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Letters to The Journal
is 13 hours, requiring injections one to three times per week. To avoid complications of mul tiple intravitreal injections, an implantable sustained-release ganciclovir pellet has been developed. 2 In the phase I trial report, no pa tient developed endophthalmitis. 2 We managed a case of Xanthomonas maltophilia endophthal mitis that developed after implantation of this device. Xanthomonas maltophilia is an opportunistic, gram-negative species of rod bacteria that is closely related to the Pseudomonas species. Xanthomonas maltophilia exhibits resistance to many drugs, including all aminoglycosides, quinolones, and most beta-lactam antibiotics. Many infections develop in patients with neutropenia and patients with indwelling cathe ters.3,4 Patients with AIDS commonly have neutropenia and indwelling catheters. Our patient was a 41-year-old man who had had AIDS for two years and who developed cytomegalovirus retinitis in the right eye. He received intravenous ganciclovir through a Hickman catheter, but his treatment was switched to intravitreal ganciclovir after neutropenia developed and intravenous access was lost. After 18 intravitreal injections over a four-month period, he elected to undergo intraocular implantation of a sustained-release ganciclovir pellet. The procedure was uncom plicated. On follow-up examination, there was remission of the retinitis in the right eye; how ever, the patient had developed cytomegalovi rus retinitis in the left eye, and thus underwent similar ganciclovir implantation in that eye. On postoperative day 7, the patient had decreased visual acuity, marked panuveitis, and hypopyon. He was also neutropenic (white blood cell count, 2,500 cells/mm 3 ; normal, 4,000 to 11,000 cells/mm 3 ). A vitrectomy was per formed with intravitreal injection of vancomycin (1 mg/0.1 ml) and amikacin (0.4 mg/0.1 ml). Adjunctive intravenous vancomycin and tobramycin were also administered. Because there was little vitreitis around the implant, the implant was not removed. Over the next four days, he developed worsening inflammation and initial vitreous cultures identified Pseudomonas organisms. A second vitrectomy with re moval of the implant and intravitreal injections of amikacin (0.4 mg/0.1 ml) and ciprofloxacin (0.2 mg/0.1 ml) was performed. Two days later, the organism was identified as X. maltophilia, sensitive only to ceftazidime and trimethoprim-sulfamethoxazole, and resistant to all aminoglycosides, quinolones, and other betalactam antibiotics. Additionally, cultures of the
773
explanted ganciclovir device also grew X. maltophilia. Blood, eyelid, and conjunctival cul tures were all negative. Intravitreal (1 mg/0.1 ml) and intravenous (1 g/day) ceftazidime ther apy was instituted. There was a rapid initial response and a gradual resolution of the panophthalmitis over the course of two weeks. The retinitis in the fellow eye remained well con trolled and in complete remission at six months of follow-up. Intravitreal ganciclovir implants are a prom ising therapy for some cases of AIDS-associated cytomegalovirus retinitis. The efficacy and complications of this therapy are undergoing evaluation.
References 1. Jabs, D.: Treatment of cytomegalovirus retinitis. 1992. Arch. Ophthalmol. 110:185, 1992. 2. Sanborn, G. E., Anand, R., Torti, R. E., Nightin gale, S. D„ Cal, S. X., Yates, B„ Ashton, P., and Smith, T.: Sustained-release ganciclovir therapy for treatment of cytomegalovirus retinitis. Use of an intravitreal device. Arch. Ophthalmol. 110:188, 1992. 3. Kerr, K. G., Hawkey, P. M., Child, J. A., Nor folk, D. R., and Anderson, A. W.: Pseudomonas maltophilia infections in neutropenic patients and the use of imipenem. Postgrad. Med. J. 782:1090, 1990. 4. Elting, L. S., Khardori, N., Bodey, G. P., and Fainstain, V.: Nosocomial infection caused by Xanthomonas maltophilia. A case-control study of predis posing factors. Infect. Control Hosp. Epidemiol. 11:134, 1990. 5. Jay, W. M., Fishman, P., Aziz, M., and Shockley, R. K.: Intravitreal ceftazidime in a rabbit model. Dose and time dependent toxicity and pharmokinetic analysis. J. Ocul. Pharmacol. 3:257, 1987.
