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Corneal blindness affects over 8 million adults and 1.5 million children worldwide, making it one of the top 5 causes of blindness. Depending on the recipient's corneal condition corneal transplantation may not be a viable treatment option. In such seemingly no-alternative situations, keratoprosthesis implantation can be an option in some patients. In terms of numbers, two types of keratoprostheses are currently used: 1. Keratoprostheses with biological haptics made of tooth or tibia bone. 2. The Boston type I-keratoprosthesis. Both types have optics made of PMMA. The most common complication is the formation of an optically disturbing retroprosthetic membrane behind the optic, which can usually be removed with YAG laser. Causes of blindness after keratoprosthesis implantation are glaucoma, endophthalmitis and retinal detachment. The extrusion rate of the Boston type I-keratoprosthesis seems to be higher than after keratoprosthesis implantation with biological haptic. Autoimmunological corneal diseases have increased extrusion rates and higher rates of endophthalmitis when compared to non-autoimmunological diseases. Visual outcomes after keratoprosthesis implantation are potentially very good and usually limited by extracorneal concomitant diseases. Advances in glaucoma diagnostic (OCT, implantation of intraocular pressure sensors), standard glaucoma prophylaxis by medication or surgery, modern retinal surgery and better treatment options in case of extrusion improve the prognosis of keratoprosthesis surgery. Still, the ideal technique for permanent anchoring of artifical optics in biological tissue has yet to be developed., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: nein; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an im Bereich der Medizin aktiven Firma: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an zu Sponsoren dieser Fortbildung bzw. durch die Fortbildung in ihren Geschäftsinteressen berührten Firma: nein. Erklärung zu nichtfinanziellen Interessen Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: A variety of findings can be obtained from enucleated eyes, which provide the ophthalmologist with information with respect to the effectiveness, improvement options and of course also the possible complications of surgical interventions. Representative for many important findings, relevant clinical and ophthalmopathological findings are presented and discussed on the basis of three enucleated eyeballs., Methods: Clinical histopathological correlation of three enucleated eyeballs., Results: Enucleated eyeballs typically exhibit advanced changes in different tissues making it sometimes difficult to draw direct conclusions about the original surgical interventions. Nevertheless, many findings on the pathophysiology of different diseases, on wound healing and also on the surgical procedures can be deduced, as shown here in three different cases of epithelial invasion, historical retinal surgery and an endogenous fungal endophthalmitis., Conclusion: Each enucleated eye should be histopathologically examined and under consideration of the clinical history in order to understand the course of the disease and to use the knowledge gained for the treatment of future patients.

This article presents a case of endophthalmitis after intravitreal injection with bevacizumab (Avastin®) in a patient suffering from exudative age-related macular degeneration (AMD). Within 1h after diagnosis the patient underwent vitrectomy with intravitreal injection of antibiotics combined with corticosteroids and 4 weeks after the endophthalmitis the visual acuity increased to 0.5. This case report demonstrates that an immediate vitrectomy combining intravitreal injection of medication can lead to a good visual outcome even in the case of severe endophthalmitis.

Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht.

Aims: The aim of this study was to evaluate the clinical features as well as the visual results and determine the prognostic factors after the removal of retained intraocular foreign bodies (IOFBs)., Patients and Methods: At our centre we conducted a non-randomised, non-comparative retrospective analysis of records of 31 patients with intraocular foreign bodies treated using pars plana vitrectomy and other conventional surgical techniques during a 3-year period between January 2006 and December 2008. Using the OTS classification for ocular injuries (United States Eye Injury Registry [USEIR]), we evaluated the visual outcome and various pre-, intra- and postoperative clinical factors., Results: Almost all patients (96.8 %) were male with a mean age of 32.29 years ± 13.38 SD (SD = standard deviation). The most common cause of ocular injury was hammering (58 %), in 27 cases the IOFB was magnetic. Follow-up ranged from 1 to 34 months with a mean of 4.5 months. In 30 eyes, the IOFBs could be removed during the first surgery. The average time between injury and surgery was 15.78 ± 23.45 SD hours for 27 patients (87.1 %). In 3 cases the intraocular foreign body (IOFB) was removed 7, 9, 14 days after the injury. In one case the IOFB was removed in a second surgery 40 days after the injury. In 23 cases we performed pars plana vitrectomy, for 8 patients we performed anterior segment surgery, in 21 cases the lens was also removed. At the time of surgery initial vitreous haemorrhage was present in 17 patients (54.8 %). OTS score for ocular injury was calculated as 2.45 ± 0.78 SD. Initial visual acuity was below 20 / 200 in 61.3 % of the cases. Subsequent to surgical treatment over a mean follow-up of 2.5 months, 25 patients (80.64 %) achieved a visual acuity of 20 / 200 or better (0.69 ± 0.35 SD). Best corrected visual acuity was significantly better for ocular injuries with a higher OTS score (p = 0.000095). Other significant factors for good visual outcome were good initial visual acuity (p = 0.002), the absence of vitreal haemorrhagies (p = 0.024) and small size of the IOFB (p = 0.043). Postoperative complications included retinal detachment (9.67 %), endophthalmitis (3.22 %) and PVR (3.22 %)., Conclusion: Acceptable visual results could be achieved after the removal of posterior segment IOFBs by vitrectomy. A reliable classification of ocular injuries may provide significant information about the prognosis of injuries with intraocular foreign bodies., (© Georg Thieme Verlag KG Stuttgart · New York.)

