Endophthalmitis Associated With Haemophilus influenzae Type b Bacteremia and Meningitis Rathna V.
Sastry, MD, Carol J. Baker, MD
\s=b\The unusual occurrence of endophthalmitis associated with Haemophilus influenzae type b bacteremia and meningitis was confirmed in three young children during a five-year period. In contrast to bacterial endophthalmitis attributed to other microorganisms, these three infections resolved completely within a few days with conventional antimicrobial therapy. Endophthalmitis is but one of the apparently increasing number of unusual complications that may be observed as a result of H influenzae type b bacteremia. (Am J Dis Child 133:606-608, 1979)
Well-recognizedHaemophilus fluenzae type tations
clinical manifes¬ of in¬ b infection include
meningitis, septic arthritis, cellulitis, pleural empyema, and epiglottitis.1-
Unusual sites of involvement have been reported, suggesting that this microorganism has a capacity to invade almost any organ. One such unusual entity attributed to H in¬ fluenzae type b infection is endoph¬ thalmitis. Only two such cases have been reported previously.'4 During the past five years, three infants with H influenzae type b meningitis have been seen at our hospital with endoph¬ thalmitis, an observation that may reflect either an increased recognition of this entity as a complication of meningeal infection, an increased occurrence of this complication, or both. In this article, the clinical features, treatment, and outcome of From the Departments of Pediatrics, Microbiology, and Immunology, Baylor College of Medicine (Dr Baker) and Texas Children's Hospital (Dr Sastry), Houston. Reprint requests to Department of Pediatrics, Baylor College of Medicine, 1200 Moursund, Houston, TX 77030 (Dr Sastry).
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015
these three
cases of H influenzae type b endophthalmitis are summarized and contrasted with cases attributed to other microorganisms.
REPORT OF CASES Case t.—A 5-month-old male infant
was
hospitalized in January 1978 with a history of fever and irritability of four days' dura¬
tion and cloudiness of the left eye of six hours' duration. He had received penicillin V orally for 48 hours prior to admission. The child was noticeably lethargic; temper¬ ature was 39 °C; pulse rate, 120 beats per minute; respiratory rate, 40/min; and blood pressure, 90/60 mm Hg. The anterior fontanel was bulging, the neck stiff, and the anterior chamber of the left eye cloudy, with the fluid layering nasally. The vitreous was hazy and the fundus could not be visualized. Visual acuity could not be determined because the infant was obtunded and unable to fix or follow. The remainder of the physical findings were unremarkable. Hemoglobin electrophoresis indicated sickle cell trait, and the chest roentgeno¬ gram showed mild perihilar infiltrates. Ampicillin-sensitive H influenzae type b was isolated from the blood and CSF. The patient was treated with ampicillin sodium and chloramphenicol sodium succinate in-
Therapy
and Outcome in Three Patients With Parenteral Antibiotics
Patient 1
Type Ampicillin sodium, 300 mg/kg Chloramphenicol sodi¬ um
Duration, Days 14
Endophthalmitis
Haemophilus influenzae Type
Subconjunctival
Topical
Medications
Medications
Duration, Days
Type Ampicillin sodium,
Type Chloramphenicol 1%
succinate, 100
Chloramphenicol
atropine sulfate
1% cyclopentolate hy¬ drochloride
Ampicillin sodium, mg/kg
300
Ampicillin sodium,
sodi¬
succinate, 100
mg/kg
14
50
mg twice a day Gentamicin sulfate, 10 mg Dexamethasone
(0.025% Decadron), days 3-7 Ampicillin sodium, 200 mg/kg
Duration, Days 10
100 mg
mg/kg
um
and
None 14
Chloramphenicol Phenylephrine (10% Neo-Synephrine) hy¬
b
Meningitis
Outcome Normal eye; severe neurological deficit
10
10 10
drochloride 0.25% scopolamine
10
1% prednisone forte Polymyxin sulfateneomycin sulfatedexamethasone
14
Normal
10
Normal
(Maxitrol) atropine sulfate
1%
travenously for three days, and then with ampicillin alone for an additional 14 days. Ampicillin was given subconjunctivally for seven days (Table). The patient had a stormy hospital course with multiple seizures necessitating treat¬ ment with phenytoin (Dilantin), phénobar¬ bital, and paraldehyde. He was semicoma¬ tose for several days, and fever persisted into the second week. On the 18th day of hospitalization, transillumination was ab¬ normal over the left parietal region. A left subdural puncture yielded 20 mL of clear sterile fluid. The left eye improved grad¬ ually; by the seventh day, the pupils, ante¬ rior chamber, vitreous, and fundus were all normal. Ten months later, on examination of the child, severe developmental delay was noted, but he seemed to have no ocular
sequelae.
