Preface

Chapter 8 **Nontuberculous Mycobacterial Keratitis 147**

Chapter 9 **Endophthalmitis: Experience from a Tertiary Eye**

Chapter 11 **Trachoma and Inclusion Conjunctivitis 231**

**Care Center 173**

**VI** Contents

Udo Ubani

Gutiérrez-Sánchez and Virginia Vanzzini-Zago

Mezaine, Yonca O. Arat and Wael Abdelghani

Chapter 10 **Eye Infection Complications in Rheumatic Diseases 213** Brygida Kwiatkowska and Maria Maślińska

Ana Lilia Pérez-Balbuena, David Arturo Ancona-Lezama, Lorena

Imtiaz A. Chaudhry, Hassan Al-Dhibi, Waleed Al-Rashed, Hani S. Al-

Since ocular infections are one of the most frequent occurrences in ophthalmology, the treat‐ ment for these infections must be fast, precise and effective. In order to address this goal, it is important to identify and characterize the culprit microorganisms involved in the patho‐ genesis of ocular infections. Clinical diagnosis of ocular infections can be confirmed by sev‐ eral techniques based on microbiological test of ocular samples. Some of these techniques include classic microbiological testing in which it is necessary to isolate microorganisms to characterize them by biochemical analysis which require significant resources and timing. Molecular biology techniques on the other hand, such as PCR, real time PCR, microarrays and aptamers (e.g. SOMAmers) can offer the results in a shorter period of time, while keep‐ ing a much higher sensitivity and specificity. Recently, mass spectrometry approach has dramatically changed the microbiological field. Some of the advantages of microbiological identification by mass spectrometry include: lack of need for culture and isolation of the mi‐ croorganisms. Further, fastidious microorganisms can be identified without lengthy wait for their growth. High sensitivity and accuracy for the microorganism identification results in a reduction of sample amount required. And resistance markers and resistance profile can be determined at the same time of identification analysis. In summary, the evolution of micro‐ biological identification methods has improved treatments that impact in the prognosis of ocular infection, reducing complications and avoiding blindness cases, and as a consequence life quality of patients will be better. In the chapter, "Diagnostics Methods in Ocular Infec‐ tions: From Microorganism Culture to Molecular Methods," Drs. Manuel, Mariana, Antonio, Luz, Carolina, Gustavo, Aurora and Herlinda, discuss current conventional methods for mi‐ croorganisms identification by the use of cultures, isolation and phenotypic characteristics along-with endpoint PCR, real-time PCR.

Infective conjunctivitis can be acute or chronic and can be caused by several bacterial and viral pathogens. Bacterial conjunctivitis is a relatively common infection and affects all peo‐ ple, although a higher incidence is seen in infants, school children and the elderly. Bacterial conjunctivitis has a higher prevalence in children, and although its incidence is continuing to decrease in developing nations, periodic rises in incidence are seen during the monsoon seasons in many countries such as Bangladesh, and thus, bacterial conjunctivitis is the most common cause of infective conjunctivitis in developing nations. In the developed world, acute infectious conjunctivitis is a common presentation in the primary care setting and many general practitioners may find it difficult to differentiate between bacterial and viral conjunctivitis. The uncertainty of the pathogenic cause of acute conjunctivitis has led to the routine practice of prescribing a broad spectrum antibiotic topically even though the patho‐ gen has not been proved to be bacterial in nature. A diagnosis of conjunctivitis is usually made on the basis of a clinical history and examination by the general practitioner since con‐