Capsular block syndrome (CBS) is a complication of uncomplicated cataract surgery. Depending on etiology and the time of onset CBS can be subdivide into three types. The cases of 4 patients with CBS type III who presented with a milky fluid in the space between the posterior surface of the implanted intraocular lens (IOL) and the anterior surface of the distended posterior capsular bag are described. All patients complained of reduced vision. The therapy of choice is Nd:YAG laser posterior capsulotomy but with suspected low-grade endophthalmitis surgical intervention can also be carried out and submitting the plug for bacterial culture.

To avoid a postoperative endophthalmitis several measures have been proposed. These are predominantly drug-related, e. g. PVP-iodine, topical antibiotics pre-, intra- and postoperatively. Due to the actual ESCRS study for intracameral antibiotics, the current discussion focusses almost exclusively on drug-related causes. Therefore, in this paper the surgical priority is pointed out without neglecting the drug-related causes. The construction of the tunnel must be water-tight even under pressure from outside to avoid a postoperative hypotony. In cases of doubt the tunnel should be sutured.

Background: To report on the diagnosis and management of a"firecracker" injury presenting with a post-traumatic intraocular inflammation., Case Report: A 10-year-old boy sustained a penetrating 16-mm cornea-sclera blast injury to his left eye with uveal prolapse and hemophthalmus and doubtful light perception. The cranial computed tomography revealed a metallic intraocular foreign body (IOFB), retinal detachment, and subretinal and subchoroidal hemorrhage. After primary wound closure and antibiotic treatment for 1 week, increasing cell infiltration and amaurosis developed, and a lensectomy, pars plana vitrectomy, and extraction of the 17x7x7-mm encapsulated IOFB via a scleral tunnel was indicated., Results: A vitreous specimen did not reveal microbial growth; however, plenty of polymorphonuclear cells, macrophages, and lymphocytes were observed. Spectroscopy of the IOFB showed copper, zinc, silicon, lead, and other metals. A diagnosis of noninfectious inflammation due to heavy metals, primarily copper (=chalcosis), was made. The postoperative course was unremarkable, the intraocular lens in place, fundus CDR 0.2, retina and macula attached, intraocular pressure 9 mmHg. Three weeks after surgery, the flash VEP showed absent potentials., Conclusions: Large projectiles or parts should be removed from the eye immediately in order to prevent complications from toxic metallosis and early fibrotic reactions.

Background: In the rare condition of endogenous (or metastatic) endophthalmitis, septicemia leads to intraocular colonization by bacteria, fungi or parasites. Immunologically compromised or multimorbid patients are commonly affected by this ophthalmological emergency. Although appropriate anti-infective drugs and modern surgical treatment are available, this disease still has a poor prognosis in terms of organ and function preservation., Patients and Methods: Between March 2003 and September 2005 nine patients (5 male, 4 female, average age: 60.6 years) with a diagnosis of endogenous endophthalmitis were treated in the Ophthalmology Department of Rostock University Hospital. The infection was in a very advanced stage in eight cases. Six patients offered no fundus view, and in three cases the intraocular view was heavily blurred. Eight patients had an initial visual acuity of

Purpose: Listeria monocytogenes is a rare cause of endogenous endophthalmitis. Controversy exists concerning clinical progress and prognosis in this bacterial infection. However, only a few reports about the clinical features have been previously published in the literature., Case Report: The case of a 24-year-old woman is reported. She developed an endogenous endophthalmitis within 3 weeks. The patient received a pars-plana vitrectomy showing Listeria monocytogenes in the vitreous body. An intensive antibiotic therapy was initiated (local, subconjunctival, intravitreal and systemic). Visual acuity was increased from hand motion to 0.5 by the end of the clinical attendance and to 1.0 three months later. There were no hints concerning systemic manifestation of listeriosis or granuloma formation., Conclusion: Frequently, endogenous endophthalmitis has a very poor prognosis. However, the presented case report describes a very prosperous progress of endogenous endophthalmitis caused by an infection with Listeria monocytogenes.

