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Purpose: The addition of antibiotics to infusion solutions for cataract surgery is becoming increasingly popular. The authors developed an in vitro model to evaluate antibacterial effects of this use of antibiotics., Methods: Clinical isolates and/or reference strains of the following organisms were examined: coagulase-negative Staphylococcus spp, Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus viridans, Streptococcus spp, Enterococcus spp, Proprionibacterium acnes, Moraxella nonliquifaciens, and Pseudomonas aeruginosa. Standardized suspensions of each organism were incubated with a control solution (Balanced Salt Solution) or Balanced Salt Solution containing the following antibiotics: vancomycin (20 micrograms/ml) or gentamicin (8 micrograms/ml) or gentamicin and vancomycin combined (8 and 20 micrograms/ml, respectively). Suspensions were incubated for 30, 60, and 120 minutes at room temperature. Samples were centrifuged, and the organisms were washed with Balanced Salt Solution before quantitative culturing. Each organism also was incubated for 48 hours in Mueller-Hinton broth with the same antibiotic concentrations., Results: Most of the organisms were not affected by exposure to the antibiotics for up to 140 minutes. P. aeruginosa and M. nonliquifaciens were exceptions, decreasing in colony numbers even with 30 minutes of exposure. Several Staphylococcus spp yielded variable results. All organisms demonstrated nearly complete inhibition of growth when exposed for an extended time to the appropriate antibiotic in broth., Conclusions: Exposure to antibiotics for a short period of time, such as during intraocular surgery, generally has no effect on organisms commonly responsible for endophthalmitis. The use of antibiotics in this manner should be critically reassessed until further study.

Purpose: We studied supratarsal injection of corticosteroid as a new therapeutic modality for treating severe vernal keratoconjunctivitis to determine its efficacy in treating patients refractory to all conventional therapy., Methods: Twelve patients with vernal keratoconjunctivitis resistant to all established therapy were prospectively studied by randomly assigning them to receive supratarsal injection of either short- or intermediate-acting corticosteroid. Relief of symptoms and resolution of clinical signs were evaluated. Patients were followed up to four years to identify side effects., Results: All patients experienced dramatic symptomatic relief within one to five days, regardless of the type of corticosteroid injected. Marked decrease in cobblestone papillae was noted in 14.9 days (mean) after short-acting corticosteroid injection and 12.8 days after intermediate-acting corticosteroid injection (P = .65). Shield ulcers and limbal involvement resolved in one to three weeks, independent of the corticosteroid used (P = .90). No complications were observed with supratarsal injection of short-acting corticosteroid. One patient developed persistent increase of intraocular pressure after injection of intermediate-acting corticosteroid., Conclusions: The dramatic symptomatic and clinical improvement suggests that supratarsal injection of corticosteroid may be a valuable therapeutic approach to treating refractory vernal keratoconjunctivitis. Short-acting and intermediate-acting corticosteroids were equally efficacious. Because of the lack of intraocular pressure increase observed with short-acting corticosteroid, we favor its use in supratarsal injection.

Although Streptococcus pneumoniae is usually extremely sensitive to penicillin, recent reports in the nonophthalmic literature indicate a rise in the prevalence of penicillin-resistant pneumococci. We report a case of penicillin-resistant S. pneumoniae keratitis in a 51-year-old woman with severe rheumatoid arthritis. This report is only the second such case in the ophthalmic literature and may indicate the emergence of penicillin-resistant strains of S. pneumoniae as ocular pathogens.

Corneal subepithelial infiltrates are a known complication of adenoviral conjunctivitis. In this article, we present a case of a 32-year-old man who developed these classic infiltrates after a well-documented adenoviral conjunctivitis. What is unique about this case is that the infiltrates recurred 8 months later after an upper respiratory infection without any clinical or laboratory evidence of a viral conjunctivitis. The possible confounding variable of corticosteroid withdrawal being responsible for the recurrence is highly unlikely because he had not used topical corticosteroids for almost 4 months.

