ciprofloxacin is effective and well tolerated and is a useful treatment of bacterial conjunctivitis and blepharitis.

Ciprofloxacin Ophthalmic Solution versus Rifamycin Ophthalmic Solution for the Treatment of Conjunctivitis and Blepharitis

The efficacy and safety of ciprofloxacin (0.3%) ophthalmic solution and rifamycin (1%) ophthalmic solution for the treatment of bacterial conjunctivitis and blepharitis was compared in this randomized, double-masked, parallel-group study. Forty-one patients, 19 on ciprofloxacin and 22 on rifamycin, were culture-positive on admission and evaluated for efficacy. There was clinical improvement in more than 90% of patients in each group at the end of the seven-day treatment period. However, clinical cure rates on day 7 appeared to be higher with ciprofloxacin (53%) than rifamycin (23%; p = 0.061, Mann-Whitney test). Bacteriological eradication rates were comparable: the infecting organisms were eradicated in 68% of patients on ciprofloxacin and 77% with rifamycin. There were no serious adverse reactions to either treatment. One patient in each group was withdrawn on account of a mild allergy. In conclusion, topical ciprofloxacin was effective and well tolerated and would be a particularly useful agent for the treatment of bacterial conjunctivitis and blepharitis.

Comparative Evaluation of Efficacy and Safety of Ciprofloxacin and Norfloxacin Ophthalmic Solutions

The efficacy and safety of ciprofloxacin ophthalmic solution 0.3% and norfloxacin ophthalmic solution 0.3% in the treatment of bacterial conjunctivitis and blepharitis were compared in a double masked randomised study. A total of 131 patients, 65 treated with ciprofloxacin (42 with conjunctivitis and 23 with blepharitis) and 66 treated with norfloxacin (39 with conjunctivitis and 27 with blepharitis) were enrolled in the study at five centres in France. In the efficacy population, pathogens were eradicated or reduced in 96% (24/25) of patients in the ciprofloxacin group and 89% (24/27) in the norfloxacin group. There was no difference between treatments with regard to eradication of particular pathogens. In the efficacy population, clinical cure or improvement was seen in 96% of the patients (24/25 in the ciprofloxacin group and 26/27 in the norfloxacin group). There were no significant differences between ciprofloxacin and norfloxacin with respect to improvements in four symptoms or ten clinical signs. No serious treatment-related adverse events were reported and both ciprofloxacin and norfloxacin were well tolerated.

Periocular necrotizing fasciitis in an infant

Periocular necrotizing fasciitis developed in a 12-month-old boy with swelling of both eyes and redness and a discharge from the left eye approximately 36 hours after blunt trauma. Computed tomography revealed preseptal and soft-tissue edema on the left side, but no signs of orbital involvement, orbital fractures, or drainable abscess in the anterior left lower eyelid. The inflammatory signs worsened over the next day, and there was purulent discharge from the left lower eyelid and an abscess and necrosis of the lower eyelid skin. He did well following surgical debridement and treatment with intravenous antibiotics. His course highlights the difficulty in diagnosing necrotizing fasciitis and the necessity for prompt surgical debridement and empirical broad-spectrum antibiotic therapy.

Topical treatments for blepharokeratoconjunctivitis in children

BACKGROUND

Blepharokeratoconjunctivitis (BKC) is a type of inflammation of the surface of the eye and eyelids that involves changes of the eyelids, dysfunction of the meibomian glands, and inflammation of the conjunctiva and cornea. Chronic inflammation of the cornea can lead to scarring, vascularisation and opacity. BKC in children can cause significant symptoms including irritation, watering, photophobia and loss of vision from corneal opacity, refractive error or amblyopia.Treatment of BKC is directed towards modification of meibomian gland disease and the bacterial flora of lid margin and conjunctiva, and control of ocular surface inflammation. Although both topical and systemic treatments are used to treat people with BKC, this Cochrane review focuses on topical treatments.

OBJECTIVES

To assess and compare data on the efficacy and safety of topical treatments (including antibiotics, steroids, immunosuppressants and lubricants), alone or in combination, for BKC in children from birth to 16 years.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 6), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE ( January 1946 to 11 July 2016), Embase (January 1980 to 11 July 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 11 July 2016. We searched the reference lists of identified reports and the Science Citation Index to identify any additional reports of studies that met the inclusion criteria.

SELECTION CRITERIA

We searched for randomised controlled trials that involved topical treatments in children up to 16 years of age with a clinical diagnosis of BKC. We planned to include studies that evaluated a single topical medication versus placebo, a combination of treatments versus placebo, and those that compared two or multiple active treatments. We planned to include studies in which participants received additional treatments, such as oral antibiotics, oral anti-inflammatories, warm lid compresses and lid margin cleaning.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of the literature search (titles and abstracts) to identify studies that met the inclusion criteria of the review and applied standards as expected for Cochrane reviews. We graded the certainty of the evidence using GRADE.

MAIN RESULTS

We included one study from the USA that met the inclusion criteria. In the study, 137 children aged zero to six years old with blepharoconjunctivitis were randomised to treatment in one of four trial arms (loteprednol etabonate/tobramycin combination, loteprednol etabonate alone, tobramycin alone or placebo) for 15 days, with assessments on days 1, 3, 7 and 15. We judged the study to be at high risk of attrition bias and bias due to selective outcome reporting. The study did not report the number of children with improvement in symptoms nor with total or partial success as measured by changes in clinical symptoms.All children showed a reduction in blepharoconjunctivitis grade score, but there was no evidence of important differences between groups. Visual acuity was not fully reported but the authors stated that there was no change in visual acuity in any of the treatment groups. The study reported ocular and non ocular adverse events but was underpowered to detect differences between the groups. Ocular adverse events were as follows: loteprednol/tobramycin 1/34 (eye pain); loteprednol 4/35 (eye pain, conjunctivitis, eye discharge, eye inflammation); tobramycin 0/34; placebo (vehicle) 0/34. The evidence was limited for all these outcomes and we judged it to be very low certainty.There was no information on clinical signs (aside from grade score), disease progression or quality of life.

