John Wright, Bristol; pp 1-28,. 116-223. Caldareili D D, Friedberg S A & Harris A A. (1979) Otolaryngologic Clinics ofNorth America 12, 767-781. Cope V Z.
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and antibiotic therapy. If untreated or mismanged the disease can be fatal; the abscess will discharge by sinus formation and pyaemia develops with secondary abscess formation in the liver, lungs and brain. Antibody tests are often negative in cervicofacial cases, since the disease is less extensive than pelvic or thoracic actinomycosis.
vitrectomy. Ophthalmologists should be aware of this problem in a relatively fit person after major surgery when intensive antibiotic therapy has been used.
Case report A previously fit, 31-year-old teacher who had travelled extensively, contracted uveitis in February 1980 whilst in Malta, and was treated Acknowledgments: We are grateful to Dr Brian apparently successfully with a two-week course of Pigott, London WI, who referred this patient; topical steroids. A few months later, in Germany, she was and Dr G A K Missen, Department of admitted to hospital with an acute abdominal Histopathology, Guy's Hospital. illness which was diagnosed as acute pancreatitis. She had a prolonged illness during which she References developed intestinal obstruction, which on Bramley P & Orton H S (1960) British Dental Journal 109, 235 laparotomy was found to be due to an ileocaecal Brandenburg J H, Finch W W & Kirkham W R intussusception and which required extensive (1978) Otolarvngology 86, 739-742 bowel resection. Postoperatively she required Bronner M & Bronner M (1971) Actinomycosis. 2nd edn. John Wright, Bristol; pp 1-28, intravenous and oral antibiotics for an extensive 116-223 period. Her recovery was further complicated by Caldareili D D, Friedberg S A & Harris A A the spontaneous abortion of a 26-week-old fetus (1979) Otolaryngologic Clinics of North America 12, 767-781 Cope V Z for which she had dilatation and curettage, (1938) Actinomycosis. Oxford University Press; pp 58-66 unfortunately followed by endometritis. Guidry D She was very ill for several weeks but during her (1971) In: The Pathologic Anatomy of Mycoses. Ed. R D Baker et al. Springer-Verlag, Berlin etc; pp 1019-1052 she developed a second episode of recovery Hertz J posterior uveitis, of a severity to cause marked (1957) Journal of the International College of Surgeons 28, 539 visual loss and requiring treatment with topical O'Mahony J B (1966) British Dental Journal 121, 23 and systemic steroids. By September 1980 she was Thomson St C & Negus V (1955) Diseases of the Nose and Throat. 6th edn. Cassell, sufficiently well to return to England. At this time she had a posterior uveitis reducing her vision to London; pp 567-568, 932-933 6/24 in each eye. She was investigated and treated with steroids in increasing doses. However, the uveitis failed to improve and she was referred to the Medical Eye Unit at St Thomas' Hospital for further investigation. On examination she was very 'cushingoid.' The corrected visual acuity was 6/24, 6/36. There was mild bilateral anterior uveitis and dense vitreous Candida endophthalmitis presenting as cellular infiltration with snowball accumulation bilateral posterior uveitis' throughout the vitreous gel. Fundus examination was otherwise normal. Three days later a Sarah Vickers MB BS2 rhegmatogenous retinal detachment developed in Elizabeth Graham MB MRCP the left eye associated with the collapse of the David Spalton MRcP FRcs3 vitreous gel and a superotemporal horsehoe tear. Medical Eye Unit, St Thomas' Hospital, London This was treated by conventional cryotherapy and plombage without drainge of subretinal fluid, with The majority of patients with candida ophthal- anatomical success. The severe uveitis persisted and worsened mitis present with eye symptoms as a minor part of a severe systemic illness. The patient described despite intensive treatment with prednisolone in here was exceptionally unusual because her combination with azathioprine and chlorambucil. Relevant investigations for the aetiology of the ophthalmic symptoms were her only complaint uveitis included WBC 12.0 x 109/1, ESR 7 mm/h and there was no evidence of generalized and tissue type HLA A2 B5. Immunological tests in The this case was made at candidiasis. diagnosis suggested a nonspecific immune disturbance with 'Case presented to Section of Ophthalmology, 14 May a raised complement C4 (0.48 g/1). Treponemal and viral serology were negative. Sigmoidoscopy 1981. Accepted 7 June 1982 2 Present address: Moorfields Eye Hospital, London EC 1 and extensive gastrointestinal radiology were 3Present address: Charing Cross Hospital, London W6 negative and repeated blood culture revealed no 0 1 41-0768/83/030228-02/$O 1.00/0
