communication I have
seen on
this
subject.
Ocular Indicator for Candida
Endophthalmitis To the Editor.\p=m-\Thearticle entitled "Intravitreal Amphotericin B Treatment of Candida Endophthalmitis" by Stern et al in the January Archives (95:89-93, 1977) suggests that intravitreal administration of amphotericin B might be preferred over intravenous administration of the drug in the treatment of selected cases of Candida endophthalmitis. Although intraocular lesions may develop after candidemia in the absence of other organ involvement, it is much more common for Candida endophthalmitis to be an indicator of widespread deep candidiasis.1 This ocular indicator is more reliable than any other clinical sign currently used to differentiate transient candidemia from deep organ candidiasis. Therefore, patients in whom intraocular candidiasis develops following candidemia should be treated preferentially with antifungal agents administered for systemic effect, not only to bring about resolution of the endophthalmitis itself, but to treat probable mycotic microabscesses in other vital organs, most commonly heart and
kidneys.
J. Robert
Griffin, MD Sacramento, Calif
1. Griffin JR, Foos RY, Pettit TH: Relationship between Candida endophthalmitis, candi-
demia, and disseminated candidiasis. XXII Concilium 11:132-135, 1974.
In Reply.\p=m-\Wewould like to submit the following reply to Dr Griffin's letter. We are in complete agreement with Dr Griffin that Candida endophthalmitis is often an important indicator of disseminated systemic candidiasis and that when systemic infection is present, therapy with intravenous amphotericin B or other systemic antifungal medication is indicated. All patients who have lesions have evaluations done, including blood and urine cultures, chest roentgenograms, careful examination for heart murmurs, and other indicated tests, in search of systemic infection. We were careful to point out in our article that our patient did not have such an evalua-
tion because he refused hospitalization on two separate occasions. We certainly did not intend to advocate treating patients with systemic candidiasis with intravitreal amphotericin B alone. However, should intravitreal spread of infection develop in such a patient, we believe that intravitreal amphotericin B should be given in addition to intravenous therapy as a means of achieving therapeutic levels in the vitreous. We believe that cases of Candida endophthalmitis complicating intra¬ venous drug abuse represent a differ¬ ent situation. While such cases should have the same detailed evaluation as those patients with other predisposing factors to candidemia, especially since Candida endocarditis is commonly seen in drug addicts, in most cases of Candida endophthalmitis complicat¬ ing drug abuse no systemic focus of infection can be found. This was the case in the references cited in our communication and is consistent with the experience of others who have seen many of these cases (oral commu¬ nication, G. R. O'Connor, Sept 17, 1977). In the case of the drug addict with Candida endophthalmitis and no evidence of systemic infection, intra¬ vitreal therapy alone might be consid¬ ered to spare the patient the side effects of amphotericin adminis¬ tered for systemic effect. George A. Stern, MD Carl L. Fetkenhour, MD Richard B. O'Grady, MD
Nonproprietary Name and Trademark of Drug
Amphotericin B—Fungizone.
Regulating 'Unnecessary Surgery' Regulations To the Editor.\p=m-\DrWong's special communication entitled, "Indications for Cataract Surgery: Psycholinguistic Considerations," which appeared in the March Archives (96:526-528, 1978), superbly states the problems facing both patient and surgeon in the often-difficult process of deciding the point at which to intervene surgically in a patient with cataract and visual complaints. The issues are discussed more masterfully than in any other
The corresponding editorial, "A Surgical Storm," which appears on p 427 of the same Archives, lights squarely on another problem, ie, un-
necessary surgery. I submit that the "storm" headlined in this editorial is mostly of political origin; that most patients don't consider their surgery unnecessary. As in any collection of human beings, there is undoubtedly an occasional ophthalmic surgeon who is too eager, but the vast majority of ophthalmic surgeons in the United
States, and the vast majority of cataract (and other) surgery performed is
undoubtedly well indicated. I find myself angered when threatened (again!) with government regulation
if we don't make ourselves miserable with regulations of our own. Dr Wong properly points out that "the resultant wide range of visual indica¬ tions ...for cataract surgery there¬ fore cannot be guided by rigid rules." In the "storm" editorial, the Editor of the Archives points out that much more cataract surgery is performed in the United States per capita than in any other country of the Western World. He goes on to state: "It is unlikely that this is due to the special visual demands of American public." Yet, one of the characteristics by which Europeans spot American tour groups is the high percentage of glasses being worn by the tourists. In fact, according to an article in the November 1977 Consumer Reports, "Some 110 million Americans wear glasses or contacts and they spend close to $4 billion a year for ophthal¬ mic products and services." The American public has become health and function oriented. The collective demands of individual Americans for the best quality of medical care has become an exceed¬ ingly expensive "right." The current national attack on unnecessary sur¬ gery is an obviously easy way to attract votes and sell newspapers. However, efforts to reduce unnecessa¬ ry surgery by the arbitrary imposition of regulations that deny visual reha¬ bilitation to thousands of our citizens will hardly be a popular remedy. Irra¬ tional regulations would make life difficult for the honest physician and for his patient, and will little deter those who are not honest. Robert C. Drews, MD Clayton, Mo
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seen on
this
subject.