Background: Infectious endophthalmitis is a serious complication following cataract surgery, since it often induces a substantial reduction of visual acuity., Patients and Methods: We retrospectively evaluated the clinical data of 53 patients with endophthalmitis following cataract surgery who were treated at the department of ophthalmology of the University Hospital in Ulm between 1995 and May 2001. Of these patients, 50 had been referred. Clinical presentation, infecting organism, treatment and visual outcome were analysed with a followup ranging from 2 weeks up to 42 months (median: 6 months)., Results: In 52 patients endophthalmitis was preceeded by cataract extraction and IOL implantation, in one case by secondary IOL implantation. Confirmed microbiologic growth was demonstrated from intraocular specimens in 26 out of 41 operated eyes (63%), the most frequent causative organisms were coagulase-negative Staphylococci (50%). All isolated bacteria were sensitive to a combination of the antibiotics vancomycin and amikacin or vancomycin and ceftazidime. 13 patients were treated with intravenous antibiotic therapy alone. In 46% of patients, who were initially treated with intraocular antibiotic injections alone, required further therapeutic intervention for recurrent infection. Only 7.7% of the patients who initially underwent intraocular antibiotic injections combined with IOL removal or pars plana vitrectomy with or without IOL removal, required further surgical intervention. Initial visual acuity was hand movements (median) only but improved during follow-up to 0.2 (median)., Conclusions: In this series all tested bacteria were susceptible to the combination of vancomycin with either amikacin or ceftazidime. Aggressive initial treatment including IOL removal may be associated with a lower frequency of recurrent disease.

Background: Postoperative endophthalmitis can be subdivided into acute and chronic forms which are typically caused by different organisms. Enterococcus faecalis is an organism which normally causes an acute form of endophthalmitis., Patients and Methods: We report on four cases of different forms of endophthalmitis following cataract extraction and intraocular lens (IOL) implantation who had been referred to our institution between 1998 and 2001. Enterococcus faecalis was the causative organism in all of them., Results: Two patients presented with an acute form and were immediately treated in our hospital after symptom onset utilizing pars plana vitrectomy with and without IOL explantation. The two other patients were initially treated with subconjunctival and/or systemic antibiotics and steroids over a period of about two months before referral to our hospital. After initial improvement the inflammation exacerbated in these two patients and vitrectomy with or without IOL and capsular bag explantation was performed. The explanted IOL and capsular bag of one patient were examined using scanning electron microscopy and it was shown that the enterococci were adherent to the IOL and the capsular bag., Conclusion: Enterococcus faecalis can be the causative organism both of an acute and of a recurrent form of postoperative endophthalmitis. The recurrent form may be caused by organisms which tend to adhere to the IOL and the capsular bag. This should be kept in mind when considering different treatment options.

Background: Acute endophthalmitis requires a vitrectomy. Vitrectomy and autokeratoplasty has been reported, if the infection originates from a stromal keratitis in an aphakic eye. This retrospective non-randomized cohort study points out the requirements, indications and results of combined keratoplasty and vitrectomy in keratitis and endophthalmitis compared with noninfectious corneal and vitreoretinal problems. PATIENTS AND SURGERY: In 1995-1999, a vitrectomy and keratoplasty was performed on 15 patients (16 eyes), 10 of these with an endophthalmitis (median 71 years) and a follow-up of 2-60 months (median 19.3 months). 14 of 15 patients had had multiple prior surgery. Stromal keratitis as a sequela of keratoplasty was seen in 5 eyes (3x ruptured suture), 5x diffuse infiltration in compromised corneas (1x with a perforation, 2x with Fuchs' corneal dystrophy, 3x postoperative). In the patients without endophthalmitis 6 eyes were aphakic with corneal scars and no fundus visualization. Five eyes had a retinal detachment, one had an intraocular foreign body. An allogeneic keratoplasty was done in 14, and an allogeneic sclerokeratoplasty and an autologous sclerokeratoplasty in one eye each., Results: Keratoplasty without keratoprosthesis allowed for fundus visualization, and a pars plana vitrectomy was done with a wide angle contact lens, 8x with C2F6-, 1x with silicone oil 5000 cs instillation, and gentamicin and 15 micrograms r-tPA added. In 5 vitrectomy specimens (50%) pathogenic bacteria were found. No recurrences of infection were seen. Conservation of the eyes and postoperative fundus visualization was possible in each case. The postoperative increase in visual acuity of 0.1 or better was significant in both patient groups. 2 eyes remained at preoperative levels, 14 ameliorated by > 1 lines. Complications were 1x directly postoperative graft decompensation, 1x rejection after 40 months, 6x persisting secondary glaucomas, 2x hypotony syndromes, 1x with phthisis and enucleation, 1x epiretinal gliosis., Conclusions: Curative surgery of acute keratitis and endophthalmitis by vitrectomy and keratoplasty may result in similarly successful outcomes as in noninfectious corneal scars and vitreoretinal pathology, if some requirements (e.g. adequate antibiotic treatment, graft material, skilled anterior and posterior segment surgeon) are fulfilled.