© 1983 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 76 March 1983 229 organisms. The aetiology of the uveitis remained obscure. Her vision continued to deteriorate as a result of the increasingly dense vitreous infiltrate. In the absence of any response to treatment or apparent aetiology it was considered that diagnostic and therapeutic vitrectomy was justified. This was performed via a pars plana approach using an Ocutome, taking vitreous samples for cytology, fungal and bacterial cultures. The gram stain of the vitreous aspirate showed numerous pus cells and a strongly gram-positive yeast-like organism, exhibiting the features of both budding and germinal tube formation characteristic of Candida albicans. Cultures yielded a heavy growth of this organism. Antifungal treatment was commenced with systemic flucytosine and amphotericin B; flucytosine has good ocular penetration but resistance to this drug emerges rapidly and it has been suggested (Folard et al. 1976, Medoff et al. 1971) that these two drugs act synergistically. Postoperatively her left visual acuity improved dramatically from counting fingers to 6/12, N5, and although little improvement occurred in the right it was elected to observe this eye to see if it would improve on antifungal treatment alone. However, despite several weeks of this aggressive antifungal treatment she developed symptoms of retinal traction in the right eye, which was confirmed by ultrasound B-scan. A right vitrectomy was performed, and specimens of vitreous were taken for repeat cultures (which were sterile) and assay of the antifungal drugs. At the time of the operation an extensive macula traction detachment was found and her postoperative progress was complicated by the recurrence of preretinal membranes obscuring her right macula. She was left with a vision of counting fingers in her right eye. Discussion In 1974 Edwardes et al. reviewed 76 patients with candida endophthalmitis and drew attention to the predisposing factors common to all of the patients. The commonest aetiological factor was
the use of multiple antibiotic therapy leading to an overgrowth of candida in the gastrointestinal tract, and hence to increased risk of candidaemia. Candida can easily be cultured from the bowel of up to 50% of the normal population. A large number of the patients in this series had had recent major surgery to the gastrointestinal tract, and it may be that operative manipulation of the bowel causes candidaemia (Griffin et al. 1973). In many of the patients intravenous lines were used and candida contamination of these is well recorded (Fishman et al. 1972). Many patients were also on immunosuppressives, or had underlying diseases which suppressed their immune system. The large number of patients in this series and the comparative rarity of this condition in the UK probably reflects the American enthusiasm for the use of intravenous feeding and massive doses of antibiotics in abdominal surgery. This case highlights the use of vitreous surgery as a diagnostic tool in patients with intractable inflammatory eye disease and the importance of complete cytological and microbiological examination of the material obtained. In this case it is interesting that the left eye which underwent vitrectomy early had a good visual result, whereas the right suffered permanent damage. Cultures of vitreous material obtained from the right eye after one month of systemic antifungal treatment were sterile. Early vitreous surgery in combination with systemic antifungal therapy may be the management of choice in patients suspected of having fungal uveitis.
References Edwardes J E jr, Foos R Y, Montgomnerie Z & Gmze L R (1974) Medicine 53, 47 Fishman L S, Griffin J R, Sapico F L & Hech R (1972) New England Journal of Medicine 286, 675-681 Folard T, Beskow D, Norby R, Wahlen P & Akstigk (1976) Journal of Antimicrobial Chemotherapy 2, 239-246 Griffin J R, Petht T H, Fishman L S & Foos R Y (1973) Archives of Ophthalmology 89, 450-456 Medoff G, Comfort M & Kobayashi G S (1971) Proceedings of the Society for Experimental Biology and Medicine 138, 571-574