AUTHORS' CONCLUSIONS

There is no high-quality evidence of the safety and efficacy of topical treatments for BKC, which resulted in uncertainty about the indications and effectiveness of topical treatment. Clinical trials are required to test efficacy and safety of current and any future treatments. Outcome measures need to be developed which can capture both objective clinical and patient-reported aspects of the condition and treatments.

[Benefit of ocular draping on bacterial contamination after intravitreal injection using a plate-type eyelid speculum]

PURPOSE

To evaluate the effect of ocular draping on rates of bacterial contamination of the ocular surface immediately after intravitreal injection using a plate-type eyelid speculum.

METHODS

Twelve institutions participated in this prospective randomized study. Patients from each institution undergoing intravitreal injections were randomly assigned to 2 groups, with and without ocular draping. Following each institution's standard protocol for aseptic preparation, intravitreal injection was performed using a plate-type eyelid speculum designed for intravitreal injections with or without draping. Immediately after the intravitreal injection, a cotton swab was used to obtain a sample at the injection site and sent for bacterial culture.

RESULTS

Of 262 eyes involved in the study, cultures were positive in five eyes (1.9%) using standard methods and positive in an additional 25 eyes (9.5%) using methods to increase culture sensitivity. There was no significant difference in the combined rate of bacterial contamination between the 2 groups (p = 0.561, Fisher's exact test).

CONCLUSION

Ocular draping did not decrease the rate of bacterial contamination immediately after intravitreal injection performed using a plate-type eyelid speculum.

Eyelid skin disinfecting and conjunctival bacteria in cataract surgery

PURPOSE

To evaluate the effect on conjunctival micro-organisms of chlorhexidine alcohol 0.5% eyelid wash in cataract patients.

METHODS

In this single-centre experimental study, 120 patients scheduled to undergo cataract operation were cultured in the conjunctiva before the operation and after the insertion of the intraocular lens. Bacterial samples for aerobic and anaerobic cultures were taken with a polyvinyl alcohol pad and transported in peptone water to the microbiological laboratory where they were analysed in a blinded fashion. Half of the patients received a standardized eyelid scrub with chlorhexidine alcohol 0.5%, while the rest did not. The conjunctiva of all patients was rinsed preoperatively with chlorhexidine solution 0.05%.

RESULTS

In all the between-group comparisons, the treated eyelid group had slightly lower bacterial counts than the control group on the postoperative samples, but differences were far from statistically significant. Within-group comparisons revealed statistically significant reduction in colonies and species between the preoperative and postoperative sampling.

CONCLUSION

In this experimental culture study, no evidence was found to suggest that preoperative eyelid chlorhexidine alcohol wash is effective in further reducing bacterial counts in the conjunctiva when the conjunctiva itself is rinsed preoperatively with chlorhexidine solution. The present results, however, do not contradict that the wash may be of some marginal help in reducing bacterial contamination of the operation field. Consequently, this part of the prophylactic protocol is still in practice in our institution.

[A man with fever and a periorbital swelling]

We report a 44-year-old man with a diagnosis of right-sided periorbital cellulitis caused by a group A β-hemolytic streptococcus who developed severe eyelid necrosis. After intravenous antibiotic treatment and necrotomy, reconstructive eyelid surgery was needed.

[Evaluating post-cataract surgery changes in bacterial culture tests with and without face-washing]

PURPOSE

To evaluate the changes in conjunctiva and eyelid culture test results before and after cataract surgery and their relation to face-washing.

METHODS

70 patients (109 eyes) who had cataract surgery at Nishi-Kobe Medical Center had conjunctiva and eyelid smears taken both preoperatively and postoperatively. They had cataract surgery by phacoemulsification and aspiration followed by intraocular lens implantation. The patients were separated into two groups. The Face-Washing group started to wash their faces on the day after the operation (POD 1). The Non Face-Washing group started to wash their faces two days after the operation (POD2). We compared the results of the Face-Washing group and the Non Face-Washing group.

RESULTS

The percentage of culture-positive organisms in both the conjunctivae and eyelids dropped significantly postoperatively. In the conjunctivae, there were a few bacteria postoperatively, but in the eyelids, there were many Staphylococcus epidermidis (S. epidermidis) and Propionibacterium acnes (P. acnes) postoperatively. Only in the Non Face-Washing group, the number of S. epidermidis and P. acnes at POD2 increased significantly compared with POD1.

CONCLUSION

There are S. epidermidis and P. acnes deep in the skin (hair follicle), so S. epidermidis and P. acnes can still be detected postoperatively. Postoperative face-washing may prove effective in keeping the eyelids clean.

Necrotising fasciitis of the eyelid with toxic shock due to Pseudomonas aeruginosa

Necrotising fasciitis is a rare and rapidly spreading soft tissue infection characterised by widespread necrosis of the superficial fascia and usually occurring in the limbs and the abdominal wall. Periocular necrotising fasciitis is unusual due to the excellent blood supply of the facial region. The usual pathogens are Group A beta-haemolytic Streptococcus and Staphylococcus aureus. We report a case of Pseudomonas necrotising fasciitis of the eyelid with septic shock, initially diagnosed as hordeolum in a young immunocompromised Chinese woman. Early recognition of the condition, followed by timely intervention with surgical debridement and intensive intravenous antibiotic treatment led to a favourable prognosis. It is important for general physicians to recognise the cardinal signs of necrotising fasciitis, as early treatment with timely surgical debridement and supportive medical therapy is the mainstay to successful management.

