VOL. 98, NO. 6
LETTERS TO THE JOURNAL
flow poorly in small capillaries, resuming in hypoxia. It is possible that the high levels of fetal hemoglobin F with its greater oxygen affinity will not relinquish its oxygen to relatively deprived retinal tissues. The thalassemia may be interact ing synergistically with an already dis eased diabetic microvasculature. REFERENCES
Fig. 2 (Perkins, Choromokos, and Raymond). Fluorescein angiogram of sea fan demonstrating leakage.
blood smear showed microcytosis, varia tion in red blood cell size, and target cells typical of thalassemia. The diagnosis of δβ-thalassemia was made based on the globin synthesis ratio of 1.88 (normal, 0.9 to 1.1). This indicated that the alpha globin chain of hemoglobin was being synthesized out of proportion to the beta and delta chains to which it pairs. Hemo globin electrophoresis showed an abnor mally high fetal hemoglobin F of 27%. Only a few cases of peripheral neovascularization without posterior pole in volvement have been reported. 2 Thalassemia is associated with proliferative retinopathy, vitreous hemorrhages, and perivascular sheathing with periph eral occlusions. 3,4 Other ocular manifesta tions include changes in color vision, visual fields, visual thresholds, retinal detachment, vitreoretinal degenerations, and thrombotic and hypertensive compli cations. 5 Sea-fan neovascularization has not been reported. Hemorrheologic studies provide in sight into the possible pathophysiology of these lesions in thalassemia. The red blood cells in patients with heterozygous ß-thalassemia have decreased flexibility.6 Perhaps, as in sickle cell disease, they
1. Welch, R., and Goldberg, M. : Sickle cell hemo globin and its relation to fundus abnormality. Arch. Ophthalmol. 75:353, 1966. 2. Muraoka, K., Kobayashi, Y., and Kitagawa, M.: Involvement of the midperipheral fundus in diabetic retinopathy. Jpn. J. Clin. Ophthalmol. 33:425, 1979. 3. Tosselli, C , Bertoni, G., Alessio, L., and Mannucci, P. M.: High incidence of thalassemia in patients with intraocular hemorrhages. Ophthalmologica 157:343, 1969. 4. Palimeris, G., Koliopoulos, J., Theodossiadis, G., and Velissaropoulos, P. : Ocular findings in hemoglobinopathies. In XXII Concilium Ophtalmologicum, Paris, 1974. Paris, Masson, 1976, vol. 1, pp. 717-722. 5. Magli, A., Fusco, R., Mettivier, V., and Pisapia, R. : Ocular manifestations in thalassemia minor. Ophthalmologica 184:139, 1982. 6. Tillman, W., and Schroter, W.: Rheological properties of erythrocytes in heterozygous and homozygous ß thalassemia. Br. J. Haematol. 43:401, 1979.
PSEUDOMONAS AERUGINOSA OPHTHALMIA NEONATORUM E L I A S I. T R A B O U L S I , M.D., I B R A H I M V. SHAMMAS, M.D., H A B I B E. R A T L , B . S C ,
AND NABIL I. JARUDI, M . D . Departments of Ophthalmology (E.I.T., I.V.S., and N.I.J.) and Pediatrics (H.E.R.), American University of Beirut Medical Center. Inquiries to Elias I. Traboulsi, M. D., American University of Beirut, Medical Center, P. O. Box 113-6044, Beirut, Lebanon.
Pseudomonas aeruginosa, a rare agent in ophthalmia neonatorum, 1 can cause a
AMERICAN JOURNAL OF OPHTHALMOLOGY
potentially blinding membranous con junctivitis in susceptible infants. 2 These are usually premature infants with a dis seminated Pseudomonas infection. Pro longed patching of the eyes is a known predisposing factor. 3 We recently witnessed an outbreak of Pseudomonas conjunctivitis in a nursery intensive care unit. Four premature in fants developed this infection within a period of two weeks. All had hyperbilirubinemia and received photothera py, during which the eyes were patched for a period of two to 13 days. In three infants the conjunctivitis developed four to ten days after discontinuation of photo therapy, and in one it developed one day before therapy. This tends to eliminate patching as a direct predisposing factor. All patients were being given systemic ampicillin and gentamicin treatment for other medical reasons when the conjunc tivitis was noted. Only the first affected infant had a P. aeruginosa pneumonia; the rest had no other foci of Pseudomonas infection. In all four cases a discharge was noted in a moderately injected eye, and treatment with gentamicin 0.3% eyedrops was immediately instituted after the appropriate smears and cultures were taken. The isolates in all four cases were sensitive only to amikacin and moxalactam and intermediately sensitive to piperacillin, using the disk sensitivity method. In three patients topical amika cin (25 mg/ml hourly) was started and in one patient only gentamicin eye ointment was applied four times per day. No sub conjunctival injections were used. In all cases marked clinical improvement was noted two to three days after initiation of treatment. Repeated cultures were nega tive in all cases after five days of therapy. Two babies received a two-week course of systemic amikacin. Altman 4 advocated the addition of sys temic antibiotics to the topical and sub conjunctival treatment of Pseudomonas conjunctivitis in the newborn; Chandler
and Rotkis 5 recommended only the latter. Subconjunctival amikacin achieves the highest intraocular levels when compared to systemic or topical administration, 6 and may be potentially useful in the treat ment or prophylaxis of Pseudomonas keratitis when the organism is resistant to other more commonly used antibiotics. Early detection and institution of therapy in our cases allowed us to avoid the use of subconjunctival injections. These are dif ficult to administer in newborns and they have unwanted local side effects. We propose the following management plan in infants suspected to have P. aeruginosa ophthalmia neonatorum: (1) prompt isolation of affected infants and strict hand washing and sterilization pre cautions; smears and cultures are taken for organism identification and antimicro bial sensitivity testing; (2) fortified antibi otic eyedrops every hour for the first three days; (3) if response is good, gradu al tapering over a period of two weeks; if there is no or poor response, subconjunc tival injections are given twice daily until cultures are negative; and (4) systemic antibiotics are reserved for patients with other foci of Pseudomonas infection. REFERENCES 1. Pierce, J. M., Ward, M. E., and Seal, D. V.: Ophthalmia neonatorum in the 1980's. Incidence, aetiology and treatment. Br. J. Ophthalmol. 66:728, 1982. 2. Cole, G. F., Davies, D. P., and Austin, D. J.: Pseudomonas ophthalmia neonatorum. A cause of blindness. Br. Med. J. 2:440, 1980. 3. Duke-Elder, S.: Pyocyaneal conjunctivitis. In System of Ophthalmology. Diseases of the Outer Eye. Conjunctiva, vol. 8, pt. 1. London, Henry Kimpton, 1965, pp. 192 and 193. 4. Altman, B.: Treatment of Pseudomonas con junctivitis in newborns. In Harley, R. D. (ed.): Pédiatrie Ophthalmology. Philadelphia, W. B. Saunders, 1983, p. 84. 5. Chandler, J. W., and Rotkis, W. M.: Ophthal mia neonatorum. In Duane, T. D., and Jaeger, E. A. (eds.): Clinical Ophthalmology. New York, Harper and Row, 1983, vol. 4, chap. 6, p. 6. 6. Eiferman, R. A., and Stagner, J. I.: Intraocular penetration of amikacin. Iris binding and bioavailability. Arch. Ophthalmol. 100:1817, 1982.