Cataracts, the world's leading cause of blindness, are an enormous public health problem in both developing and industrialized countries. Identifying the risk factors responsible for cataract formation is a difficult and complicated problem because a realistic causal model in cataract formation would not be a simple linear sufficient cause paradigm (e.g., one exposure-one cataract type). A more complex model depicting each risk factor as a component cause, or part of a sufficient cause such as the sufficient/component cause model proposed by Rothman (62), is a more realistic way to summarize how multiple risk factors act in cataract etiology. Moreover, even this model has shortcomings, especially in explaining cataract etiology. It ignores the obvious importance of time to cataract formation and the way different component causes may act on different etiologic branches of cataract formation, e.g., nuclear sclerosis, posterior subcapsular cataracts, and mixed. Despite the complexity in identifying cataract risk factors, attempting to do so provides new hope in dealing with the morbidity, mortality, and cost of this disease. The evidence is overwhelming that age, trauma, and intraocular inflammation are important cataract risks. However, these exposures either are inevitable or are not major contributors to the population attributable risk. On the basis of both coherence and predictive performance, undernutrition is an important risk factor that can be altered. However, work still needs to be done in two areas related to this risk. First, regarding individuals in developing nations, the question must be asked about which nutrients (or lack thereof) are the culprits. The epidemiologic evidence that antioxidants are the missing nutrients is far from overwhelming. For developed nations, the obvious question still to be answered is whether the results of the Linxian Cataract Studies (11) and the India-US Case-Control Study (12) can be generalized to industrial nations. To help answer this question, an intervention study sponsored by the National Institutes of Health is now underway (K. Kupfer, Director, National Eye Institute of the USA, Bethesda, Maryland, personal communication, 1993). Ultraviolet radiation, especially ultraviolet B radiation, is an important risk for cortical cataracts, and one study (27) has even demonstrated a dose-response relation. However, the public health implication of this finding is not clear. Isolating the risk of ultraviolet B radiation exposure as a cause of cortical cataracts (and, in general, not of other types) indicates that the risk is small on a public health scale. This is because cortical cataracts are well tolerated and frequently require no treatment at all. The evidence that links ultraviolet B radiation to other cataract types comes mainly from ecologic studies and needs to be verified by analytic studies that are specifically designed to study the association. The strength of the association, consistency of studies, coherence, and biologic plausibility all indicate that both systemic and topical steroids are significant risk factors for the formation of posterior subcapsular cataracts. Given that most people are not chronic steroid users, the population attributable risk is low; however, the relative risk of those unfortunate enough to require chronic steroid use is high. The evidence is accumulating that cataracts can be added to the list of illnesses that are at least partially attributed to smoking. Although consistency among studies has not been obtained, this is certainly a plausible cause, and dose-response relations have been demonstrated (53). At this point, nuclear sclerosis is the most important cataract type associated with smoking. More work needs to be done to assess the role of smoking on other cataract types and to assess the risk of those who stop smoking. Retrospective studies that examine diabetes as a risk for cataracts are almost inevitably marred by hte selection bia

Objective: To determine the association between patterns of inflammation in labial salivary glands (LSG) and the ocular component of Sjögren's syndrome (SS)., Methods: We classified LSG biopsy specimens from 618 patients with suspected SS as showing focal lymphocytic sialadenitis (FLS), other chronic sialadenitis (CS), or other diagnoses. We then determined the association of the other component of primary SS, keratoconjunctivitis sicca (KCS), with FLS, CS, parotid flow rate, and xerostomia., Results: FLS, rather than CS, was associated with a diagnosis of KCS (chi 2 = 191, P < 0.0001). The severity of KCS correlated directly with the severity of FLS (r = 0.52, P < 0.0001), but not of CS, and correlated inversely with parotid flow rate in those patients who had FLS (r = -0.29), but not in those who had CS (r = -0.03). Xerostomia was marginally associated with KCS (chi 2 = 5, P = 0.02)., Conclusion: The stronger KCS association found in patients whose LSG biopsies show FLS makes FLS the best criterion presently available for diagnosing the salivary component of SS. CS is a common feature of labial salivary glands but is neither associated with SS nor an end stage of primary SS. Histopathologic examination of salivary tissue is currently essential for diagnosing primary SS as well as secondary SS in which KCS is lacking, especially cases to be included in studies of SS.

