Letters to the Editor

Ocular Penetration by Anesthetic Injection Dear Editor: Three articles on the management of ocular penetration from local anesthesia have recently been published, two in this journal) ·2 and a third in another journal. 3 The most recent article noted that "Penetration of the globe may be difficult to notice at the time of surgery.,,3 In that series, the proper diagnosis was made at the time of injection in only 5 of 12 cases. This is consistent with one of your articles reporting that the diagnosis was immediately recognized in only 12 of 23 cases. 2 For many years, I have used a quick and simple examination to avoid missing this complication. After every retrobulbar or peribulbar injection, I check the fundus with an indirect ophthalmoscope to be sure that the sclera has not been perforated and that the retinal vessels are patent. In cases where the fundus is known to be abnormal (e.g., diabetic retinopathy or retinal detachment), it would be useful to check the fundus both before and after the local anesthetic injection. ROBERT M. FEIBEL, MD St. Louis, Missouri

Second, although we agree that the use of intravitreal corticosteroids may often enhance ocular tissue preservation after staphylococcal endophthalmitis, the authors have not shown that the intravitreal route of administration of dexamethasone is preferable to other routes of delivery such as parenteral, periOCUlar, or even oral. We understand that Maxwell and his colleagues elected to study only one route of drug administration and applaud their fine effort. A comparison of various routes of administration of anti-inflammatory agents in the treatment of bacterial endophthalmitis is to be encouraged, especially for delivery of such agents after initial treatment. Finally, we have wondered for some time if nonsteroidal anti-inflammatory drugs might be as good or even superior to corticosteroids in reducing ocular damage in endophthalmitis. JULES BAUM, MD Brookline, Massachusetts Reference I. Baum JL, Barza M, Lugar J, et aI. The effect of corticosteroid in the treatment of experimental bacterial endophthalmitis. Am J Ophthalmol1975; 80:513-17.

References I. Grizzard WS, Kirk NM, Pavan PR, et al. Perforating ocular injuries caused by anesthesia personnel. Ophthalmology 1991; 98:1011-6. 2. Hay A, flynn HW Jr, Hoffman 11, Rivera AH. Needle penetration of the globe during retrobulbar and peri bulbar injections. Ophthalmology 1991; 98:1017-24. 3. Rinkoff JS, Doft BH, Lobes LA. Management of ocular penetration from injection of local anesthesia preceding cataract surgery. Arch Ophthalmol1991; 109:1421-5.

Intravitreal Steroids for Endophthalmitis Dear Editor: In a recent article entitled, "Effect of Intravitreal Dexamethasone on Ocular Histopathology in a Rabbit Model of Endophthalmitis" (Ophthalmology 1991; 98:1370-5), Maxwell et al documented the salutary effect ofintravitreal dexamethasone in a rabbit model of Staphylococcus epidermidis endophthalmitis. We would like to address two points related to their well-performed study. First, the authors state, "Despite previous studies in animal models, the histologic changes associated with endophthalmitis have not been documented." In addition to published clinical and experimental reports detailing such changes, we have noted the salutary clinical effects of corticosteroid use in a rabbit model of staphylococcal endophthalmitis. ) In our study, the steroids were given by retrobulbar injection. Although we mentioned them only briefly, we also performed histopathologic studies that supported the ophthalmoscopic results.

Authors' reply

Dear Editor: We appreciate the comments made by Dr. Baum concerning our article. As Dr. Baum notes, our study was not designed to compare the effect of different routes of steroid delivery (i.e., intravitreal, systemic, peribulbar, etc.) on ocular histopathology. Meredith and associates have previously reported better media clarity in eyes treated with vitrectomy, intraocular antibiotics, and corticosteroids, whether they were administered intraocularly or systemically.) Interestingly, they also found that the inflammation in those eyes treated with antibiotic only and control eyes exhibited worsening of inflammation at I week before improving at 2 to 3 weeks. They also noted that eyes treated with systemic or intraocular corticosteroids exhibited less intraocular inflammation as an independent but additive effect in those eyes also undergoing vitrectomy. Although previous reports have made reference 2,3 to the histopathologic changes of study eyes, there has been lack of documentation of these histologic changes by photomicrographs in a comparative study of Staphylococcus epidermidis endophthalmitis. In a literature search, we were only able to document a study by Peyman and associates,4 who presented a similar histopathologic study in an animal model. However, their study was on an uncommon type of endophthalmitis (i.e., Pseudomonas). This study was hampered by a very narrow (5 hour) "treatment window" during which a beneficial treatment

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Intravitreal steroids for endophthalmitis.

Letters to the Editor Ocular Penetration by Anesthetic Injection Dear Editor: Three articles on the management of ocular penetration from local anest...
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