junctivitis is often a self limiting illness and the antibiotics currently used have a good spec‐ trum of pathogen coverage. Swabs and cultures may be indicated in vital situations where a correct diagnosis may be necessary to rule out more serious causes and medical emergencies that would require hospital admission. Such cases may include bacterial keratitis. Hyper‐ acute bacterial conjunctivitis is commonly seen in patients affected with N. Gonorrhoea. The onset is often rapid with an exaggerated form of conjunctival injection, chemosis and copi‐ ous purulent discharge. Prompt treatment is essential to prevent complications. Chronic bacterial conjunctivitis, ie, red eye with purulent discharge persisting for longer than a few weeks, is generally caused by Chlamydia trachomatis or may be associated with dacryocys‐ titis. Bacterial keratitis is a well known but rare complication of bacterial conjunctivitis. Her‐ pes simplex conjunctivitis is due to a viral pathogens symptoms of which may include a red eye, photophobia, eye pain and mucoid discharge. Herpes zoster ophthalmicus causes shin‐ gles of the opthalmic branch of the trigeminal nerve, which innervates the cornea and the tip of the nose. It begins with unilateral neuralgia, followed by a vesicular rash in the distribu‐ tion of nerve. Once spread to the eye, it may lead to an extremely painful conjunctivitis. Ne‐ onatal Conjunctivitis also known as ophthalmia neonatorum is inflammation of the conjunctiva occurring in the first month of life and is caused by a number of different patho‐ gens that may include bacteria, viruses and chemical agents. In recent times prophylaxis has led to decreased morbidity in the developed world. In their chapter, "Infective Conjunctivi‐ tis - its Pathogenesis, Management and Complications," Drs. Haq, Wardak and Kraskian de‐ scribe various causes of infectious conjunctivitis along with its treatment modalities. The authors emphasize that the general practitioners must remain vigilant when diagnosing vi‐ ral from bacterial conjunctivitis and try to ensure that patient education of the condition is at an optimum level to prevent spread.

Treatment of infectious and allergic conjunctivitis can be challenging because of the diverse infectious agents and immunological mechanisms which can result in the damage of the oc‐ ular surface causing significant visual disability. Currently, a wide range of antibiotic and antiallergic topical medications are available and can be confusing due to lack of improve‐ ment at the ocular surface in terms of avoiding anatomical changes in severe cases and con‐ trol of symptoms in the long run. In the chapter, "Treatments in Infectious and Allergic Conjunctivitis: Is Immunomodulation the Future?," Drs. Santacruz, Perez-Tapia, Nava, Es‐ trada-Parra and Jimenez-Martinez, investigate the novel and developing therapies, with special emphasis in immunomodulatory drugs/molecules that could have clinical indication in the treatment of infectious and allergic conjunctivitis in future.

Both the bacterial and fungal keratitis as well as corneal ulceration may be vision threaten‐ ing ocular condition requiring prompt and accurate diagnosis and early medical interven‐ tion to obtain a reasonable outcome. Since keratitis caused by Gram negative bacteria and some fungal pathogens may clinically seem very similar by signs and symptoms, the help which the microbiology service can provide in the differentiation of two entities may be very crucial. Obviously the treatment required by these causative agents require different drugs. Keratitis caused by Gram positive bacteria and yeast like fungus may be too similar in inflammatory signs, however in this cases one smear can make the difference. In Neisse‐ ria gonohorroae keratitis, delayed laboratory confirmation of the correct diagnosis may car‐ ry a high risk because of the corneal tissue loss since keratitis due to these organisms may not respond well to the commonly applied empirical antibiotics. Other options for detection of yeast or filamentous fungi in corneal samples are PCR techniques especially in cases of previous antibiotics or antifungal therapy and despite having negative cultures. High- reso‐ lution melting technique can detect and differentiate yeast and filamentous fungi in kerato‐ mycose samples in a more simple, specific and cost- efficient methods. It is very important for the best prognosis in keratitis cases, to confirm the clinical diagnosis by the laboratory work since the first consultation, for to start immediately the specific medical topical treat‐ ment. For all those reasons the laboratory support in the clinical diagnosis of keratitis is very important in order to achieve a shorter evaluation time and to avoid any corneal scarring resulting in a reasonable visual prognosis in patients suffering from any infectious keratitis. In their chapter, "Laboratory in the Diagnosis of Bacterial and Fungal Keratitis," Drs. Zago and Perez-Balbuena discuss the role of laboratory in the diagnosis of infectious keratitis.