Upper lid skin bacterial count of surgical eye patients in Ibadan, Nigeria

Infective endophthalmitis can follow contamination from eyelid of surgical eye patients. Information about peri-ocular skin bacterial isolates and their determinants would help in planning appropriate interventions. This study aimed to determine the upper lid skin bacterial count and factors related to high counts if any, among surgical eye patients. A cross section of consenting new surgical eye patients seen at the Eye clinic of the University College Hospital Ibadan between May and July 2006 was studied. They were interviewed with a standard questionnaire, and swab of the upper eyelid skin taken. Specimens were Gram-stained, bacterial counts and culture were carried out using standard techniques. A total of 80 subjects were studied, age range 13 to 87 years (mean 57.8 +/- 15.8) years. Females were 42 (52.5%) while males were 38 (47.5%). Bacterial culture was obtained from 76 (95.0%) of those studied, with 24 (30.0%) having Staphylococcus aureus sensitive to gentamycin and amoxicillin + clavulanic acid combination while 52 (65.0%) had coagulase negative Staphylococcus. The mean bacterial count was 218 +/- 321 colony forming units (CFUs) per ml. Higher bacterial counts (> 50 CFUs per ml) were found amongst non-literates, patients older than 60 years of age, and male gender. Older age and male gender remained significantly associated with a high bacterial count using the logistic regression model (OR = 4.9, P = 0.03 and OR = 8.06, P = 0.005 respectively). The conclusion reached was that risk of having positive bacterial culture from the upper lid skin increases with older patient age and male sex of eye surgery patients. Adequate care should be taken to ensure proper skin preparation of elderly and male patients to prevent contamination of operation site.

[Comparison in effectiveness of sterilization between chlorhexidine gluconate and povidone-iodine]

PURPOSE

To evaluate the positive value of bacterial cultures which were collected soon after various types of ophthalmic surgery, from eyelids and conjunctiva disinfected by dilute chlorhexidine gluconate or povidone-iodine solution.

METHODS

This study evaluated 179 cases (mean age, 65.6 +/- 15.3) (210 eyes) who underwent cataract surgery, vitrectomy and scleral buckling performed by the same surgeon between April 2005 and December 2005. We divided all the cases into two groups: cases whose eyelids and conjunctiva were disinfected with dilute 0.05% solution of chlorhexidine gluconate, and the other cases whose eyelids were disinfected with 10% solution of povidone-iodine, and the conjunctiva was treated with 16 times dilute povidone-iodine solution. Soon after surgery, samples for bacterial culture were scraped from all eyelids and conjunctiva by swabs.

RESULTS

From the eyelids, bacteria were detected from 39 of the 107 eyes in the chlorhexidine gluconate group, and 19 of the 103 eyes in the povidone-iodine group (p<0.01). There was no significant difference between the chlorhexidine gluconate and povidone-iodine groups with respect to the number of positive cases from the conjunctiva. However, a higher positive value in bacterial culture collected from eyelids was shown in the chlorhexidine gluconate group.

CONCLUSIONS

Therefore, based on this result, we consider that povidone-iodine solution has a superior disinfectant effect compared to chlorhexidine gluconate.

Tacrolimus ointment vs steroid ointment for eyelid dermatitis in patients with atopic keratoconjunctivitis

AIMS

The main objective of this explorative study was to evaluate if tacrolimus ointment could be safer than corticosteroid ointment, with special reference to the intraocular pressure in the treatment of eyelid eczema in patients with atopic keratoconjunctivitis (AKC). Secondary aims were to compare the effects of the treatments on eyelid eczema and their potential impact on ocular surface inflammation.

METHODS

Tacrolimus 0.1% ointment and clobetasone butyrate 0.05% ointment were compared in a double-masked explorative crossover study. In total, 25 AKC patients were included. Each ointment was applied twice daily for 3 weeks, with 2 weeks of washout before, between, and after treatments. Efficacy was determined by eye examination and the patients' own symptom scoring. Cytology and cytokine measurements were performed on tear samples. Safety parameters were intraocular pressure, presence of bacteria and fungi, and the patients' reports of adverse events. The validity of the crossover design was explored with analysis of variance, and the effect of each medication was calculated with paired t-test and Wilcoxon paired test.

RESULTS

A total of 20 patients completed the study. Both treatments were effective in reducing signs and symptoms of eyelid eczema, with a near superior benefit for tacrolimus in terms of eczema (total skin score) signs (P=0.05). No serious adverse events occurred and interestingly, intraocular pressure was not evidently affected by either treatment.

CONCLUSION

Tacrolimus 0.1% ointment is a promising alternative therapy for eyelid eczema in AKC patients. Long-term studies are needed to further determine the value of tacrolimus in this patient group.

Effect of antibacterial honey on the ocular flora in tear deficiency and meibomian gland disease

PURPOSE

To assess for differences in the ocular flora of patients with dry eye caused by tear deficiency and/or meibomian gland disease and to assess the effect of antibacterial honey on the ocular flora in these forms of dry eye.

METHODS

In this prospective, open-label pilot study, bacteria isolated from the eyelid margin and conjunctiva were identified and quantified before and at 1 and 3 months after initiation of treatment with topical application of antibacterial honey 3 times daily. Subjects had non-Sjogren tear deficiency (n = 20), Sjogren syndrome tear deficiency (n = 11), meibomian gland disease (n = 15), and non-Sjogren tear deficiency with meibomian gland disease (n = 20), and there were 18 non-dry eye subjects.

RESULTS

The total colony-forming units (CFUs) isolated from each of the dry eye subgroups before antibacterial honey use was significantly greater than the total CFU isolated from the non-dry eye group. Antibacterial honey use significantly reduced total CFUs for the eyelids and the conjunctiva of dry eye subjects from baseline at month 1 (eyelids: P = 0.0177, conjunctiva: P = 0.0022) and month 3 (eyelids: P < 0.0001, conjunctiva: P < 0.0001). At month 3, there were reductions in total CFUs for all dry eye subgroups such that the CFUs were not significantly different from those of the non-dry eye group.

CONCLUSION

From these results, there is sufficient preliminary data to warrant further study of the effects of antibacterial honey in chronic ocular surface diseases.