Background: Endogenous fungal endophthalmitis is mostly seen as opportunistic infection, particularly in immunocompromised patients and under special risk factors. The therapeutical approach and the value of vitrectomy in diagnosis and therapy are discussed., Patient: A 42-years-old intravenous heroin addicted male patient with unilateral Candida albicans endophthalmitis, determined by cultivation is presented. The visual acuity at initial was 20/25 but decreased to hand-movements within 14 days despite systemic therapy. Treatment with systemic Fluconazole was extended and vitrectomy performed. The infection resolved but left a scar in the macula. The patient recovered a visual acuity of 20/80., Conclusion: Candida albicans endophthalmitis is a dreaded situation in ophthalmology. It has poor visual prognosis if left untreated. Therefore immediate diagnosis and aggressive therapy, if necessary vitrectomy are required.

Background: Ocular manifestations of Lyme borreliose present with unusual forms of conjunctivitis, keratitis, optic nerve disease, uveitis, vitritis and rarely endophthalmitis., Case Report: A 57-year-old man working as logger in Sax-ony-Anhalt suffering from an endophthalmitis on his left eye was referred to us. The vision of his left eye was intact light perception and hand motions. The slit-lamp examination revealed severe inflammation of the anterior chamber with hypopyon, posterior synechiae, and opacity of the posterior lens capsule. Funduscopy showed no red reflex, no retinal details. In the local hospital serum analysis was performed and showed in Western-Blot IgM- and IgG-antibodies against Borrelia burgdorferi. Despite of intravenous application of ceftriaxon for 14 days panuveitis persisted, and endophthalmitis developed when antibiotic therapy was finished., Results: During pars plana vitrectomy a sharply delineated cystic lesion containing yellowish fluid was revealed, and creamy yellow fluid was aspirated. Microscopically in hematoxylineosin stained slides of the aspirate structures consistent with Borrelia burgdorferi were found. Postoperatively vision increased to 1/15. Despite of a second intravenous ceftriaxon treatment for 14 days we observed a retinal vasculitis in the follow up of 6 months., Conclusions: Despite intravenous ceftriaxon-therapy borrelia burgdorferi must have survived in the vitreous body. Further investigations are required with respect to the use of other antibiotics or immunosuppressives.

Background: The endogenous endophthalmitis is a septic-metastatic late complication of a generalized bacterial or fungal infection or an asymptomatic fungaemia. Aspergillus organisms are a rare cause of endophthalmitis. Aspergillus ocular manifestations have been mostly reported in connection with immunosuppression, severe diseases or drug abuse., Patient and Methods: A 51-year-old man underwent a kidney transplantation, an immunosuppressive therapy, and, in addition, treatments for some other generalized diseases. Endogenous endophthalmitis was diagnosed in both eyes at an interval of about eight weeks. The treatment included pars-plana-vitrectomy on both eyes., Results: At first, an endogenous endophthalmitis was found in the right eye which was assumed to be induced by bacteria. About eight weeks later, however, an endogenous endophthalmitis was diagnosed in the left eye, also, which was caused by Aspergillus. The patient received an intensive medical care including operative, antibacterial and antimycotic treatments. The bacterial endophthalmitis in the right eye was healed, and the state of the left eye was found to be post-operatively stabilized. Unfortunately, the patient died of a septic shock in systemic Aspergillus infection., Conclusion: Endogenous endophthalmitis has a very poor prognosis. To our knowledge, the described medical history seems to be the first reported case of an endophthalmitis on both sides, apparently caused by bacteria in one eye and by fungi in the other one.