girl with Down's hospitalized in February 1977 with a history of high-grade fever, vomiting, and irritability of five days' Case 2.—A 6-month-old
syndrome
was
duration and cloudiness of the left eye for two days. Prior to admission, the patient had received a single intramuscular injec¬ tion of penicillin G procaine, followed by erythromycin estolate orally for two days. The child was irritable; temperature was 39 °C; pulse rate, 140 beats per minute; respiratory rate, 30/min; and blood pres¬ sure, 100/70 mm Hg. The anterior fontanel was full, the anterior chamber of the left eye cloudy, and the conjunctiva was injected. The vitreous was hazy and the fundus could not be visualized. Except for the stigmata of Down's syndrome, the remainder of the physical findings were unremarkable.
Ampicillin-sensitive H influenzae type b isolated from the blood and CSF cultures. Initial treatment included ampi¬ cillin and chloramphenicol intravenously for three days, followed by chlorampheni¬ col alone for a total of 14 days. In addition, 50 mg of ampicillin sodium was injected subconjunctivally twice daily for five days was
(Table).
On the second day, the first left metatarsophalangeal joint appeared to be swollen, erythematous, and tender. This subsided within 48 hours of treatment. Roentgeno¬ grams of the feet were normal. The eye gradually improved; on the eighth day, the hypopyon had disappeared, the vitreous was clear, and the fundus was normal. Twelve months later, the child seemed to have no neurological or visual sequelae. Case 3.-A 14-month-old girl was hospi¬ talized in February 1972 with fever and lethargy of three days' duration and cloudi¬ ness of the right eye for 24 hours. Physical examination disclosed a lethargic child with nuchal rigidity; temperature was 38 °C; pulse rate, 116 beats per minute; respiratory rate, 28/min; and blood pres¬ sure, 100/60 mm Hg. The anterior chamber of the right eye was hazy and contained purulent-appearing material. The fundus could not be visualized. The remainder of the physical findings were unremarkable. Ampicillin-sensitive H influenzae type b was isolated from the blood and CSF, and the patient was treated with ampicillin intravenously for 14 days (Table). One week after admission, the right eye was completely normal and the child was alert and afebrile. No visual or neurologic seque¬ lae were noted at 36 months of age.
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COMMENT
Endophthalmitis as a complication meningitis was first Virchow5 in 1856. How¬ recognized by ever, its association with H influenzae type b meningitis is recent and has been reported previously in only two of bacterial
instances.3·4 Several authors have sug¬
gested that the incidence of H in¬ fluenzae type b infection is increasing, and it is possible that our observation of three cases of endophthalmitis with H influenzae type b meningitis during a relatively short time interval is but a reflection of a larger number of cases
from which an unusual manifestation of infection might be expected. Since the eye findings in our patients and the patient described by GomezBarreto and Nahmias' were obvious, it is unlikely that this complication has been overlooked in other children. The pathogenesis of ocular involve¬ ment in association with bacterial meningitis is incompletely under¬ stood. In 1911, Collins and Mayou" speculated that metastatic spread to the eye was a result of bacteremia. The degree of bacteremia and the presence of nonpenetrating trauma have been shown to be two major variables in the pathogenesis of endophthalmitis.7 None of our pa¬ tients experienced local trauma, but all three were bacteremic. The experimental rat model of
H influenzae type b endophthalmitis described by Myerowitz et al8 has done much to elucidate the pathogenesis of suppurative endophthalmitis in asso¬ ciation with bacterial meningitis. These investigators demonstrated that bacterial infection of the eye was
secondary to hematogenous spread during "high grade" bacteremia. Inoc¬ ulation with H influenzae type b intranasally or intraperitoneally re¬