Bilateral Panuveitis, Sebopsoriasis, and Secondary Syphilis in a Patient with Acquired Immunodeficiency Syndrome Sasikala Pillai, M.D., and Francis DiPaolo, M.D. District of Columbia General Hospital, Georgetown University Medical Center. Inquiries to Sasikala Pillai, M.D., District of Columbia General Hospital, Ophthalmology Service, 1900 Massachusetts Ave. S.E., Washington, DC 20003. We treated a patient with acquired immuno deficiency syndrome (AIDS) who had acute
774
December, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 1 (Pillai and DiPaolo). Hyperpigmented scaly plaques of the palms. bilateral panuveitis, sebopsoriasis, and secon dary syphilis. A 40-year-old man, who was seropositive for human immunodeficiency virus (HIV), had lacrimation, photophobia, and diminished vision in both eyes for three days. At initial examina tion, he had scaly, hyperkeratotic, pigmented plaques involving the scrotum, perianal area, forearms, soles, palms, and extensor areas of the lower legs (Figs. 1 and 2). Visual acuity was light perception in both eyes and notable findings included bilateral seborrheic blephari tis, fine keratic precipitates with 4+ cells (an intense inflammatory response) and flare in the anterior chamber, posterior synechiae for near ly 360 degrees, and severe vitreitis. Dermatol ogie diagnosis was sebopsoriasis of the scalp,
face, and body, and secondary syphilis of the palms and soles. Laboratory examination dis closed a reactive rapid plasma reagin titer of 1:512 and a reactive fluorescent treponemal antibody-absorption test. Cerebrospinal fluid examination showed a reactive rapid plasma reagin titer of 1:1, and a reactive fluorescent treponemal antibody-absorption test. The test for HLA-B27 was negative. The purified protein derivative test was nonreactive and thoracic radiography disclosed no abnormalities. A skin biopsy of the extensor surface of the leg done to exclude psoriasis disclosed chronic eczema. Treatment with topical corticosteroids and cycloplegics was started. The patient received intravenous aqueous penicillin, 4 million units every four hours for 14 days and oral zidovudine, 100 mg, five times a day. The patient's visual acuity gradually improved to 20/50 in both eyes. The fundi were normal except for mild vitreitis. The skin lesions also improved. Seborrheic dermatitis, secondary syphilis, and psoriasis may all have ocular manifesta tions. Seborrhea is one of the most common cutaneous manifestations of AIDS 1 and may be associated with blepharitis. Psoriasis develops in 1.3% to 2% of HIV-positive patients. 2 · 3 Syph ilis and psoriasis may manifest as iritis and chorioretinitis. 4 · 5 Psoriasis was excluded on the basis of clinical findings and skin biopsy in our patient. The panuveitis responded to systemic penicillin therapy and topical corticosteroid and cycloplegic drops. Our patient had an interesting combination of dermatologie and ophthalmic diseases: se borrhea (sebopsoriasis) with blepharitis and secondary syphilis with panuveitis. The preva lence of dermatologie problems associated with ocular manifestations in patients with HIV in fections makes it imperative for ophthalmolo gists to be familiar with these conditions. Prop er diagnosis and treatment can cure the condition.
References
Fig. 2 (Pillai and DiPaolo). Hyperpigmented scaly plaques of the legs.
1. Dover, J. S.: Cutaneous manifestations of hu man immunodeficiency virus infection. Arch. Dermatol. 127:1549, 1991. 2. Duvic, M., Johnson, T. N., Rapini, R. P., Freese, T., Brewton, G., and Rios, A.: Acquired immunodefi ciency syndrome. Associated psoriasis and Reiter's syndrome. Arch. Dermatol. 123:1622, 1987. 3. Kaplan, M. H., Sadick, N. S., Wieder, J., Färber, B. F., and Neidt, G. W.: Antipsoriatic effects of
Vol. 114, No. 6
Letters to The Journal
zidovudine in human immunodeficiency virus. Asso ciated psoriasis. J. Am. Acad. Dermatol. 20:76, 1989. 4. Moore, J. R.: Syphilitic iritis. A study of 249 patients. Am. J. Ophthalmol. 14:110, 1931. 5. Knox, D. L.: Psoriasis and intraocular inflamma tion. Trans. Am. Ophthalmol. Soc. 77:210, 1979.