Corneal ulceration is one of the most frequent causes of blindness in developing countries. Between September 1985 and August 1987, 405 patients with corneal ulceration were examined at Tribhuvan University Teaching Hospital in Kathmandu, Nepal. Males and females were equally affected. The most common predisposing cause of ulceration was corneal trauma, usually with organic agricultural materials. Microorganisms were grown from 324 (80%) of the ulcers. Pure bacterial cultures were obtained from 256 (63.2%) of the patients, whereas pure fungal cultures were obtained from 27 (6.7%) of the patients. In 41 patients (10.1%), corneal cultures yielded a mixed growth of bacteria and fungi. Of a total of 398 bacterial isolates, 124 (31.1%) were positive for Streptococcus pneumoniae, the most commonly isolated organism in the series. Other frequently isolated bacteria included Staphylococcus epidermidis, S. aureus, and Pseudomonas species. Of 68 positive fungal isolates obtained, 32 (47.0%) were identified as Aspergillus species. Candida species and Fusarium species were less commonly seen.

A 27-year-old man who was a heroin addict had light flashes in front of the right eye and a hemicentral scotoma immediately after intravenous cocaine. The initial ophthalmoscopic appearance was of a white foreign body lying over the papillomacular bundle of the retina in the right eye. This ophthalmoscopic finding was consistent with intraocular talc, cornstarch, or lactose, common diluting agents that are present in intravenous injections of heroin, cocaine, or methylphenidate hydrochloride, and are known to cause systemic embolic phenomena in chronic drug abusers. This glistening crystal on the surface of the retina changed and evolved into a noninfectious but inflammatory organization of retinal granuloma, in which the foreign body crystal could still be visualized at the apex of the lesion. The anterior and posterior segments of the eye remained free of inflammatory signs throughout the course of the organization of the retinal granuloma.

By use of enzyme-lined immunosorbent assay (ELISA), patients with Sjögren's syndrome were found to have levels of serum IgG antibody to cytomegalovirus twice those of matched control subjects, and IgM antibody levels which were three times as high. It may be relevant that features of cytomegalovirus infection are similar to those of Sjögren's syndrome.

Sjögren syndrome, consisting of keratoconjunctivitis sicca and xerostomia with or without another autoimmune disease, is uncommon in children. We describe our retrospective experience with eight pediatric patients with SS. All had recurrent parotid enlargement and abnormal salivary gland biopsies, six had keratoconjunctivitis sicca, and five had other autoimmune manifestations, although only two of these had other clearly defined autoimmune disorders (mixed connective tissue disease and hypergammaglobulinemic purpura). Our patients had a higher incidence of primary SS, parotid enlargement, and hematologic abnormalities than did children previously reported with SS. Children with SS demonstrate a clinical heterogeneity comparable to that seen in adults.

We present a case of endophthalmitis caused by Propionibacterium acnes seven months following extracapsular cataract extraction and intraocular lens implantation. The markedly delayed clinical course of endophthalmitis associated with this organism appears to be highly stereotypical. Recognition and treatment of this complication of cataract surgery allows an excellent chance at cure.