[The assessment of bacterial flora and antibiotic-sensitivity of bacteria isolated from conjunctival sac, skin of the eyelids and inflammatory lesions in patients with acne vulgaris and rosacea]

AIM

To evaluate bacterial flora of conjunctival sac, the skin of the eyelids and inflammatory lesions in patients with acne vulgaris, rosacea and of healthy people. Bacterial colonization of conjunctival sac, the skin of the eyelids and skin lesions is more frequent in patients with acne vulgaris and rosacea. Because antibiotic resistant strains of bacteria are quite often met, it seems important to determine antibiotic-sensitivity of isolated bacteria.

MATERIAL AND METHODS

178 people underwent bacteriological examination of conjunctival sac, skin of the eyelids and skin lesions: 64 patients with acne vulgaris, 59 patients with rosacea and 55 healthy persons. Microorganisms were identified with laboratory techniques with the use of bio-Merieux kits and determination of drug-sensitivity was performed with recognized laboratory techniques.

RESULTS

Positive cultures and general frequencies of the isolations were found to be higher in both groups in comparison with the reference group (the group of clinically healthy people). In healthy persons practically the only saprophytic bacteria--the most often S. epidermidis and S. viridans--were isolated. Whereas in patients suffering from acne vulgaris and rosacea the pathogenic bacteria--S. aureus, P. fluorescens, P. acnes, P. aeruginosa--were additionally isolated. Different spectrum of sensitivity to antibiotics of bacteria isolated from conjunctival sac, the skin of the eyelids and skin lesions in the cases of acne vulgaris and rosacea was proved.

CONCLUSIONS

1. In the cases of acne vulgaris the majority of isolated bacteria from conjunctival sac included Streptococcus spp., Staphylococcus spp. and Enterobacteriaceae. 2. In the severe cases of rosacea the main bacteria found in conjunctival sac were S. aureus, S.pyogenes, P.aeruginosa, E. faecalis, A. baumanii, P. fluorescens. 3. Because of changeable drug-sensitivity of bacterial strains, it seems to be necessary to perform individual culture and antibiogram in every patient with inflammatory lesions, in particular in clinically severe and resistant to therapy cases of acne vulgaris and rosacea. 4. The higher frequency of the bacterial colonisations in the conjunctival sac in patients with acne vulgaris and rosacea can be a potential source of ocular infections in the cases of local and systemic disorders of protective mechanisms. 5. Estimation of bacterial flora and antibiotic sensitivity of bacteria isolated from conjunctival sac, the skin of the eyelids and skin lesions should be perform, especially when patients are prepared for eye surgery.

Fluorescent amplified fragment length polymorphism (FAFLP) genotyping demonstrates the role of biofilm-producing methicillin-resistant periocular Staphylococcus epidermidis strains in postoperative endophthalmitis

Background

An observational case series was used to study the virulence characteristics and genotypes of paired Staphylococcus epidermidis isolates cultured from intraocular samples and from periocular environment of patients with postcataract surgery endophthalmitis.

Methods

Eight S. epidermidis isolates were obtained from three patients (2 from patients #1 and 2 and 4 from patient #3) whose vitreous and/or anterior chamber (AC) specimens and preoperative lid/conjunctiva samples were culture positive. Cultures were identified by API-Staph phenotypic identification system and genotypically characterized by Fluorescent Amplified Fragment Length Polymorphism (FAFLP) and checked for their antimicrobial susceptibility. The isolates were tested for biofilm-production and methicillin-resistance (MR) by PCR amplification of icaAB and mecA gene respectively.

Results

Four out of eight S. epidermidis strains showed multiple drug resistance (MDR). All the eight strains were PCR positive for mecA gene whereas seven out of eight strains were positive for icaAB genes. In all three patients FAFLP typing established vitreous isolates of S. epidermidis strains to be indistinguishable from the strains isolated from the patient's conjunctival swabs. However, from patient number three there was one isolate (1030b from lid swab), which appeared to be nonpathogenic and ancestral having minor but significant differences from other three strains from the same patient. This strain also lacked icaAB gene. In silico analysis indicated possible evolution of other strains from this strain in the patient.

Conclusion

Methicillin-resistant biofilm positive S. epidermidis strains colonizing the conjunctiva and eyelid were responsible for postoperative endophthalmitis (POE).

Dermatophyte infection of the eyelid in a neonate

A 25-day-old neonate had redness and swelling on her left upper eyelid. Examination revealed a 16 x 10-mm yellow, crusted, ring-like rash on the left upper eyelid. Microscopic examination of a skin scraping on 10% potassium hydroxide revealed Microsporium canis. The patient was treated successfully with topical miconazole.

Tick inoculation in an eyelid region: report on five cases with one complication of the orbital myositis associated with Lyme borreliosis

PURPOSE

To determine the frequency and dependence of Lyme borreliosis after tick infestation in the eyelid region.

MATERIAL AND METHODS

Five patients after tick inoculation were investigated by immunofluorescence assays for IgM and IgG system). Ophthalmologic evaluation of myositis was supported with MRI, laboratory, and internal clinical investigations.

RESULTS

Four children showed negative Borrelia serology after a bite from a tick. In one case the left abducens nerve palsy was found, which was diagnosed in MRI as a thickened left lateral rectus muscle. The diagnosis of myositis with positive Borrelia burgdorferi serology was consistent with Lyme borreliosis. Other laboratory examinations were negative. The symptoms were reduced after treatment with ceftriaxon.

CONCLUSIONS

Lyme borreliosis was found in one in five patients after tick infestation in the eyelid region. Antibiotic prophylaxis against Lyme borreliosis with ampicillin is recommended for children after a tick bite.

Bacterial flora--A potential source of endophthalmitis after cataract surgery

OBJECTIVES

To study bacteria from eye lids and conjunctival sac of patients undergoing cataract surgery before and after the application of antiseptics.

MATERIAL AND METHOD

Patients undergoing elective cataract extraction in one university hospital were randomly enrolled. Cultures for bacteria and candida were done by swabbing the eye lids before and after cleaning with 4% chlorhexidine gluconate. Subsequently 10% povidone iodine was applied on eye lids and conjunctival sacs. Cultures of specimens from eye lids and conjunctival sac were taken after the application of 10% povidone iodine and at the end of the operation.