Bilateral Radiant Damage to the Cornea and Retina After Exposure to a 700-V Electric Discharge Kip Dolphin, M.D., and Harvey Lincoff, M.D. New York Hospital-Cornell University Medical Cen ter. Inquiries to Harvey Lincoff, M.D., New York Hospital, 525 E. 68th St., New York, NY 10021.
775
Radiant damage to ocular tissues occurs through the following: (1) direct thermal ener gy, (2) thermoacoustic energy that converts sonic transients to induce thermal injury, and (3) photochemical energy that generates oxy gen free radicals and other electronegative spe cies that injure viable tissue. 1,2 We examined a patient who sustained ocular damage by photo chemical energy from exposure to a high-vol tage electric discharge. A 26-year-old man, a railroad worker, inad vertently engaged a third rail, which was carry ing 700 V of electricity, while attempting to position a steel rail. He tried to avert his eyes, but nevertheless saw an electric arc when the two rails met, which he described as blue and blinding. Within an hour after the accident, the patient had decreased vision and a blue-dot-like scoto-
Fig. 1 (Dolphin and Lincoff). The posterior pole of both eyes four hours after exposure to a high-energy electric flash. There are homonymous oval areas of edema in the external layers of the retina (arrows).
Fig. 2 (Dolphin and Lincoff). The posterior pole of both eyes Four months after exposure to electric flash. Left, The lesions in the right eye have matured, becoming glial opacities in the outer retina (arrow). Right, The smaller lesion in the left eye was no longer apparent (arrows).
Letters to The Journal
is 13 hours, requiring injections one to three times per week. To avoid complications of mul tiple intravitreal injections, an implantable sustained-release ganciclovir pellet has been developed. 2 In the phase I trial report, no pa tient developed endophthalmitis. 2 We managed a case of Xanthomonas maltophilia endophthal mitis that developed after implantation of this device. Xanthomonas maltophilia is an opportunistic, gram-negative species of rod bacteria that is closely related to the Pseudomonas species. Xanthomonas maltophilia exhibits resistance to many drugs, including all aminoglycosides, quinolones, and most beta-lactam antibiotics. Many infections develop in patients with neutropenia and patients with indwelling cathe ters.3,4 Patients with AIDS commonly have neutropenia and indwelling catheters. Our patient was a 41-year-old man who had had AIDS for two years and who developed cytomegalovirus retinitis in the right eye. He received intravenous ganciclovir through a Hickman catheter, but his treatment was switched to intravitreal ganciclovir after neutropenia developed and intravenous access was lost. After 18 intravitreal injections over a four-month period, he elected to undergo intraocular implantation of a sustained-release ganciclovir pellet. The procedure was uncom plicated. On follow-up examination, there was remission of the retinitis in the right eye; how ever, the patient had developed cytomegalovi rus retinitis in the left eye, and thus underwent similar ganciclovir implantation in that eye. On postoperative day 7, the patient had decreased visual acuity, marked panuveitis, and hypopyon. He was also neutropenic (white blood cell count, 2,500 cells/mm 3 ; normal, 4,000 to 11,000 cells/mm 3 ). A vitrectomy was per formed with intravitreal injection of vancomycin (1 mg/0.1 ml) and amikacin (0.4 mg/0.1 ml). Adjunctive intravenous vancomycin and tobramycin were also administered. Because there was little vitreitis around the implant, the implant was not removed. Over the next four days, he developed worsening inflammation and initial vitreous cultures identified Pseudomonas organisms. A second vitrectomy with re moval of the implant and intravitreal injections of amikacin (0.4 mg/0.1 ml) and ciprofloxacin (0.2 mg/0.1 ml) was performed. Two days later, the organism was identified as X. maltophilia, sensitive only to ceftazidime and trimethoprim-sulfamethoxazole, and resistant to all aminoglycosides, quinolones, and other betalactam antibiotics. Additionally, cultures of the
773
explanted ganciclovir device also grew X. maltophilia. Blood, eyelid, and conjunctival cul tures were all negative. Intravitreal (1 mg/0.1 ml) and intravenous (1 g/day) ceftazidime ther apy was instituted. There was a rapid initial response and a gradual resolution of the panophthalmitis over the course of two weeks. The retinitis in the fellow eye remained well con trolled and in complete remission at six months of follow-up. Intravitreal ganciclovir implants are a prom ising therapy for some cases of AIDS-associated cytomegalovirus retinitis. The efficacy and complications of this therapy are undergoing evaluation.