sulted in bacteremia in 70 of 114 rats, and suppurative endophthalmitis de¬ veloped in 18 of 32 survivors. Histo¬ pathologic studies of these 18 rats disclosed evidence of meningitis in 11, varying degrees of involvement of the anterior and posterior segments of the eye in all 18, and, in a few, total disorganization of the eye. Haemophi¬ lus influenzae type b was recovered from the aqueous humor of 92% of affected eyes. There was no evidence of spread along the optic nerve in these animals, nor of sinusitis or rhini¬ tis to implicate spread to the orbit
from these sites. Since endophthalmitis is unusual in association with any form of bacterial meningitis, little information regard¬ ing optimal therapy is available. In our patients, parenterally adminis¬ tered ampicillin or chloramphenicol or both were used for the treatment of meningitis. In the presence of inflam¬ mation, both these agents diffuse well into ocular tissues.913 The value of subconjunctival injections of antibiot¬ ics as an adjunct to parenteral admin¬ istration is not known. Two of our patients were treated with subcon¬ junctival and topical antibiotics, and one was not; however, the endophthal¬ mitis in all three patients resolved rapidly without sequelae. Subconjunc¬ tival injections of ampicillin and chlor¬ amphenicol produce higher and more consistent levels in the ocular tissues than parenteral antibiotics alone.812 Whether the use of topical and subconjunctival antibiotics as an ad¬ junct to parenteral antibiotics is
superior to parenteral therapy alone for the treatment of H influenzae type b endophthalmitis cannot be stated definitively from this or pre¬ vious studies. However, the benign outcome observed in our three pa¬ tients and in the one reported by Gomez-Barreto and Nahmias3 con¬ trasts with the relatively poor results of endophthalmitis following trauma or surgery14 or as a complication of bacterial meningitis associated with other microorganisms.7 " 1ß Martha Yow, MD, and Ralph D. Feigin, MD, reviewed this article. Judy Rodgers and Jo Ann Wladysiak assisted in its preparation. David Schrum, MD, and Elizabeth Batmanis, MD, gave permission for us to report their patients.
Nonproprietary Names and Trademarks of Drugs Ampicillin soaixim-Alpen-N, Amcill-S, Omnipen-N, Penbritin-S, Polycillin-N, Principen/N. Gentamicin sulfate—Garamycin.
References 1. Todd KJ, Bruhn FW: Severe Haemophilus influenzae infections: Spectrum of disease. Am J
Dis Child 129:607-611, 1975. 2. Granoff DM, Nankervis GA: Cellulitis due to Haemophilus influenzae type b. Am J Dis Child 130:1211-1214, 1976. 3. Gomez-Barreto J, Nahmias AJ: Hypopyon and orbital cellulitis associated with Haemophilus influenzae type b meningitis. Am J Dis Child 131:215-217, 1977. 4. Ward JI, Gorman G, Phillips C, et al: Haemophilus influenzae type b disease in a day-care center. J Pediatr 92:713-717, 1978. 5. Virchow R: Ueber capillare embolie. Virchows Arch Pathol Anat 9:307-322, 1856. 6. Collins ET, Mayou MS: Pathology and Bacteriology of theEye. Philadelphia, Blakiston's Son &
Co, 1911,
p 511. 7. Selenkowsky J, Woizechowsky N: Experimentelles uker die endogene infektion des Auges. Arch Augenheilkd 47:299-344, 1903. 8. Myerowitz RL, Klaw R, Johnson BL: Experimental endogenous endophthalmitis caused by Haemophilus influenzae type b. Infect Immun 14:1043-1051, 1976. 9. Records RE, Ellis PP: The intraocular penetration of ampicillin, methicillin and oxacillin. Am J Ophthalmol 64:135-143, 1967. 10. Barza M, Baum J: Penetration of ocular
compartments by penicillins. Surv Ophthalmol 18:71-82, 1973. 11. Broughton W, Goldman JN: The intraocular penetration of chloramphenicol succinate in rabbits. Ann Ophthalmol 5:71-80, 1973.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015
12. Goldman JN, Klein JO: Penetration of
ampicillin and penicillin G into aqueous humour. Ann Ophthalmol 2:35-42, 1970. 13. George J, Hanna C: Ocular penetration of chloramphenicol. Arch Ophthalmol 95:879-882,
1977. 14. Forster RK: Endophthalmitis. Arch Ophthalmol 92:387-392, 1974. 15. Duke-Elder S: Diseases of the uveal tract, in Duke-Elder S (ed): System of Ophthalmology. St Louis, CV Mosby Co, 1966, vol 9, pp 53-60, 88-107, 218-255. 16. Forster RK, Zachary IG, Cottingham AJ, et al: Further observations on the diagnosis, causes and treatment of endophthalmitis. Am J Ophthalmol 81:52-56, 1976.