Ocular Indicator for Candida
Endophthalmitis To the Editor.\p=m-\Thearticle entitled "Intravitreal Amphotericin B Treatment of Candida Endophthalmitis" by Stern et al in the January Archives (95:89-93, 1977) suggests that intravitreal administration of amphotericin B might be preferred over intravenous administration of the drug in the treatment of selected cases of Candida endophthalmitis. Although intraocular lesions may develop after candidemia in the absence of other organ involvement, it is much more common for Candida endophthalmitis to be an indicator of widespread deep candidiasis.1 This ocular indicator is more reliable than any other clinical sign currently used to differentiate transient candidemia from deep organ candidiasis. Therefore, patients in whom intraocular candidiasis develops following candidemia should be treated preferentially with antifungal agents administered for systemic effect, not only to bring about resolution of the endophthalmitis itself, but to treat probable mycotic microabscesses in other vital organs, most commonly heart and
kidneys.
J. Robert
Griffin, MD Sacramento, Calif
1. Griffin JR, Foos RY, Pettit TH: Relationship between Candida endophthalmitis, candi-
demia, and disseminated candidiasis. XXII Concilium 11:132-135, 1974.
In Reply.\p=m-\Wewould like to submit the following reply to Dr Griffin's letter. We are in complete agreement with Dr Griffin that Candida endophthalmitis is often an important indicator of disseminated systemic candidiasis and that when systemic infection is present, therapy with intravenous amphotericin B or other systemic antifungal medication is indicated. All patients who have lesions have evaluations done, including blood and urine cultures, chest roentgenograms, careful examination for heart murmurs, and other indicated tests, in search of systemic infection. We were careful to point out in our article that our patient did not have such an evalua-
tion because he refused hospitalization on two separate occasions. We certainly did not intend to advocate treating patients with systemic candidiasis with intravitreal amphotericin B alone. However, should intravitreal spread of infection develop in such a patient, we believe that intravitreal amphotericin B should be given in addition to intravenous therapy as a means of achieving therapeutic levels in the vitreous. We believe that cases of Candida endophthalmitis complicating intra¬ venous drug abuse represent a differ¬ ent situation. While such cases should have the same detailed evaluation as those patients with other predisposing factors to candidemia, especially since Candida endocarditis is commonly seen in drug addicts, in most cases of Candida endophthalmitis complicat¬ ing drug abuse no systemic focus of infection can be found. This was the case in the references cited in our communication and is consistent with the experience of others who have seen many of these cases (oral commu¬ nication, G. R. O'Connor, Sept 17, 1977). In the case of the drug addict with Candida endophthalmitis and no evidence of systemic infection, intra¬ vitreal therapy alone might be consid¬ ered to spare the patient the side effects of amphotericin adminis¬ tered for systemic effect. George A. Stern, MD Carl L. Fetkenhour, MD Richard B. O'Grady, MD
Nonproprietary Name and Trademark of Drug
Amphotericin B—Fungizone.
Regulating 'Unnecessary Surgery' Regulations To the Editor.\p=m-\DrWong's special communication entitled, "Indications for Cataract Surgery: Psycholinguistic Considerations," which appeared in the March Archives (96:526-528, 1978), superbly states the problems facing both patient and surgeon in the often-difficult process of deciding the point at which to intervene surgically in a patient with cataract and visual complaints. The issues are discussed more masterfully than in any other
The corresponding editorial, "A Surgical Storm," which appears on p 427 of the same Archives, lights squarely on another problem, ie, un-
necessary surgery. I submit that the "storm" headlined in this editorial is mostly of political origin; that most patients don't consider their surgery unnecessary. As in any collection of human beings, there is undoubtedly an occasional ophthalmic surgeon who is too eager, but the vast majority of ophthalmic surgeons in the United
States, and the vast majority of cataract (and other) surgery performed is
undoubtedly well indicated. I find myself angered when threatened (again!) with government regulation
if we don't make ourselves miserable with regulations of our own. Dr Wong properly points out that "the resultant wide range of visual indica¬ tions ...for cataract surgery there¬ fore cannot be guided by rigid rules." In the "storm" editorial, the Editor of the Archives points out that much more cataract surgery is performed in the United States per capita than in any other country of the Western World. He goes on to state: "It is unlikely that this is due to the special visual demands of American public." Yet, one of the characteristics by which Europeans spot American tour groups is the high percentage of glasses being worn by the tourists. In fact, according to an article in the November 1977 Consumer Reports, "Some 110 million Americans wear glasses or contacts and they spend close to $4 billion a year for ophthal¬ mic products and services." The American public has become health and function oriented. The collective demands of individual Americans for the best quality of medical care has become an exceed¬ ingly expensive "right." The current national attack on unnecessary sur¬ gery is an obviously easy way to attract votes and sell newspapers. However, efforts to reduce unnecessa¬ ry surgery by the arbitrary imposition of regulations that deny visual reha¬ bilitation to thousands of our citizens will hardly be a popular remedy. Irra¬ tional regulations would make life difficult for the honest physician and for his patient, and will little deter those who are not honest. Robert C. Drews, MD Clayton, Mo
Downloaded From: http://archopht.jamanetwork.com/ by a University of Pennsylvania User on 06/19/2015