RESULTS

Fifty-one patients were enrolled. Positive cultures were found in 90.2% and 82.4% before and after cleaning the face with 4% chlorhexidine. After topical application of 10% povidone iodine, only 19.6% had positive cultures from eye lids and conjunctival sac; a significant reduction (p=0.001). At the end of the operation, positive cultures were found from eye lids in 10 patients and from the conjunctival sac in 4 patients. Isolates were skin flora and candida species in 2 patients. None of the patients had endophthalmitis.

CONCLUSION

Cleaning eye lids with 4% chlorhexidine followed by applying 10% povidone iodine was effective in decreasing skin flora in cataract surgery. The organisms were not completely eliminated. Postoperative follow-up to detect infectious complications is warranted.

Evaluation of normal ocular bacterial flora with two different culture media

BACKGROUND

The purpose of this study was to determine if the use of broth culture medium is efficient in investigating bacterial flora of the normal eyelid and conjunctiva.

METHODS

Samples from the conjunctiva and eyelid of healthy patients of various ages who were undergoing ocular surgeries were obtained and cultured at 3 periods: before topical antibiotic prophylaxis, in the postoperative period during topical antibiotic treatment, and 15 days after discontinuation of antibiotic use. Samples were inoculated into both brain heart infusion broth and blood agar plate, and the growth results of both media were analyzed.

RESULTS

Brain heart infusion broth medium showed a significantly higher bacterial growth of gram-positive cocci in most periods. The solid blood agar medium had a higher recovery of gram-positive bacilli before prophylaxis only in the older patients.

INTERPRETATION

Our results show that a more complete analysis of eyelid and conjunctival flora can be obtained using both liquid and solid media to increase the chances of isolate recovery. The inclusion of liquid media in this analysis was even more relevant in the period of concomitant use of antibiotic treatment.

Blepharokeratoconjunctivitis in children: diagnosis and treatment

AIM

Blepharokeratoconjunctivitis (BKC) is a poorly described entity in children. This study characterises this syndrome in childhood and evaluates epidemiology, clinical grading, and treatment strategies.

METHODS

44 children (20 white, 22 Asian, 2 Middle Eastern, median age 5.4 (range 1-14) years) with a diagnosis of BKC were followed for a median of 7 years. Diagnostic criteria included recurrent episodes of chronic red eye, watering, photophobia, blepharitis including recurrent styes or meibomian cysts, and a keratitis. Clinical features were graded as mild, moderate, or severe. The lids and conjunctiva were cultured. The treatment regimen incorporated lid hygiene, topical and/or systemic antibiotics, and topical corticosteroids.

RESULTS

The disease was most severe in the Asian and Middle Eastern children (p <0.001), who had a statistically higher risk of subepithelial punctate keratitis (p = 0.008), corneal vascularisation (p <0.001), and marginal corneal ulcerations (p = 0.003), than the white group. 15 children had culture positive lid swabs. Most children had a reduction in symptoms and signs with treatment, and progression of disease after the age of 8 was rare.

CONCLUSIONS

BKC in children can be defined as "a syndrome usually associated with anterior or posterior lid margin blepharitis, accompanied by episodes of conjunctivitis, and a keratopathy including punctate erosions, punctate keratitis, phlyctenules, marginal keratitis, and ulceration." BKC is common in children in a tertiary referral corneal and external diseases clinic, with the more severe manifestations in the Asian and Middle Eastern populations. Therapy is effective and loss of sight can be prevented in most cases.

Dermatophytosis on the eyelid caused by Microsporum gypseum

We report a case of tinea on the eyelid in a woman with psoriasis. Due to the history of psoriasis and clinical aspect of the lesion the diagnosis of psoriasis was suggested in the first place; however, laboratory examination revealed Microsporum gypseum. The patient was treated with oral itraconazole resulting in clinical and mycological cure. We emphasize the uncommon location of tinea caused by M. gypseum and the importance of searching for fungal infection on scaly lesions.

The lipid layer of tears: dependent on meibomian gland function

There is growing laboratory and clinical evidence implicating the meibomian glands of the eyelid as playing a critical role in the pathogenesis of various ocular surface disorders such as chronic blepharitis and dry eye. Meibomian glands produce a lipid material whose synthesis is dependent on factors such as stem cells, neurological stimulants and hormones. This lipid material is fluid, spreads easily, is a surfactant as well as an aqueous barrier, and must remain functional after a blink. Before delivery it can be modified by factors such as hormone abnormalities and even after delivery it may be modified by lipases produced by ocular bacteria.

Antibiotic resistance patterns of ocular bacterial flora

PURPOSE

To determine the antibiotic susceptibility patterns of conjunctival bacterial flora isolated preoperatively from patients undergoing anterior segment surgery.

DESIGN

Prospective observational study.

PARTICIPANTS

One hundred fifty-six eyes from 139 patients scheduled for anterior segment surgery were enrolled over a 6-month period from August 2001 to February 2002.

METHODS

Conjunctival cultures were obtained on the day of surgery before povidone-iodine or antibiotic application.

MAIN OUTCOME MEASURES

Bacterial isolates were identified and tested for antibiotic susceptibility using the Kirby-Bauer disc-diffusion technique.

RESULTS

Among the 156 eyes studied, 36 were from patients who had undergone either bilateral surgery or more than one surgery in the same eye. Only the first eyes of the 120 patients that underwent initial ocular surgery were included in our analysis. Of these 120 eyes, 21 (18%) showed no bacterial growth. Of the 143 bacterial strains isolated from the remaining 99 eyes, 112 (78%) were coagulase-negative staphylococci (CNS). Among the CNS, greater than 90% were susceptible to cefotaxime, levofloxacin, imipenem, meropenem, vancomycin, and each of the aminoglycosides except neomycin. Between 70% and 90% of the CNS were susceptible to cefazolin, neomycin, ciprofloxacin, ofloxacin, norfloxacin, and chloramphenicol. Less than 70% of the isolated CNS were sensitive to the penicillin analogues, ceftazidime, erythromycin, and tetracycline.