junctivitis is often a self limiting illness and the antibiotics currently used have a good spec‐ trum of pathogen coverage. Swabs and cultures may be indicated in vital situations where a correct diagnosis may be necessary to rule out more serious causes and medical emergencies that would require hospital admission. Such cases may include bacterial keratitis. Hyper‐ acute bacterial conjunctivitis is commonly seen in patients affected with N. Gonorrhoea. The onset is often rapid with an exaggerated form of conjunctival injection, chemosis and copi‐ ous purulent discharge. Prompt treatment is essential to prevent complications. Chronic bacterial conjunctivitis, ie, red eye with purulent discharge persisting for longer than a few weeks, is generally caused by Chlamydia trachomatis or may be associated with dacryocys‐ titis. Bacterial keratitis is a well known but rare complication of bacterial conjunctivitis. Her‐ pes simplex conjunctivitis is due to a viral pathogens symptoms of which may include a red eye, photophobia, eye pain and mucoid discharge. Herpes zoster ophthalmicus causes shin‐ gles of the opthalmic branch of the trigeminal nerve, which innervates the cornea and the tip of the nose. It begins with unilateral neuralgia, followed by a vesicular rash in the distribu‐ tion of nerve. Once spread to the eye, it may lead to an extremely painful conjunctivitis. Ne‐ onatal Conjunctivitis also known as ophthalmia neonatorum is inflammation of the conjunctiva occurring in the first month of life and is caused by a number of different patho‐ gens that may include bacteria, viruses and chemical agents. In recent times prophylaxis has led to decreased morbidity in the developed world. In their chapter, "Infective Conjunctivi‐ tis - its Pathogenesis, Management and Complications," Drs. Haq, Wardak and Kraskian de‐ scribe various causes of infectious conjunctivitis along with its treatment modalities. The authors emphasize that the general practitioners must remain vigilant when diagnosing vi‐ ral from bacterial conjunctivitis and try to ensure that patient education of the condition is at

Treatment of infectious and allergic conjunctivitis can be challenging because of the diverse infectious agents and immunological mechanisms which can result in the damage of the oc‐ ular surface causing significant visual disability. Currently, a wide range of antibiotic and antiallergic topical medications are available and can be confusing due to lack of improve‐ ment at the ocular surface in terms of avoiding anatomical changes in severe cases and con‐ trol of symptoms in the long run. In the chapter, "Treatments in Infectious and Allergic Conjunctivitis: Is Immunomodulation the Future?," Drs. Santacruz, Perez-Tapia, Nava, Es‐ trada-Parra and Jimenez-Martinez, investigate the novel and developing therapies, with special emphasis in immunomodulatory drugs/molecules that could have clinical indication

Both the bacterial and fungal keratitis as well as corneal ulceration may be vision threaten‐ ing ocular condition requiring prompt and accurate diagnosis and early medical interven‐ tion to obtain a reasonable outcome. Since keratitis caused by Gram negative bacteria and some fungal pathogens may clinically seem very similar by signs and symptoms, the help which the microbiology service can provide in the differentiation of two entities may be very crucial. Obviously the treatment required by these causative agents require different drugs. Keratitis caused by Gram positive bacteria and yeast like fungus may be too similar in inflammatory signs, however in this cases one smear can make the difference. In Neisse‐ ria gonohorroae keratitis, delayed laboratory confirmation of the correct diagnosis may car‐ ry a high risk because of the corneal tissue loss since keratitis due to these organisms may not respond well to the commonly applied empirical antibiotics. Other options for detection of yeast or filamentous fungi in corneal samples are PCR techniques especially in cases of

in the treatment of infectious and allergic conjunctivitis in future.

an optimum level to prevent spread.