Background: We present the course of an endogenous Aspergillus endophthalmitis in a 38-year-old HIV-positive man. HISTORY AND CLINICAL SIGNS: The first examination because of a sudden visual loss in the right eye showed a central subretinal infiltration, peripheral vascular sheeting and retinal hemorrhages., Therapy and Outcome: In spite of high-dose systemic antifungal therapy we could not prevent the penetration of the posterior wall of the eye and infiltration of adjacent orbital structures. Enucleation had to be performed., Conclusions: In case of scleral involvement in Aspergillus endophthalmitis the necessity of enucleation has to be considered.

Background: Endophthalmitis is a serious complication after cataract surgery., Patients and Methods: Therefore, a retrospective study was performed by reviewing patient-records of all cases of end-ophthalmitis after catract surgery that were treated at the department of ophthalmology of the University Hospital in Mainz between January 1986 and December 1995., Results: 44 eyes were treated for endophthalmitis. Of those, 38 had been referred. In 15 eyes cataract surgery was performed on an outpatient basis. In 20 cases the onset of end-ophthalmitis occurred within the first postoperative week. We isolated staphylococcus epidermidis (14), staphylococcus aureus (4), other gram-positive microorganisms (15), gram-negative bacteria (2) and candida (1). As risk factors we found a wound dehiscence (14), an intraoperative loss of vitreous (11), diabetes (11), skin-diseases like rosacea or neurodermatitis (6). In 36 cases a vitrectomy was performed. After a mean follow-up of 25 +/- 22 months 26 patients had a visual acuity of 0.05 or better., Conclusion: Gram-positive bacteria showed to be the most common causetive microorganisms. In a third of all cases the sample demonstrated no growth. More than 80% of the eyes were treated by vitrectomy. About 60% of the patients obtained a visual acuity of 0.05 or better.

Unlabelled: From January 1994 to January 1996, 18 patients underwent vitrectomy as a result of endophthalmitis. All patients received intraocular and systemic antibiotics in accordance with the first group of patients in the Endophthalmitis Vitrectomy Study. The aim of this retrospective study was to analyze the visual outcome of surgical treatment., Methods: Data from 18 consecutive patients, 11 women and 7 men, with the diagnosis of endophthalmitis as indication for vitrectomy were evaluated. The patients' ages ranged from 14 to 93 years (mean 66.6 +/- 21.3). Postoperative follow-up ranged from 6 weeks to 10 months., Results: Endophthalmitis resulted from cataract surgery with implantation of an intraocular lens in 14 patients and from ocular trauma in 2 patients. Endophthalmitis followed the resection of posterior capsule fibrosis in 1 patient. Another patient suffered from endogenous endophthalmitis. Positive cultures were obtained in 12 patients. The most frequent causative organisms were coagulase-negative Staphylococcus (n = 7) and Streptococcus species (n = 4). Visual outcome: 13 of 18 patients (72%) gained a visual acuity of 20/400 or better at the final examination after vitrectomy. Four patients (22%) reached a visual acuity of 20/50 or better. Two eyes were enucleated. Good functional outcome was achieved in 2 patients with streptococcal infection (20/200; 30/50)., Conclusion: Vitrectomy in combination with intraocular antibiotics is a suitable method for the treatment of endophthalmitis and results in preservation of ambulatory vision in 72% of patients. Vitrectomy in endophthalmitis can result in good functional outcome even in the case of infections with streptococcal species.

History and Signs: A 37-y-old worker for a recycling company suffered from a corneal perforation by a wire which had been in contact with dirt and moisture., Therapy and Outcome: Initially, the typical signs of an endophthalmitis were missing so that we only irrigated and instilled antibiotics into the anterior chamber. However, later on two pars-plana vitrectomies became necessary. At each operation a bacteriological examination was performed and we found four different species-Pseudomonas aeruginosa. Klebsiella oxytoca, Aeromonas caviae, Flavobacterium odoratum., Conclusion: The latter two species are very rare in ophthalmology. This fact and some peculiarities in the clinical course of the patient's disease make him an unusual case. After unsuccessful irrigation of the anterior chamber vitrectomy ought to be performed immediately.