CONCLUSIONS

Preoperative conjunctival isolates of CNS seem to be most sensitive to vancomycin, the aminoglycosides (except neomycin), and levofloxacin.

Extended wear contact lenses

The experience with the complications associated with extended wear contact lenses has made practitioners and patients fearful of this modality. Today, strong scientific evidence suggest that the hypoxia problems associated with extended wear lenses have been solved. Good clinical evidence suggests that the new high-Dk silicone lenses are safe and can be worn successfully for up to 30 days. Patients can now be offered contact lenses that meet their desire of continuous vision; however, practitioners and patients must be instructed regarding the signs and symptoms of contact lens complications. Practitioners need to be educated in the diagnosis and management of the complications. Patients need to be educated about the need for proper eye care, contact lens care regimens, and appropriate follow-up visits.

Bilateral methicillin-resistant staphylococcus aureus keratitis in a medical resident following an uneventful bilateral photorefractive keratectomy

PURPOSE

To present a case of bilateral methicillin-resistant Staphylococcus aureus (MRSA) keratitis after photorefractive keratectomy (PRK).

METHODS

Retrospective chart review. RESULTS A 26-year-old female internal medicine resident underwent an uneventful bilateral PRK. After the procedure, the patient was fit with a bandage contact lens and was prescribed tobramycin 0.3%, fluorometholone 0.1%, and diclofenac sodium 0.1% four times per day. Postoperatively, corneal ulcers were noted in each eye, and the patient was referred for a consultation. Gram stain showed gram-positive cocci. The patient immediately started using vancomycin, 35 mg/mL every half hour, and ofloxacin 0.3% every hour around the clock. Forty-eight hours later, corneal and lid cultures were positive for MRSA. Three months after the infection, there was approximately 40% corneal thinning in the right eye and 10% thinning in the area of the corneal ulceration of the left eye. The patient is awaiting corneal transplantation of the right eye.

CONCLUSIONS

To our knowledge, this represents the first reported case of bilateral MRSA keratitis after PRK. Methicillin-resistant S. aureus is a potentially serious infectious agent after PRK and may be associated with exposure to a hospital setting. For patients who have had extensive exposure to a hospital environment and are undergoing ocular surgery, we recommend prophylaxis against MRSA. To treat a possible MRSA keratitis, we suggest starting a fourth-generation topical fluoroquinolone every 30 minutes, alternating it with vancomycin 50 mg/mL every 30 minutes, and discontinuing steroid use. A high degree of suspicion coupled with rapid and appropriate treatment may result in improved visual recovery.

Methicillin-resistant Staphylococcus aureus and methicillin-resistant coagulase-negative Staphylococcus ocular surface infection efficacy of chloramphenicol eye drops

PURPOSE

Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase-negative Staphylococcus (MR-CNS) are two major multidrug-resistant pathogens. In this paper we report the prevalence of MRSA and MR-CNS in ocular surface infections.

METHODS

We investigated the proportion of MRSA and MR-CNS in bacterial isolates from conjunctiva of elderly patients with and without bacterial conjunctivitis. The relationship between conjunctival MRSA carriers and general background conditions was studied. We evaluated the efficacy of chloramphenicol eye drops in the treatment of MRSA conjunctivitis. We also investigated the presence of MRSA and MR-CNS in lid skin and conjunctiva of patients with atopic dermatitis.

RESULTS

In conjunctival bacterial flora of elderly patients the proportion of MRSA in S. aureus was 57%, and the proportion of MR-CNS in coagulase-negative Staphylococcus was 25%. Conjunctival MRSA carriers were more likely to have anemia, malignant tumor, liver dysfunction, and dementia, and to be postoperation and chronically bedridden. The efficacy rate of chloramphenicol eye drops in the treatment of MRSA conjunctivitis was 81%. In conjunctival sacs of patients with atopic dermatitis, S. aureus was the most frequent species (48%), and the proportion of MRSA was 18%.

CONCLUSION

Methicillin-resistant S. aureus and MR-CNS are widespread in elderly hospitalized patients and in patients with atopic dermatitis. Chloramphenicol eye drops were useful for the treatment of MRSA ocular surface infections.

Association of acinetobacter species with contact lens-induced adverse responses

PURPOSE

To determine the levels of Acinetobacter species associated with normal soft contact lens wear and to determine whether Acinetobacter species are involved in adverse reactions that occur during contact lens wear.

METHODS

Patients wore soft contact lenses on an extended-wear basis. The bacteria on lenses and ocular swabs during asymptomatic and symptomatic lens wear were identified using standard microbiologic methods.

RESULTS

Acinetobacter species were isolated and identified from 16 (13%) of 126 patient samples. Greater numbers of Acinetobacter species were isolated from lenses of patients experiencing adverse responses than from asymptomatic patients. Acinetobacter species were isolated from patients experiencing symptomatic adverse responses in 4 (13%) of 32 cases.

CONCLUSION

It appeared that Acinetobacter species colonized the eye of extended contact lens wearers at a time when the normal functioning of the eye was compromised by contact lens wear. When Acinetobacter species were in high numbers on a contact lens, an adverse response occurred. This may implicate Acinetobacter species as a contributing factor to adverse responses associated with contact lens wear.

Anthrax as the cause of preseptal cellulitis and cicatricial ectropion

A 54-year-old female farmer with anthrax infection of the eyelids is presented. She was initially managed with high dose intravenous penicillin G treatment. Following complete healing of the eyelid lesions, significant cicatricial ectropion resulted. Her right lower eyelid ectropion was corrected by surgical reconstruction using full thickness skin graft after a period of 6 months during which the cicatrization process stabilized. Satisfactory cosmetic and functional improvement was achieved. Anthrax of the eyelid must be considered in the differential diagnosis of preseptal or orbital cellulitis and any reconstructive procedure should be attempted only after the cessation of the healing process.