VIII Preface

Microbial keratitis can be a very serious infection that can result in significant visual disability around the world with estimates ranging from 11 cases to almost 800 per 100,000 persons depending on the country and geography. Wide geographical variation exists in the epidemi‐ ology of microbial keratitis based on economic and climatic factors. Almost any microorgan‐ ism can invade the corneal stroma if the normal corneal defense mechanisms are compromised. A wide spectrum of microbial organisms can produce corneal infections and, consequently, the therapeutic strategies adopted for its treatment may be varied. Several po‐ tential risk factors such as contact lenses, trauma, aqueous tear deficiencies, neurotrophic ker‐ atopathy, eyelid alterations or malposition, decreased immunologic defenses, use of topical corticoid medications and surgery may cause the development of bacterial keratitis. Trauma is a major risk factor for corneal infection in developing countries and the main risk factor for bacterial keratitis in developed countries is the use of contact lenses, particularly extendedwear contact lenses. In the chapter, "Bacterial Keratitis Infection: A Battle between Virulence Factors and the Immune Response,"Drs. Robles-Contreras, Perez-Cano, Babayan-Sosa and Baca-Lozada provide an extensive review of the most common corneal bacterial infections that cause the diseases along with the involvement of the immune system and its regulatory mechanisms which prevent tissue damage. The authors discuss bacterial virulence factors which help the microorganism in evading the host defense mechanisms. There are several clinical features which can be observed in setting of infections due to bacterial keratitis as a result of their unique immunological mechanisms which are evident at the ocular surface when observed carefully. The chapter also focusses on the regulatory defense mechanisms which the host utilizes to minimize the damage caused by the bacterial pathogens.

In the chapter, "Preseptal Cellulitis," Drs. Fida, Kocinaj, Abazi and Grezda, discuss infec‐ tions of the periorbital area anterior to the septum also called preseptal cellulitis. This is a common infection which tends to be a less severe disease than orbital cellulitis. Preseptal cellulitis can result from the spread of the upper respiratory tract infection, external eye in‐ fection or eyelid trauma. Patients with preseptal cellulitis present with acute eyelid erythe‐ ma and edema along with pain in the absence of any obvious proptosis. The diagnosis is usually made based upon the clinical findings, microbiological and radiological examina‐ tion. The most common microorganisms causing preseptal cellulitis are Staphylococcus aur‐ eus, Staphylococcus epidermidis, Streptococcus species, and anaerobes, known organisms that commonly cause upper respiratory tract infections and external eyelid infections. Cold weather and upper respiratory tract infections are sometimes correlated with increased fre‐ quency of sinusitis. Untreated preseptal cellulitis can lead to orbital cellulitis which can be a serious infection especially in children and can result in significant complications including blindness, cavernous sinus thrombosis, meningitis, subdural empyema, and intracranial ab‐

scess. The correct treatment of the preseptal cellulitis during the antibiotic era makes these complications less likely but the correct diagnoses and early treatment is important to pre‐ vent the life threatening complications. The authors emphasize on the difficulty in distin‐ guishing preseptal cellulitis from orbital cellulitis based just on clinical findings especially in children. In such cases, imaging studies may be helpful in delineating preseptal cellulitis from orbital cellulitis. Antibiotics may be necessary to treat prespetal cellulitis and in certain cases, eyelid abscesses may need to be drained surgically with the incision and drainage while avoiding damage to the critical structures.

Patients with orbital cellulitis may present with swelling of the eyelids, pain, proptosis, con‐ junctival chemosis, limitation of eye movements and decreased vision. In most patients, the most common predisposing factor for such infection is sinus disease, particularly in the younger age group. Despite advances in diagnosis and in anti-microbial therapy and mod‐ ern surgical techniques, complications from orbital cellulitis can result. After sinusitis, peri‐ ocular trauma and history of ocular or periocular surgery are the most common cause of orbital cellulitis. Less common causes of orbital cellulitis include dacryocystitis, dental infec‐ tion, endophthalmitis and retained orbital foreign bodies. Meningitis and death may be the most feared complication of untreated or undertreated orbital cellulitis. Imaging studies can influence the initial therapeutic plan by demonstrating the size and the location of the ab‐ scess. Commonly reported bacteria from the abscesses of the infected orbit may include S. aureus, S. epidermidis, Streptococci, Diphtheroids, H. influenza, E. Coli, multiple species in‐ cluding aerobes and anaerobes. Intravenous antibiotics are usually started once the diagno‐ sis of orbital cellulitis is suspected. Broad-spectrum antibiotics that cover most gram positive and gram negative bacteria are selected initially. In addition to starting intravenous antibiot‐ ics, emergent drainage of the orbital abscess has been suggested in patients with compro‐ mised vision regardless of patient age. Timely drainage has been recommended for large abscesses, for extensive superior or inferior orbital abscesses, for patients with intracranial complications, for infections of known dental origin in which anaerobes might be expected. In the chapter, "Diagnosis and Management of Orbital Cellulitis," Drs. Chaudhry, Al-Rash‐ ed, Al-Sheikh and Arat, emphasize on an individualized therapeutic approach which re‐ quires clinician to carefully follow patients with orbital cellulitis and expected abscess. They recommend surgical option when improvement does not occur as expected based on medi‐ cal treatment. Surgical treatment may be indicated for significant underlying sinus disease, orbital or subperiosteal abscess or both in the younger age group when no improvement occurs as expected. In the adults, sinus surgery remains the most common surgical interven‐ tion when there is no improvement with initial systemic antibiotics. The authors mention that the mechanism for loss of vision in orbital cellulitis may involve optic neuritis, ische‐ mia, or compressive effects. Cavernous sinus thrombosis represents the most severe form of postseptal cellulitis which may be suspected clinically by bilateral disease with ophthalmo‐ plegia and loss of vision. Proper management of these patients may include a multidiscipli‐ nary team that may include an orbital surgeon, otolaryngologists, neurosurgeon, and infectious disease expert.