Background: Most penetrating needle puncture injuries occur in retro- or peribulbar anesthesia. Hereby only a small percentage of patients develop endophthalmitis. Ocular penetration after enoral infraorbital nerve block has not yet been reported in literature., History and Findings: In June 1995 a 74-year-old man presented with a fulminant fibrinous and purulent endophthalmitis. Because he suffers from trigeminal neuralgia his anesthesiologist performed an infraorbital nerve block from enoral two days ago. During this procedure the patient felt a sharp ocular pain., Therapy and Outcome: We suspected an ocular penetration and performed a vitrectomy with intravitreal antibiotic instillation on the admission-day. A needle penetration site near the inferior rectus muscle was detected and after exocryocoagulation a 5 mm wide radial buckle was sutured over penetration site. Three months postoperatively vision recovered from hand moving to 20/50 and all infiltrations had been disappeared. Only preexisting cataract prevented a better vision. 10 months later after successful cataract extraction with intraocular lens implantation patient left hospital with a vision of 20/30., Conclusion: Careful anamnesis would have prevented this accidental globe penetration. Right upper palate is absent presumably due to congenital cleft malformation or surgery. This allowed needle penetration through smooth tissue into the right globe. Fortunately, endophthalmitis develops only in a small percentage after needle puncture. We recommend immediate pars-plana-vitrectomy and intravitreal antibiotics in case of endophthalmitis after ocular penetration.

History: Dental regulation with the Headgear System is a method applied worldwide, and only few cases of device induced injuries have been documented. However, such injuries can be very severe, as can be seen from our case. Therefore, the risk/benefit relation should be considered., Patient: In December 1995, a 10-year-old female patient with a scleral perforation near the limbus was sent to Zürich university eye clinic as emergency case. The evening before, the patient had tried to remove her dental brace (Headgear) by pulling it over her head without disengaging the rubber bands serving for fixation before. During this attempt, the brace escaped at eye level, shot into her face and caused a skeletal perforation in her left eye as well as contusion bulbi in her right eye. In the further course, a fulminant endophthalmitis (streptococcus spp and anaerobic mixed oral flora) developed in the patient's left eye, which could not be controlled inspite of two interventions with vitrectomy and finally made an enucleation necessary., Conclusion: Disregarding the worldwide application of this device in the treatment of defective positions of teeth, the present case demonstrates that it is necessary to thoroughly instruct the patients regarding the handling of the Headgear and to inform them of possible dangers.

Postsurgical endophthalmitis frequently requires emergency vitrectomy. Loss of corneal transparency can preclude vitreoretinal surgery. Due to the narrow time frame in which surgical treatment needs to be performed, donor corneas are often not available for grafting. In addition, the risk of primary graft failure is higher in eyes with acute endophthalmitis. Later regrafting after primary graft failure carries a higher risk of graft rejection. By a clinical case of endophthalmitis after cataract surgery, we demonstrate the surgical technique of combined pars plana vitrectomy, keratoprosthesis, and autokeratoplasty. Loss of corneal transparency precluded standard pars plana vitrectomy with fundus contact lenses. The cornea was trephined and replaced by a keratoprosthesis. The trephined cornea was stored in tissue culture medium and pars plana vitrectomy was performed. At the end of the procedure, the keratoprosthesis was removed and the patient's own cornea was re-implanted. The transparency of the cornea improved during the postoperative course, permitting slit-lamp biomicroscopy of the anterior segment.

We report a case of a 60 year old male who presented with a therapy resistant endophthalmitis which led to an evisceratio bulbi. Histologically, a granulomatous inflammation was present, in which acid-fast bacilli could not be detected. Molecular genetic examination by means of polymerase-chain-reaction technique (PCR) of the routinely processed tissue material revealed the diagnosis of an atypical mycobacterial infection, because DNA specific for atypical mycobacteria was detected. This example shows that PCR technique provides a useful tool in the diagnosis of mycobacterial infections as an adjunct to surgical pathology.

Background: The aim of our study was to develop possible criteria for the choice of vitrectomy in the treatment of endophthalmitis., Materials and Methods: Ninety-two patients with endophthalmitis who were seen between 1980 and 1993 were reviewed retrospectively and analysed regarding pathogenesis, bacteriological aetiology, as well as pre- and postoperative visual acuity comparing intravenous (i.v.) therapy alone to a combination with vitrectomy in 3 pretherapeutic visual acuity classes (class I < 0.02, class II 0.02- < 0.1 and class III > or = 0.1)., Results: Endophthalmitis most commonly occurred after cataract extraction (39%). The best prognosis regarding final visual acuity was found with Staph. epidermidis infection, the worst with Streptococci. Postoperative visual acuity in class I was significantly better after vitrectomy with 0.18 +/- 0.06 (Standard Error = SE) compared to i.v. therapy alone (0.06 +/- 0.03 SE) (p < 0.05 unpaired Student t-Test). In class II, no such difference could be demonstrated. In class III, i.v. therapy yielded significantly better results (0.8 +/- 0.09 SE) than vitrectomy (0.53 +/- 0.14 SE), however only by comparing the final - but not the best - obtained posttherapeutic visual acuity., Conclusion: The more favourable results after vitrectomy in patients with very poor pretherapeutic vision suggest an important role of vitrectomy in the presence of extensive vitreous opacifications. The better outcome after i.v. therapy in patients with pretherapeutic vision > or = 0.1 could be influenced by the very short follow-up period which renders an evaluation of a potential loss of vision due to late complications after endophthalmitis impossible.