A high incidence of Staphylococcus aureus colonization in the external eyes of patients with atopic dermatitis

OBJECTIVE

To determine the frequency distribution of bacteria on the external surface of eyes of patients with atopic dermatitis (AD) and to investigate the relationship between the frequency of bacterial colonization and the grade of atopy or ocular diseases associated with AD.

DESIGN

Comparative cross-sectional study.

PARTICIPANTS

Thirty-six AD patients (mean age, 24.5 years) and 16 nonatopic, age-matched control participants (mean age, 25.5 years).

INTERVENTION

The eyelid margins and conjunctival sacs were scraped with sterile swabs. These samples were inoculated into aerobic and anaerobic culture media.

MAIN OUTCOME MEASURES

The frequency distribution of bacteria isolated from the eyelid margins and conjunctival sacs.

RESULTS

Bacteria isolated from AD patients were: Staphylococcus aureus in 21 of 36 patients (including methicillin-resistant Staphylococcus aureus in two patients); Staphylococcus epidermidis in two patients (including methicillin-resistant Staphylococcus epidermidis in one patient); other coagulase-negative Staphylococcus in six patients;alpha-streptococcus in three patients; Corynebacterium species in three patients; Neisseria species in two patients; and Propionibacterium acnes in one patient. From the nonatopic control participants, we isolated S. aureus in one patient, S. epidermidis in two patients and alpha-streptococcus in one patient. S. aureus was isolated from 67% of the AD patients, and any type of bacteria was isolated from 86% of the patients. These rates were significantly higher than those of nonatopic control participants (6% S. aureus and 25% any bacteria). There was no significant relationship between the frequency distribution of bacteria and the grade of atopy or associated ocular diseases.

CONCLUSIONS

High rates of bacterial colonization, especially S. aureus, were found in the conjunctival sacs and eyelid margins of AD patients. In case management of AD patients, this unique distribution of bacteria must be carefully considered.

Effect of taurolidine on the normal eyelid and conjunctival flora

PURPOSE

The effectiveness of the topical taurolidine was evaluated in eradicating or reducing microorganisms in the normal flora of human eyes in a randomized controlled study and analyzed also the irritating effects of taurolidine on the ocular surface.

METHODS

One hundred and twenty eyes of 110 patients awaiting cataract surgery were randomly divided into four groups consisting of 30 eyes each. The first group received 0.05% taurolidine, the second received 0.3% gentamicin, the third received vehicle eyedrops and the fourth received saline to the preoperative eye four times daily for two days. Cultures were obtained from the eyelids and conjunctivas of all subjects prior to the therapy and again at the end of 48 hours. Micro-biological identification and colony counts were performed by standard laboratory methods, and the results were compared. The patients were clinically evaluated for symptoms and signs at the end of therapies.

RESULTS

Taurolidine and gentamicin produced a significant decrease from the basal bacteriological state: the number of colonies (p < 0.01 for taurolidine, p < 0.01 for gentamicin) was reduced by both agents. Staphylococcus epidermidis was the most common microorganism isolated before therapy, and the number of its colonies was significantly reduced in taurolidine-treated (p < 0.001) and gentamicin-treated (p < 0.01) subjects. There was no significant difference in terms of the irritating effects for all therapies tested (p > 0.05).

CONCLUSIONS

Taurolidine solution with its unique properties is an effective antimicrobial agent for reducing the number of bacteria in the flora of the eye. Taurolidine appears to be well tolerated and offers promise as a potential new antimicrobial drug.

Comparison of antibiotic drops placed in the conjunctival cul-de-sac to antibiotic ointment applied to the lid margin in reduction of bacterial colonization on the lid margin

PURPOSE

To compare the efficacy of antibiotic drops placed in the conjunctival cul-de-sac to antibiotic ointment applied to the lid margin in reduction of bacterial colonization on the lid margin.

METHODS

A randomized, prospective, single-masked study was conducted on 19 patients with culture-proven colonization of bacteria on the lid margins. Ophthalmic eligibility criteria included the presence of > or =50 colony-forming units/mL (CFU/mL) of bacteria on both right and left lids. Each patient received one drop of ofloxacin in one eye every night for one week, followed by one drop once a week for one month. In the same manner, each patient received bacitracin ointment (erythromycin or gentamicin ointment if lid margin bacteria were resistant to bacitracin) to the lid margin of the fellow eye. Quantitative lid cultures were taken at initial visit, one week, one month, and two months. Fifteen volunteers (30 lids) served as controls. Lid cultures were taken at initial visit, one week, and one month.

RESULTS

Both antibiotic drop and ointment reduced average bacterial CFU/mL at one week and one month. Average bacterial CFU/mL reestablished to baseline values at two months. There was no statistically significant difference between antibiotic drop and ointment in reducing bacterial colonization on the lid margin.

CONCLUSION

Antibiotic drops placed in the conjunctival cul-de-sac appear to be as effective as ointment applied to the lid margins in reducing bacterial colonization in patients with > or =50 CFU/mL of bacteria on the lid margins.

Chlamydia-induced bilateral ectropion of the inferior eyelids in pigeons

In this study we described four cases of bilateral ectropion in pigeons that were investigated in Greece. Anemia, leukocytosis, and increased levels of enzymes lactate dehydrogenase, aspartate aminotransferase, creatine phosphokinase, and total serum proteins were found. Chlamydial elementary bodies were observed by modified Ziehl-Neelsen stain in direct smears of conjunctiva, liver, and spleen as well as in yolk sac samples after egg inoculation with eyelid material. Histologically, significant hyperplasia of the conjunctival epithelium was observed. Using immunohistochemical methods, chlamydial antigen was revealed in eyelid, liver, and spleen paraffin sections. This study suggests that Chlamydia spp. was the causative agent that induced ectropion.

Necrotizing fasciitis after cosmetic blepharoplasty

PURPOSE

To report a case of necrotizing fasciitis after cosmetic blepharoplasty.