We treated two sporadic cases of postoperative endophthalmitis caused by rapidly growing (Runyon's group IV) mycobacteria. Both involved intraocular lenses, one a secondary implant after intracapsular cataract extraction (Mycobacterium chelonae subspecies abscessus) and the other a primary posterior chamber lens implantation after extracapsular cataract extraction (pigment-producing member group IV). Signs of inflammation were judged severe enough to warrant diagnostic and therapeutic intervention during the fourth postoperative week in both cases. In both eyes the organism seemed to be eradicated by intravitreal amikacin in combination with vitrectomy, as well as topical, subconjunctival, and, in one case, systemic antibiotic therapy.

Herpes simplex keratitis was found to be a common ophthalmic problem in Tunisia. Dendritic and geographic ulcers were complicated by deep stromal keratitis in 31% of patients, two thirds of whom were known to have been treated previously with corticosteroids. Herpes simplex virus was isolated from 41% of patients from whom corneal material was cultured. To develop an effective program for management of epithelial herpes in developing countries, treatment with idoxuridine was compared with debridement and patching. Average healing time for 31 ulcers treated with idoxuridine was 13 days, with three treatment failures; average healing time for 20 ulcers treated with debridement and patching was five days, with one failure. Debridement and patching of herpetic ulcers was an efficient way to treat herpes simplex keratitis within the context of overall medical care in Tunisia.

Acute hemorrhagic conjunctivitis (AHC), a new disease entity first reported in 1969, has since become pandemic throughout the world. In Tunisia during an epidemic in 1972 to 1973 we studied 25 cases of AHC, which were characterized by explosive onset of lid edema, chemosis, conjunctival hemorrhages, follicular hypertrophy, and epithelial keratitis. Clinical signs peaked in 48 hours and cleared without sequelae in five to seven days. Paired acute- and convalescent-phase sera from six of the patients showed a rising titer of neutralizing antibody to the prototype strain of AHC virus (J6 70/71), which was isolated in Japan. Two viral isolates from Tunisian patients were also antigenically related to the Japanese strain, indicating that a single etiologic agent (a new member of the picornavirus group) is probably responsible for the current pandemic of AHC.

The effect of purified proflavine and light exposure was assessed in rabbits whose eyes had been infected with one of two strains of herpesvirus. In comparing proflavine-light and placebo-light treatment, 0.1% proflavine administered twice daily for 5 days had a significant effect in suppressing herpetic eye disease, but 0.05% proflavine was less effective. In addition to being effective in infections with either virus strain, the 0.1% proflavine also suppressed intensity of corneal epithelial ulceration and stromal opacity in animals pretreated with subconjunctival corticosteroids to produce more severe disease. Proflavine or idoxuridine (IDU) alone or in combination showed no differences in suppressing herpetic ocular disease, but all were significantly more effective than placebo. Virus recovery rates were approximately the same from eyes treated with proflavine, IDU, or placebo, indicating that viral replication in the cornea and conjunctiva was not completely suppressed by either of the antiviral drugs alone or in combination.

A 62-year-old white man developed an acute anterior chamber inflammation in his left eye. Listeria monocytogenes was cultured from the vitreous aspirate. There was no evidence for ocular trauma or distant site of infection from which hematogenous spread of the organism occurred. No underlying state of immunocompromise was demonstrated. The endophthalmitis responded well to therapy.

There has been a relative lack of literature on the association of hypohidrosis in Sjögren's syndrome with any lesion having specific histologic findings. We looked at a recent case presentation of a 55-year-old man with complaints of dry mouth and dry eyes, becoming easily overheated in direct sunlight, and having difficulty in perspiring. Physical examination showed fissuring and atrophy of the tongue and angular cheilitis. A punch biopsy of the skin showed a moderate number of eccrine gland and ductal structures in the lower reticular dermis, each surrounded by a dense cellular infiltrate of plasma and lymphocytic cells. Our patient also had a markedly decreased sweating response to methacholine. In reviewing the literature as far back as 1951 and on the basis of findings in our present case study, we conclude that it seems probable that the severity of the skin disease is an important determining factor in predicting whether the sweat gland lesion does exist.