The aim of this study was to evaluate the effect of progress made in cataract surgery regarding the indications and results of intraocular lens (IOL) removal. For this purpose, the charts of all patients who had undergone IOL explantation at our institution between January 1990 and December 1992 were reviewed. Indications were divided into six groups: (a) chronic low-grade endophthalmitis; (b) pseudophakic bullous keratopathy; (c) luxation; (d) traumatic expulsion; (e) high-degree aniseikonia; (f) acute endophthalmitis. Visual acuities were grouped according to a good (1.0 to 0.5), acceptable (0.4 to 0.05) and poor (less than 0.05) outcome. Fifty-two IOL were removed from 52 eyes of 52 patients during the period considered in this study. Sixteen were anterior chamber, 5 were iris-fixated, and 31 were posterior chamber lenses. The removal rates were 30.8% for chronic, low-grade endophthalmitis (n = 16), 28.8% for bullous keratopathy (n = 15), 28.8% for luxation (n = 15), 5.8% for traumatic expulsion (n = 3), 3.8% for high-degree aniseikonia (n = 2), and 1.9% for acute endophthalmitis (n = 1). After explantation vision equal to or better than 20/400 was achieved by the vast majority of patients in all groups with the exception of those with bullous keratopathy. The progress made in cataract surgery over the last decade has greatly influenced the rate of complications leading to IOL removal. Continuous monitoring of explanted IOLs is mandatory to evaluate further changes in surgical technique and lens design.

A 23-year-old female received a very severe burn in the anterior eye segment of both eyes from hydrochloric acid. During medical treatment over a period of 4 weeks in an outpatient clinic, the left eye perforated because of corneal and scleral ulceration. In the first emergency operation the necrotic tissue was excised in both eyes. Scleral ulceration in the right eye was treated by a tenonplasty. In the left eye a tenonplasty was carried out in all quadrants. Because of the large amount of ulceration in the cornea, a keratoplasty with a scleral rim was performed. On this occasion a fibrinous membrane was pulled off the iris. The cataractous lens released spontaneously. Finally an anterior vitrectomy was carried out. Two weeks later endophthalmitis occurred. Therefore, a vitrectomy was performed. Microbiological examination yielded mold fungus. Seven days after this operation another infiltration of the vitreous could be detected sonographically. During the third operation 10 mm of the first 16-mm transplant was trephined for another keratoplasty. An open-air vitrectomy was carried out as well. Nevertheless, the bulbus became phthisic afterwards. Amazingly the tenonplasty led to complete regeneration of the conjunctiva and healing of the scleral ulceration. It was possible to take an autologous transplant of the conjunctiva from the eye and graft it on the right eye to relieve a nasal superior symblepharon. After successful keratoplasty visual acuity of the right eye is 0.5.

We report an exceptional case of fulminant endophthalmitis after uncomplicated extracapsular cataract extraction with posterior chamber lens implantation. The first unusual finding was the causative organisms, group G streptococci. These organisms are commonly found as normal flora of the skin, pharynx and gastrointestinal tract. They are also well known as pathogens of neonatal sepsis, otitis media and pneumonia, but there are only three case reports describing a streptococcus G endophthalmitis. The second unusual finding was the delayed onset of the fulminant endophthalmitis, occurring later than 9 days after surgery. A retrospective analysis of 17 additional cases showed that endophthalmitis occurred either during the first 5 days after surgery or later than 35 days after surgery. If endophthalmitis developed shortly after surgery it progressed rapidly and with intense inflammation. The other cases showed more chronic inflammatory reaction. From the latter finding we conclude that long postoperative monitoring remains necessary even if at first no signs of intraocular inflammation are detectable.

Advances of therapeutic strategies in the management of critically ill patients have resulted in an increased life expectancy and more frequent presentations to ophthalmic surgeons. Six patients with postoperative endophthalmitis after elective intraocular surgery suffering from Sharp-syndrome, metastasizing antrum carcinoma, granulomatous vasculitis and immunosuppressive therapy, agranulocytosis, silico-tuberculosis and chronic lymphatic leukemia revealed traditionally pathogenic agents (Proteus mirabilis, P. aeruginosa, enterococci, coagulase-negative Staph). Two patients had to be enucleated, one turned blind and three had a visual acuity 5/100 to 20/60. In our hands prognosis for successful therapy in immunodeficient patients seems worse than in otherwise healthy persons. Painstaking evaluation of history, medical work-up, conjunctival swabs and application of bactericidal topical antibiotics preoperatively and perioperatively are particularly important in these patients.