METHOD

Case report. A 74-year-old woman with history of type II diabetes mellitus underwent bilateral upper eyelid blepharoplasty. Postoperatively she developed fever, grayish discoloration of the skin, violaceous bullae, and a right facial nerve palsy. Necrotizing fasciitis was diagnosed and treated with intravenous antibiotics, debridement of necrotic tissue, and hyperbaric oxygen therapy.

RESULTS

The infection resolved, but the patient required reconstruction for correction of cicatricial ectropion.

CONCLUSION

Necrotizing fasciitis is a potentially fatal infection that typically occurs in the setting of trauma. Early recognition of its pathognomonic signs and aggressive management are paramount.

Colonization of hydrogel lenses with Streptococcus pneumoniae: risk of development of corneal infiltrates

PURPOSE

To report the association between colonization of contact lenses with Streptococcus pneumoniae and the observation of corneal infiltrative events in a group of patients wearing disposable hydrogel lenses on an extended-wear schedule.

METHODS

In a prospective clinical trial, 330 patients wore disposable hydrogels on a 6-night extended-wear and replacement schedule. The contact lens, lid, and conjunctival microbiota of these subjects was analyzed at frequent intervals and at the time of an adverse event.

RESULTS

Streptococcus pneumoniae was an uncommon isolate and was recovered from only one of the 3,763 conjunctival samples, five (0.1%) of the 3,764 lid samples, and 33 (0.8%) of the 4,315 contact lens samples. Of the 33 lens samples, 10 (30%) were associated with corneal infiltrative events. Many of the events were mild inflammatory responses and resolved rapidly on discontinuation of lens wear. The presence of S. pneumoniae on the contact lens was associated with a significant risk of development of corneal infiltrates (odds ratio, 3.0; p = 0.0227, logistic-regression analysis).

CONCLUSIONS

Presence of S. pneumoniae on hydrogel lenses is a significant risk factor for the development of corneal infiltrates.

Acute inflammation of the eyelid and cornea in Staphylococcus keratitis in the rabbit

PURPOSE

The inflammatory response during Staphylococcus keratitis was analyzed biochemically and histologically to determine the source of the neutrophils infiltrating the tear film and cornea.

METHODS

Rabbit eyes were swabbed and then examined by slit-lamp microscopy at 0, 5, 10, 15, 20, and 25 hours after intracorneal inoculation with Staphylococcus aureus. Bacterial colony-forming units were quantified in the cornea, eyelid, and acute inflammatory exudate. Myeloperoxidase activity of ocular swabs of acute inflammatory exudate, corneal homogenates, and eyelid homogenates was determined. Gross and microscopic examinations of corneas and eyelids were performed.

RESULTS

The colony-forming units per cornea exceeded 10(7) after 10 hours, whereas no bacteria were cultured from the eyelid until 15 hours postinfection. Slit-lamp examination revealed progressive pathology, and the myeloperoxidase activities of ocular swabs, corneas, and eyelids increased markedly by 15 hours postinfection. Corneas showed a wave of neutrophils moving from the tear film toward bacteria in the central corneal stroma and early neutrophil migration from the limbus into the stroma. In the eyelid, neutrophils migrated from the stromal vessels to the tear film.

CONCLUSIONS

Staphylococcus keratitis in the rabbit causes acute inflammation in the overlying eyelid. Neutrophils of the acute inflammatory exudate interact with the infected cornea, whereas neutrophils migrating through the cornea from the limbus remained distant from the site of infection.

Prospective evaluation of external ocular microbial growth and aqueous humor contamination during cataract surgery

PURPOSE

To analyze the route of aqueous humor contamination leading to the development of postoperative endophthalmitis.

SETTING

Department of Ophthalmology, University of Helsinki, Finland.

METHODS

Forty-nine eyes of 49 patients (31 having phacoemulsification and 18 extracapsular cataract extraction [ECCE]) participated in the study. Four bacterial cultures were taken: preoperative conjunctival swab, lid margin culture, intraoperative lacrimal lake sample, and immediate postoperative anterior chamber fluid sample.

RESULTS

Preoperative lid margin cultures were positive in 59.2% of eyes, conjunctival cultures in 69.4%, and lacrimal lake cultures in 24.9%. Four aqueous humor samples (8.2%) showed bacterial growth in the anterior chamber aspirate: 3 in the phacoemulsification and 1 in the ECCE group. The bacteria isolated in this study, Staphylococcus epidermidis and Propionibacterium acnes (2 positive isolates each) were sensitive to the preoperative topical antibiotics used. No aqueous humor sample or any from other locations showed gram-negative microbe growth. The most frequently recovered microbes in all samples collected from the 3 other sources were S epidermidis and other coagulase-negative staphylococcus species, followed by P acnes and other propionibacterium species. Staphylococcus aureus, and diptheroids.

CONCLUSION

The ocular surface significantly contributed to the transmission of microbes into the eye during cataract surgery. These microbes could not be eradicated by topical preoperative antibiotics. However, no patient developed postoperative endophthalmitis. Natural defense mechanisms appear to fend off a minor inoculum with these microbes of relatively low pathogenicity.

Pseudomonal eyelid necrosis: clinical characteristics and review of the literature

Pseudomonal eyelid necrosis is a rare condition that has not been well characterized. Five case reports have been previously described. The authors present an additional case, describe its unique features, review the previous reports, and establish the clinical characteristics of the disorder. Pseudomonal eyelid necrosis always occurs in the setting of neutropenia. It may be unilateral or bilateral, and is managed with wound debridement, intravenous and local antibiotics, and, most important, restoration of the neutrophil count. A delay in diagnosis and treatment may lead to functional impairment and cosmetic disfigurement. Although not previously reported in association with eyelid necrosis, uncorrected neutropenia in association with pseudomonal soft tissue infection elsewhere in the body has been associated with septicemia and death. Familiarization with the salient features of the disorder allows prompt therapeutic intervention and may prevent potentially serious complications.