References 1. Jabs, D.: Treatment of cytomegalovirus retinitis. 1992. Arch. Ophthalmol. 110:185, 1992. 2. Sanborn, G. E., Anand, R., Torti, R. E., Nightin gale, S. D„ Cal, S. X., Yates, B„ Ashton, P., and Smith, T.: Sustained-release ganciclovir therapy for treatment of cytomegalovirus retinitis. Use of an intravitreal device. Arch. Ophthalmol. 110:188, 1992. 3. Kerr, K. G., Hawkey, P. M., Child, J. A., Nor folk, D. R., and Anderson, A. W.: Pseudomonas maltophilia infections in neutropenic patients and the use of imipenem. Postgrad. Med. J. 782:1090, 1990. 4. Elting, L. S., Khardori, N., Bodey, G. P., and Fainstain, V.: Nosocomial infection caused by Xanthomonas maltophilia. A case-control study of predis posing factors. Infect. Control Hosp. Epidemiol. 11:134, 1990. 5. Jay, W. M., Fishman, P., Aziz, M., and Shockley, R. K.: Intravitreal ceftazidime in a rabbit model. Dose and time dependent toxicity and pharmokinetic analysis. J. Ocul. Pharmacol. 3:257, 1987.
Bilateral Panuveitis, Sebopsoriasis, and Secondary Syphilis in a Patient with Acquired Immunodeficiency Syndrome Sasikala Pillai, M.D., and Francis DiPaolo, M.D. District of Columbia General Hospital, Georgetown University Medical Center. Inquiries to Sasikala Pillai, M.D., District of Columbia General Hospital, Ophthalmology Service, 1900 Massachusetts Ave. S.E., Washington, DC 20003. We treated a patient with acquired immuno deficiency syndrome (AIDS) who had acute
774
December, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 1 (Pillai and DiPaolo). Hyperpigmented scaly plaques of the palms. bilateral panuveitis, sebopsoriasis, and secon dary syphilis. A 40-year-old man, who was seropositive for human immunodeficiency virus (HIV), had lacrimation, photophobia, and diminished vision in both eyes for three days. At initial examina tion, he had scaly, hyperkeratotic, pigmented plaques involving the scrotum, perianal area, forearms, soles, palms, and extensor areas of the lower legs (Figs. 1 and 2). Visual acuity was light perception in both eyes and notable findings included bilateral seborrheic blephari tis, fine keratic precipitates with 4+ cells (an intense inflammatory response) and flare in the anterior chamber, posterior synechiae for near ly 360 degrees, and severe vitreitis. Dermatol ogie diagnosis was sebopsoriasis of the scalp,
face, and body, and secondary syphilis of the palms and soles. Laboratory examination dis closed a reactive rapid plasma reagin titer of 1:512 and a reactive fluorescent treponemal antibody-absorption test. Cerebrospinal fluid examination showed a reactive rapid plasma reagin titer of 1:1, and a reactive fluorescent treponemal antibody-absorption test. The test for HLA-B27 was negative. The purified protein derivative test was nonreactive and thoracic radiography disclosed no abnormalities. A skin biopsy of the extensor surface of the leg done to exclude psoriasis disclosed chronic eczema. Treatment with topical corticosteroids and cycloplegics was started. The patient received intravenous aqueous penicillin, 4 million units every four hours for 14 days and oral zidovudine, 100 mg, five times a day. The patient's visual acuity gradually improved to 20/50 in both eyes. The fundi were normal except for mild vitreitis. The skin lesions also improved. Seborrheic dermatitis, secondary syphilis, and psoriasis may all have ocular manifesta tions. Seborrhea is one of the most common cutaneous manifestations of AIDS 1 and may be associated with blepharitis. Psoriasis develops in 1.3% to 2% of HIV-positive patients. 