A 10-year-old boy was referred to the authors three days after bimedial faden operation (posterior fixation), with a purulent endophthalmitis in his right eye and visual acuity of LP. Systemic combined antibiotics "ad hoc", including cephalosporins and amikacin, were administered in combination with immunosuppressive doses of methylprednisolone after swabs had been taken for bacteriologic workup. Nine days after admission a pars plana vitrectomy was performed. Both the conjunctival swabs and the vitreous aspirate grew coagulase-negative, gram-positive cocci with high colony counts. Traction retinal detachment developed, and 30 days after the squint surgery lensectomy and silicone oil instillation had to be performed. Visual acuity 3 months after squint surgery was RE cc 0.2.

Our records on endogenous Candida endophthalmitis in 13 eyes in 10 patients are presented. The diagnosis was confirmed by culture from vitreous aspirate or serologic examination. The records show that cases with immediate diagnosis and treatment by antimycotics and vitrectomy have a better prognosis than late diagnosis or treatment without vitrectomy. Only the 4 cases that were vitrectomized within 4 weeks after onset of the complaints resulted in good visual acuity (greater than 2/5). The other cases were often complicated by traction, retinal scars or choroidal proliferation. Unclear uveitis with a high risk for fungal infection in the patient's history should be evaluated for Candida infection. Every patient with candidemia needs periodic ophthalmologic examinations for endophthalmitis. Diagnosis, treatment and possible prevention of endogenous Candida endophthalmitis are discussed.

Our of 688 eyes with perforating injuries in 16 cases (2.33%) which were operated on in the years 1973 to 1979, a serious intraocular infection occurred. In 8.94% of the cases in which there were foreign bodies, and in 0.88% of the remaining cases, without intraocular foreign bodies, infection also occurred, although antibiotics were administered prophylactically. With intensive combined antibiotic therapy, and by performing vitrectomy as early as possible it is sometimes possible to save the bulb, and in some cases useful residual function can be achieved. The success of early results of vitrectomy in endophthalmitis recorded in the literature to date could not be obtained as late results in our cases.

This study describes the ultramicroscopic alterations in several types of intraocular lenses removed from eyes with persistent ocular inflammation or elevated intraocular pressure. In some instances the alterations found in the lens material could have caused ocular disease. The corneal edema present in eyes with intraocular lenses sometimes is related to trauma at the trauma at the time of intraocular lens implantation. In most cases the alterations are similar to those found in Fuchs' dystrophy. The presence of warts in Descemet's membrane indicate previous corneal pathology, an obvious contraindication to the use of these devices.

An early pars plana vitrectomy was performed without any additional intravitreal antimycotic therapy in 8 eyes of 5 patients with candida endophthalmitis; anatomic healing with a good functional result was obtained. The good prognosis of vitrectomy without intravitreal antimycotic therapy in our patients is seen in (1) a total surgical extraction of the abscess and (2) the better intraocular ventilation obtained for endogenous resistance.

The authors report on 14 cases of fulminant and delayed forms of endophthalmitis, in which a diagnostic and therapeutic vitrectomy, were performed. By diagnostic processing of the excised vitreous the chances of obtaining positive findings were increased, especially with a combination of bacteriological and histopathological methods. As advantages of a diagnostic and therapeutic vitrectomy versus purely antibiotic treatment in endophthalmitis the authors discuss the following factors: (1) improved diagnostic possibilities in combination with vitrectomy; (2) a reduction in the quantities of infective organisms and toxins; and (3) improved penetration of antibiotic into and out of the vitreous body cavity.

Local and systemic applications of antibiotics in cases of vitreous bacterial infections have proved insufficient because of blood-vitreous barriers. Intravitreal antibiotic injections overcome these barriers and may control the infection. Recommendations are given for intravitreal therapy with Gentamicin, combined with a pars plana vitrectomy in advanced infections.

Eight patients with chronic endogenous uveitis, chorioretinitis, toxoplasmosis and infective endophthalmitis underwent pars plana vitrectomy mainly to improve vision by clearing the media or removing membranes. Beyond this it turned out that in eyes with chronic endogenous uveitis vitrectomy might also alter or diminish the severity as well as the frequency of attacks. The role of the vitreous as an autoimmune agent is discussed.