Sastry, MD, Carol J. Baker, MD
\s=b\The unusual occurrence of endophthalmitis associated with Haemophilus influenzae type b bacteremia and meningitis was confirmed in three young children during a five-year period. In contrast to bacterial endophthalmitis attributed to other microorganisms, these three infections resolved completely within a few days with conventional antimicrobial therapy. Endophthalmitis is but one of the apparently increasing number of unusual complications that may be observed as a result of H influenzae type b bacteremia. (Am J Dis Child 133:606-608, 1979)
Well-recognizedHaemophilus fluenzae type tations
clinical manifes¬ of in¬ b infection include
meningitis, septic arthritis, cellulitis, pleural empyema, and epiglottitis.1-
Unusual sites of involvement have been reported, suggesting that this microorganism has a capacity to invade almost any organ. One such unusual entity attributed to H in¬ fluenzae type b infection is endoph¬ thalmitis. Only two such cases have been reported previously.'4 During the past five years, three infants with H influenzae type b meningitis have been seen at our hospital with endoph¬ thalmitis, an observation that may reflect either an increased recognition of this entity as a complication of meningeal infection, an increased occurrence of this complication, or both. In this article, the clinical features, treatment, and outcome of From the Departments of Pediatrics, Microbiology, and Immunology, Baylor College of Medicine (Dr Baker) and Texas Children's Hospital (Dr Sastry), Houston. Reprint requests to Department of Pediatrics, Baylor College of Medicine, 1200 Moursund, Houston, TX 77030 (Dr Sastry).
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015
these three
cases of H influenzae type b endophthalmitis are summarized and contrasted with cases attributed to other microorganisms.
REPORT OF CASES Case t.—A 5-month-old male infant
was
hospitalized in January 1978 with a history of fever and irritability of four days' dura¬
tion and cloudiness of the left eye of six hours' duration. He had received penicillin V orally for 48 hours prior to admission. The child was noticeably lethargic; temper¬ ature was 39 °C; pulse rate, 120 beats per minute; respiratory rate, 40/min; and blood pressure, 90/60 mm Hg. The anterior fontanel was bulging, the neck stiff, and the anterior chamber of the left eye cloudy, with the fluid layering nasally. The vitreous was hazy and the fundus could not be visualized. Visual acuity could not be determined because the infant was obtunded and unable to fix or follow. The remainder of the physical findings were unremarkable. Hemoglobin electrophoresis indicated sickle cell trait, and the chest roentgeno¬ gram showed mild perihilar infiltrates. Ampicillin-sensitive H influenzae type b was isolated from the blood and CSF. The patient was treated with ampicillin sodium and chloramphenicol sodium succinate in-
Therapy
and Outcome in Three Patients With Parenteral Antibiotics
Patient 1
Type Ampicillin sodium, 300 mg/kg Chloramphenicol sodi¬ um
Duration, Days 14
Endophthalmitis
Haemophilus influenzae Type
Subconjunctival
Topical
Medications
Medications
Duration, Days
Type Ampicillin sodium,
Type Chloramphenicol 1%
succinate, 100
Chloramphenicol
atropine sulfate
1% cyclopentolate hy¬ drochloride
Ampicillin sodium, mg/kg
300
Ampicillin sodium,
sodi¬
succinate, 100
mg/kg
14
50
mg twice a day Gentamicin sulfate, 10 mg Dexamethasone
(0.025% Decadron), days 3-7 Ampicillin sodium, 200 mg/kg
Duration, Days 10
100 mg
mg/kg
um
and
None 14
Chloramphenicol Phenylephrine (10% Neo-Synephrine) hy¬
b
Meningitis
Outcome Normal eye; severe neurological deficit
10
10 10
drochloride 0.25% scopolamine
10
1% prednisone forte Polymyxin sulfateneomycin sulfatedexamethasone
14
Normal
10
Normal
(Maxitrol) atropine sulfate
1%
travenously for three days, and then with ampicillin alone for an additional 14 days. Ampicillin was given subconjunctivally for seven days (Table). The patient had a stormy hospital course with multiple seizures necessitating treat¬ ment with phenytoin (Dilantin), phénobar¬ bital, and paraldehyde. He was semicoma¬ tose for several days, and fever persisted into the second week. On the 18th day of hospitalization, transillumination was ab¬ normal over the left parietal region. A left subdural puncture yielded 20 mL of clear sterile fluid. The left eye improved grad¬ ually; by the seventh day, the pupils, ante¬ rior chamber, vitreous, and fundus were all normal. Ten months later, on examination of the child, severe developmental delay was noted, but he seemed to have no ocular
sequelae.