Non-Tuberculosis Mycobacteria (NTM), also called "Atypical Mycobacteria" are ubiquitous in soil and water and have been found as normal flora of skin, sputum, and gastric contents. These bacteria are resistant to common disinfectants such as chlorine, formaldehyde and glutaraldehyde. NTM-caused keratitis is rare, having devastating complications along with a diagnostic and therapeutic challenge. Infectious keratitis due to NTM have been reported

in several isolated cases as well as in outbreaks. NTM can cause infections of all adnexal and ocular tissues including cornea, iris, lens, retina, choroid and optic nerve. Refractive as well as therapeutic surgical procedures such as LASIK, LASEK, PRK and PKP constitute a risk factor for infection by these organisms. Several factors may contribute to the development of NTM keratitis following corneal procedures. Mycobacterium chelonei, M. abscessus, M. for‐ tuitum, M. szulgai, and M. mucogenicum have been reported usually as the result of im‐ proper asepsis. Most NTM infections are caused by M. chelonae and M. fortuitum, belong to the rapid growers group. NTM keratitis can often be mistaken with other bacterial infections that cause non-suppurative keratitis having similar clinical features. In such situations, dif‐ ferential diagnosis include, fungal keratitis, infectious crystalline keratopathy, Nocardia ker‐ atitis, herpes simplex virus, and rarely Acanthamoeba keratitis. The principal differential diagnosis must be made between fungal and Nocardia keratitis. Keratitis caused by atypical Mycobacteria is characterized by an indolent course and poor response to antibiotics. The diagnosis requires a high index of suspicion since the early diagnosis of NTM may not be an easy one because the overlying, un-involved corneal stroma may hinder obtaining of suffi‐ cient material for culture. Further, such organisms can only be detectable by culture on spe‐ cial media such as Lowenstein-Jensen, and be identified by special stains like Ziehl-Neelsen. In the chapter, "Nontuberculous Mycobacterial Keratitis," Drs. Pérez-Balbuena, Ancona-Le‐ zama and Gutiérrez-Sánchez, focus on keratitis caused by NTM, since a great number of recent clinical reports of NTM ocular infections in the form of keratitis have been reported. The authors describe their 10 years of clinical experience in the diagnosis and treatment of NTM keratitis from México. They substantiate their experience by providing a descriptive retrospective case series of five patients with NTM keratitis treated in their service. Almost all cases of their NTM keratitis had a previous history of surgery, specifically LASIK and PKP. The average age of their patients was of 36.6 years with a range from 12 to 58 years. The average time that took from the onset of symptoms to the establishment of correct diag‐ nosis was over 4 weeks. Antibiotic resistance continues to be an emerging problem in the treatment of NTM keratitis. The authors emphasize the need for vigilance in the follow-up of patients having infectious keratitis. Appropriate adjustment of antimicrobial therapy may be required based on cultures and sensitivity tests when NTM are responsible for keratitis. The authors believe that fourth-generation fluoroquinolones combined with first-line antibi‐ otics constitute the best option to treat NTM keratitis.