2 · 3 Syph ilis and psoriasis may manifest as iritis and chorioretinitis. 4 · 5 Psoriasis was excluded on the basis of clinical findings and skin biopsy in our patient. The panuveitis responded to systemic penicillin therapy and topical corticosteroid and cycloplegic drops. Our patient had an interesting combination of dermatologie and ophthalmic diseases: se borrhea (sebopsoriasis) with blepharitis and secondary syphilis with panuveitis. The preva lence of dermatologie problems associated with ocular manifestations in patients with HIV in fections makes it imperative for ophthalmolo gists to be familiar with these conditions. Prop er diagnosis and treatment can cure the condition.
References
Fig. 2 (Pillai and DiPaolo). Hyperpigmented scaly plaques of the legs.
1. Dover, J. S.: Cutaneous manifestations of hu man immunodeficiency virus infection. Arch. Dermatol. 127:1549, 1991. 2. Duvic, M., Johnson, T. N., Rapini, R. P., Freese, T., Brewton, G., and Rios, A.: Acquired immunodefi ciency syndrome. Associated psoriasis and Reiter's syndrome. Arch. Dermatol. 123:1622, 1987. 3. Kaplan, M. H., Sadick, N. S., Wieder, J., Färber, B. F., and Neidt, G. W.: Antipsoriatic effects of
Vol. 114, No. 6
Letters to The Journal
zidovudine in human immunodeficiency virus. Asso ciated psoriasis. J. Am. Acad. Dermatol. 20:76, 1989. 4. Moore, J. R.: Syphilitic iritis. A study of 249 patients. Am. J. Ophthalmol. 14:110, 1931. 5. Knox, D. L.: Psoriasis and intraocular inflamma tion. Trans. Am. Ophthalmol. Soc. 77:210, 1979.
Bilateral Radiant Damage to the Cornea and Retina After Exposure to a 700-V Electric Discharge Kip Dolphin, M.D., and Harvey Lincoff, M.D. New York Hospital-Cornell University Medical Cen ter. Inquiries to Harvey Lincoff, M.D., New York Hospital, 525 E. 68th St., New York, NY 10021.
775
Radiant damage to ocular tissues occurs through the following: (1) direct thermal ener gy, (2) thermoacoustic energy that converts sonic transients to induce thermal injury, and (3) photochemical energy that generates oxy gen free radicals and other electronegative spe cies that injure viable tissue. 1,2 We examined a patient who sustained ocular damage by photo chemical energy from exposure to a high-vol tage electric discharge. A 26-year-old man, a railroad worker, inad vertently engaged a third rail, which was carry ing 700 V of electricity, while attempting to position a steel rail. He tried to avert his eyes, but nevertheless saw an electric arc when the two rails met, which he described as blue and blinding. Within an hour after the accident, the patient had decreased vision and a blue-dot-like scoto-
Fig. 1 (Dolphin and Lincoff). The posterior pole of both eyes four hours after exposure to a high-energy electric flash. There are homonymous oval areas of edema in the external layers of the retina (arrows).
Fig. 2 (Dolphin and Lincoff). The posterior pole of both eyes Four months after exposure to electric flash. Left, The lesions in the right eye have matured, becoming glial opacities in the outer retina (arrow). Right, The smaller lesion in the left eye was no longer apparent (arrows).
