Chronic Alternaria alternata
Endophthalmitis Following Intraocular Lens Implantation Alternaria alternata is a widespread, airborne hyphomycete living as a phytoparasite on leaves or vegetable fruits. This imperfect fungus possesses typical conidiospores. Its asthmogenic potential plays an important role as a releasing factor for bronchial asthma, but it is of little importance, causing ophthalmic diseases such as blephari-
tis, conjunctivitis,
or
keratomycosis.1
To our knowledge, fungal endophthalmitis caused by A alternata has not been previously described.
Report of a Case.\p=m-\A69-year old diabetic underwent extracapsular cataract
woman
extraction in another institution with posterior chamber intraocular lens implantation in the left eye in August 1987. After surgery, visual acuity was 40/50 OS and 20/20 OD 3 years after extracapsular cataract extraction and intraocular lens implantation. Intraocular pressure was 16 mm Hg in both eyes. Two months later, slit-lamp examination disclosed 3+ cells, flare, fibrinous exudate, and a 1.5-mm hypopyon in the anterior chamber of the left eye. The patient had no pain. With topical steroid and antibiotic therapy, the hypopyon totally resolved. Visual acuity dete¬ riorated to 20/50 OS. During the next 11 months, the patient developed recurrent and more severe endophthalmitis. Conjunc¬ tival smears and aqueous humor samples failed to detect either bacteria or fungi. Due to the tentative diagnosis of a "toxic lens syndrome," the intraocular lens implant was removed in August 1988. Following re¬ moval of the intraocular lens, the inflam¬ mation persisted and actually worsened despite treatment with topical steroids. On presentation at our hospital in September 1988, the patient had a reactive ptosis with swelling of the left eyelids, 3+ cells, flare, a 0.5-mm hypopyon in the anterior chamber, and vitreous cells and infiltrates (Fig 1). Visual acuity deteriorated to 10/50 OS and intraocular pressure was 21 mm Hg. The diagnosis of chronic endophthalmitis over 1 year after intraocular lens implan¬ tation was made and a diagnostic and ther¬ apeutic pars plana vitrectomy with excision of the posterior lens capsule was per-
Fig 1.—Left eye of
69-year old
woman with fibrin in the anterior chamber, and fibrosis of the posterior lens capsule 1 month after removal of the intraoc¬ ular lens implant. a
0.5-mm
a
hypopyon,
Fig 2.—Histologie section of the posterior lens capsule with dense infiltration of hyphomycetes (Alternaría alternata) (GrocottGomori methenamine-silver nitrate, original
magnification X63; inset, original magnifica¬ tion X480).
formed. Silicone oil had to be injected dur¬ ing surgery due to a mycotic traction reti¬ nal detachment. Histologie examination of the posterior lens capsule showed a dense infiltration with hyphomycetes (Fig 2). Aerobic and anaerobic cultures of vitreous samples for bacteria and cultures for fungi on Sabouraud's agar disclosed A alternata, which was causing chronic fungal endoph¬ thalmitis. With systemic antimycotic ther¬ apy that included up to 60 mg of amphotericin daily and 250 mg of flucytosine four times daily for 3 weeks, combined with cycloplegic eyedrops three times daily, the inflammation totally resolved. At the last examination in August 1989, there were no signs of inflammation, and visual acuity had deteriorated to 1/10 OS due to cystoid macular edema. The intraocular pressure was 16 mm Hg and the retina remained flat.
Comment.—Clinical and experimen¬ tal observations have previously failed to show evidence of intraocular infec¬ tions with A alternata.1 The saprophytic fungus is often cultured as asymptomatic contamination of the healthy conjunctiva. It was presum¬ ably sequestered between the intraoc¬ ular lens implant and the lens capsule at surgery, causing a localized chronic endophthalmitis similar to that de¬ scribed for other organisms, such as Propionibacterium.3 We recommend diagnostic and therapeutic pars plana vitrectomy with laboratory diagnosis
of vitreous samples in every case of re¬ current intraocular inflammation as soon as possible after intraocular sur¬ gery.
Volker Rummelt, MD Klaus W. Ruprecht, MD Horst J. Boltze, MD Gottfried O. H. Naumann, MD Erlangen, Federal Republic of Germany
Reprint requests to the Department of Oph¬ thalmology, University of Erlangen-Nürnberg, Schwabachanlage 6, D-8520 Erlangen, Federal Republic of Germany (Dr Rummelt). 1. Chin GN, Hyndiuk RA, Kwasny GP, Schultz RO. Keratomycosis in Wisconsin. Am J Ophthalmol. 1975;79:121-125. 2. Oesterle CS, Kronenberg HA, Peyman GA. Endophthalmitis caused by an Erwinia species. Arch Ophthalmol. 1977;95:824-825. 3. Meisler DM, Mandelbaum S. Propionibacterium-associated endophthalmitis after extracapsular cataract extraction: review of reported cases.
Ophthalmology. 1989;96:54-61.