girl with Down's hospitalized in February 1977 with a history of high-grade fever, vomiting, and irritability of five days' Case 2.—A 6-month-old
syndrome
was
duration and cloudiness of the left eye for two days. Prior to admission, the patient had received a single intramuscular injec¬ tion of penicillin G procaine, followed by erythromycin estolate orally for two days. The child was irritable; temperature was 39 °C; pulse rate, 140 beats per minute; respiratory rate, 30/min; and blood pres¬ sure, 100/70 mm Hg. The anterior fontanel was full, the anterior chamber of the left eye cloudy, and the conjunctiva was injected. The vitreous was hazy and the fundus could not be visualized. Except for the stigmata of Down's syndrome, the remainder of the physical findings were unremarkable.
Ampicillin-sensitive H influenzae type b isolated from the blood and CSF cultures. Initial treatment included ampi¬ cillin and chloramphenicol intravenously for three days, followed by chlorampheni¬ col alone for a total of 14 days. In addition, 50 mg of ampicillin sodium was injected subconjunctivally twice daily for five days was
(Table).
On the second day, the first left metatarsophalangeal joint appeared to be swollen, erythematous, and tender. This subsided within 48 hours of treatment. Roentgeno¬ grams of the feet were normal. The eye gradually improved; on the eighth day, the hypopyon had disappeared, the vitreous was clear, and the fundus was normal. Twelve months later, the child seemed to have no neurological or visual sequelae. Case 3.-A 14-month-old girl was hospi¬ talized in February 1972 with fever and lethargy of three days' duration and cloudi¬ ness of the right eye for 24 hours. Physical examination disclosed a lethargic child with nuchal rigidity; temperature was 38 °C; pulse rate, 116 beats per minute; respiratory rate, 28/min; and blood pres¬ sure, 100/60 mm Hg. The anterior chamber of the right eye was hazy and contained purulent-appearing material. The fundus could not be visualized. The remainder of the physical findings were unremarkable. Ampicillin-sensitive H influenzae type b was isolated from the blood and CSF, and the patient was treated with ampicillin intravenously for 14 days (Table). One week after admission, the right eye was completely normal and the child was alert and afebrile. No visual or neurologic seque¬ lae were noted at 36 months of age.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015
COMMENT
Endophthalmitis as a complication meningitis was first Virchow5 in 1856. How¬ recognized by ever, its association with H influenzae type b meningitis is recent and has been reported previously in only two of bacterial
instances.3·4 Several authors have sug¬
gested that the incidence of H in¬ fluenzae type b infection is increasing, and it is possible that our observation of three cases of endophthalmitis with H influenzae type b meningitis during a relatively short time interval is but a reflection of a larger number of cases
from which an unusual manifestation of infection might be expected. Since the eye findings in our patients and the patient described by GomezBarreto and Nahmias' were obvious, it is unlikely that this complication has been overlooked in other children. The pathogenesis of ocular involve¬ ment in association with bacterial meningitis is incompletely under¬ stood. In 1911, Collins and Mayou" speculated that metastatic spread to the eye was a result of bacteremia. The degree of bacteremia and the presence of nonpenetrating trauma have been shown to be two major variables in the pathogenesis of endophthalmitis.7 None of our pa¬ tients experienced local trauma, but all three were bacteremic. The experimental rat model of
H influenzae type b endophthalmitis described by Myerowitz et al8 has done much to elucidate the pathogenesis of suppurative endophthalmitis in asso¬ ciation with bacterial meningitis. These investigators demonstrated that bacterial infection of the eye was
secondary to hematogenous spread during "high grade" bacteremia. Inoc¬ ulation with H influenzae type b intranasally or intraperitoneally re¬