Eyelid Lymphedema
Lymphedema is a form of tissue edema resulting from the accumulation of lymph fluid and can occur anywhere. Eyelid involvement is often seen after various surgical procedures, but is short-lived and resolves as the lid heals. Chronic eyelid lymphedema is
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Endophthalmitis Following Intraocular Lens Implantation Alternaria alternata is a widespread, airborne hyphomycete living as a phytoparasite on leaves or vegetable fruits. This imperfect fungus possesses typical conidiospores. Its asthmogenic potential plays an important role as a releasing factor for bronchial asthma, but it is of little importance, causing ophthalmic diseases such as blephari-
tis, conjunctivitis,
or
keratomycosis.1
To our knowledge, fungal endophthalmitis caused by A alternata has not been previously described.
Report of a Case.\p=m-\A69-year old diabetic underwent extracapsular cataract
woman
extraction in another institution with posterior chamber intraocular lens implantation in the left eye in August 1987. After surgery, visual acuity was 40/50 OS and 20/20 OD 3 years after extracapsular cataract extraction and intraocular lens implantation. Intraocular pressure was 16 mm Hg in both eyes. Two months later, slit-lamp examination disclosed 3+ cells, flare, fibrinous exudate, and a 1.5-mm hypopyon in the anterior chamber of the left eye. The patient had no pain. With topical steroid and antibiotic therapy, the hypopyon totally resolved. Visual acuity dete¬ riorated to 20/50 OS. During the next 11 months, the patient developed recurrent and more severe endophthalmitis. Conjunc¬ tival smears and aqueous humor samples failed to detect either bacteria or fungi. Due to the tentative diagnosis of a "toxic lens syndrome," the intraocular lens implant was removed in August 1988. Following re¬ moval of the intraocular lens, the inflam¬ mation persisted and actually worsened despite treatment with topical steroids. On presentation at our hospital in September 1988, the patient had a reactive ptosis with swelling of the left eyelids, 3+ cells, flare, a 0.5-mm hypopyon in the anterior chamber, and vitreous cells and infiltrates (Fig 1). Visual acuity deteriorated to 10/50 OS and intraocular pressure was 21 mm Hg. The diagnosis of chronic endophthalmitis over 1 year after intraocular lens implan¬ tation was made and a diagnostic and ther¬ apeutic pars plana vitrectomy with excision of the posterior lens capsule was per-
Fig 1.—Left eye of
69-year old
woman with fibrin in the anterior chamber, and fibrosis of the posterior lens capsule 1 month after removal of the intraoc¬ ular lens implant. a
0.5-mm
a
hypopyon,
Fig 2.—Histologie section of the posterior lens capsule with dense infiltration of hyphomycetes (Alternaría alternata) (GrocottGomori methenamine-silver nitrate, original
magnification X63; inset, original magnifica¬ tion X480).
formed. Silicone oil had to be injected dur¬ ing surgery due to a mycotic traction reti¬ nal detachment. Histologie examination of the posterior lens capsule showed a dense infiltration with hyphomycetes (Fig 2). Aerobic and anaerobic cultures of vitreous samples for bacteria and cultures for fungi on Sabouraud's agar disclosed A alternata, which was causing chronic fungal endoph¬ thalmitis. With systemic antimycotic ther¬ apy that included up to 60 mg of amphotericin daily and 250 mg of flucytosine four times daily for 3 weeks, combined with cycloplegic eyedrops three times daily, the inflammation totally resolved. At the last examination in August 1989, there were no signs of inflammation, and visual acuity had deteriorated to 1/10 OS due to cystoid macular edema. The intraocular pressure was 16 mm Hg and the retina remained flat.
Comment.—Clinical and experimen¬ tal observations have previously failed to show evidence of intraocular infec¬ tions with A alternata.1 The saprophytic fungus is often cultured as asymptomatic contamination of the healthy conjunctiva. It was presum¬ ably sequestered between the intraoc¬ ular lens implant and the lens capsule at surgery, causing a localized chronic endophthalmitis similar to that de¬ scribed for other organisms, such as Propionibacterium.3 We recommend diagnostic and therapeutic pars plana vitrectomy with laboratory diagnosis
of vitreous samples in every case of re¬ current intraocular inflammation as soon as possible after intraocular sur¬ gery.
Volker Rummelt, MD Klaus W. Ruprecht, MD Horst J. Boltze, MD Gottfried O. H. Naumann, MD Erlangen, Federal Republic of Germany
Reprint requests to the Department of Oph¬ thalmology, University of Erlangen-Nürnberg, Schwabachanlage 6, D-8520 Erlangen, Federal Republic of Germany (Dr Rummelt). 1. Chin GN, Hyndiuk RA, Kwasny GP, Schultz RO. Keratomycosis in Wisconsin. Am J Ophthalmol. 1975;79:121-125. 2. Oesterle CS, Kronenberg HA, Peyman GA. Endophthalmitis caused by an Erwinia species. Arch Ophthalmol. 1977;95:824-825. 3. Meisler DM, Mandelbaum S. Propionibacterium-associated endophthalmitis after extracapsular cataract extraction: review of reported cases.
Ophthalmology. 1989;96:54-61.
Eyelid Lymphedema
Lymphedema is a form of tissue edema resulting from the accumulation of lymph fluid and can occur anywhere. Eyelid involvement is often seen after various surgical procedures, but is short-lived and resolves as the lid heals. Chronic eyelid lymphedema is
Downloaded From: http://archopht.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 01/12/2013