sulted in bacteremia in 70 of 114 rats, and suppurative endophthalmitis de¬ veloped in 18 of 32 survivors. Histo¬ pathologic studies of these 18 rats disclosed evidence of meningitis in 11, varying degrees of involvement of the anterior and posterior segments of the eye in all 18, and, in a few, total disorganization of the eye. Haemophi¬ lus influenzae type b was recovered from the aqueous humor of 92% of affected eyes. There was no evidence of spread along the optic nerve in these animals, nor of sinusitis or rhini¬ tis to implicate spread to the orbit
from these sites. Since endophthalmitis is unusual in association with any form of bacterial meningitis, little information regard¬ ing optimal therapy is available. In our patients, parenterally adminis¬ tered ampicillin or chloramphenicol or both were used for the treatment of meningitis. In the presence of inflam¬ mation, both these agents diffuse well into ocular tissues.913 The value of subconjunctival injections of antibiot¬ ics as an adjunct to parenteral admin¬ istration is not known. Two of our patients were treated with subcon¬ junctival and topical antibiotics, and one was not; however, the endophthal¬ mitis in all three patients resolved rapidly without sequelae. Subconjunc¬ tival injections of ampicillin and chlor¬ amphenicol produce higher and more consistent levels in the ocular tissues than parenteral antibiotics alone.812 Whether the use of topical and subconjunctival antibiotics as an ad¬ junct to parenteral antibiotics is
superior to parenteral therapy alone for the treatment of H influenzae type b endophthalmitis cannot be stated definitively from this or pre¬ vious studies. However, the benign outcome observed in our three pa¬ tients and in the one reported by Gomez-Barreto and Nahmias3 con¬ trasts with the relatively poor results of endophthalmitis following trauma or surgery14 or as a complication of bacterial meningitis associated with other microorganisms.7 " 1ß Martha Yow, MD, and Ralph D. Feigin, MD, reviewed this article. Judy Rodgers and Jo Ann Wladysiak assisted in its preparation. David Schrum, MD, and Elizabeth Batmanis, MD, gave permission for us to report their patients.
Nonproprietary Names and Trademarks of Drugs Ampicillin soaixim-Alpen-N, Amcill-S, Omnipen-N, Penbritin-S, Polycillin-N, Principen/N. Gentamicin sulfate—Garamycin.
References 1. Todd KJ, Bruhn FW: Severe Haemophilus influenzae infections: Spectrum of disease. Am J
Dis Child 129:607-611, 1975. 2. Granoff DM, Nankervis GA: Cellulitis due to Haemophilus influenzae type b. Am J Dis Child 130:1211-1214, 1976. 3. Gomez-Barreto J, Nahmias AJ: Hypopyon and orbital cellulitis associated with Haemophilus influenzae type b meningitis. Am J Dis Child 131:215-217, 1977. 4. Ward JI, Gorman G, Phillips C, et al: Haemophilus influenzae type b disease in a day-care center. J Pediatr 92:713-717, 1978. 5. Virchow R: Ueber capillare embolie. Virchows Arch Pathol Anat 9:307-322, 1856. 6. Collins ET, Mayou MS: Pathology and Bacteriology of theEye. Philadelphia, Blakiston's Son &
Co, 1911,
p 511. 7. Selenkowsky J, Woizechowsky N: Experimentelles uker die endogene infektion des Auges. Arch Augenheilkd 47:299-344, 1903. 8. Myerowitz RL, Klaw R, Johnson BL: Experimental endogenous endophthalmitis caused by Haemophilus influenzae type b. Infect Immun 14:1043-1051, 1976. 9. Records RE, Ellis PP: The intraocular penetration of ampicillin, methicillin and oxacillin. Am J Ophthalmol 64:135-143, 1967. 10. Barza M, Baum J: Penetration of ocular
compartments by penicillins. Surv Ophthalmol 18:71-82, 1973. 11. Broughton W, Goldman JN: The intraocular penetration of chloramphenicol succinate in rabbits. Ann Ophthalmol 5:71-80, 1973.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Calgary User on 05/27/2015
12. Goldman JN, Klein JO: Penetration of
ampicillin and penicillin G into aqueous humour. Ann Ophthalmol 2:35-42, 1970. 13. George J, Hanna C: Ocular penetration of chloramphenicol. Arch Ophthalmol 95:879-882,
1977. 14. Forster RK: Endophthalmitis. Arch Ophthalmol 92:387-392, 1974. 15. Duke-Elder S: Diseases of the uveal tract, in Duke-Elder S (ed): System of Ophthalmology. St Louis, CV Mosby Co, 1966, vol 9, pp 53-60, 88-107, 218-255. 16. Forster RK, Zachary IG, Cottingham AJ, et al: Further observations on the diagnosis, causes and treatment of endophthalmitis. Am J Ophthalmol 81:52-56, 1976.