scess. The correct treatment of the preseptal cellulitis during the antibiotic era makes these complications less likely but the correct diagnoses and early treatment is important to pre‐ vent the life threatening complications. The authors emphasize on the difficulty in distin‐ guishing preseptal cellulitis from orbital cellulitis based just on clinical findings especially in children. In such cases, imaging studies may be helpful in delineating preseptal cellulitis from orbital cellulitis. Antibiotics may be necessary to treat prespetal cellulitis and in certain cases, eyelid abscesses may need to be drained surgically with the incision and drainage

Patients with orbital cellulitis may present with swelling of the eyelids, pain, proptosis, con‐ junctival chemosis, limitation of eye movements and decreased vision. In most patients, the most common predisposing factor for such infection is sinus disease, particularly in the younger age group. Despite advances in diagnosis and in anti-microbial therapy and mod‐ ern surgical techniques, complications from orbital cellulitis can result. After sinusitis, peri‐ ocular trauma and history of ocular or periocular surgery are the most common cause of orbital cellulitis. Less common causes of orbital cellulitis include dacryocystitis, dental infec‐ tion, endophthalmitis and retained orbital foreign bodies. Meningitis and death may be the most feared complication of untreated or undertreated orbital cellulitis. Imaging studies can influence the initial therapeutic plan by demonstrating the size and the location of the ab‐ scess. Commonly reported bacteria from the abscesses of the infected orbit may include S. aureus, S. epidermidis, Streptococci, Diphtheroids, H. influenza, E. Coli, multiple species in‐ cluding aerobes and anaerobes. Intravenous antibiotics are usually started once the diagno‐ sis of orbital cellulitis is suspected. Broad-spectrum antibiotics that cover most gram positive and gram negative bacteria are selected initially. In addition to starting intravenous antibiot‐ ics, emergent drainage of the orbital abscess has been suggested in patients with compro‐ mised vision regardless of patient age. Timely drainage has been recommended for large abscesses, for extensive superior or inferior orbital abscesses, for patients with intracranial complications, for infections of known dental origin in which anaerobes might be expected. In the chapter, "Diagnosis and Management of Orbital Cellulitis," Drs. Chaudhry, Al-Rash‐ ed, Al-Sheikh and Arat, emphasize on an individualized therapeutic approach which re‐ quires clinician to carefully follow patients with orbital cellulitis and expected abscess. They recommend surgical option when improvement does not occur as expected based on medi‐ cal treatment. Surgical treatment may be indicated for significant underlying sinus disease, orbital or subperiosteal abscess or both in the younger age group when no improvement occurs as expected. In the adults, sinus surgery remains the most common surgical interven‐ tion when there is no improvement with initial systemic antibiotics. The authors mention that the mechanism for loss of vision in orbital cellulitis may involve optic neuritis, ische‐ mia, or compressive effects. Cavernous sinus thrombosis represents the most severe form of postseptal cellulitis which may be suspected clinically by bilateral disease with ophthalmo‐ plegia and loss of vision. Proper management of these patients may include a multidiscipli‐ nary team that may include an orbital surgeon, otolaryngologists, neurosurgeon, and

Non-Tuberculosis Mycobacteria (NTM), also called "Atypical Mycobacteria" are ubiquitous in soil and water and have been found as normal flora of skin, sputum, and gastric contents. These bacteria are resistant to common disinfectants such as chlorine, formaldehyde and glutaraldehyde. NTM-caused keratitis is rare, having devastating complications along with a diagnostic and therapeutic challenge. Infectious keratitis due to NTM have been reported

while avoiding damage to the critical structures.

X Preface

infectious disease expert.

Endophthalmitis is one of the most feared ocular infection which may have potential to cause visual, cosmetic and even serious life threatening complications if not diagnosed and treated on a timely basis. Description of epidemiology of endophthalmitis, its diagnosis, management and study of its complications may help in the prognostic evaluation of pa‐ tients presenting to a clinician. Endophthalmitis is a vital ocular emergency in which most of the patients present with complaints of decreased vision, photophobia, pain or ophthalmo‐ plegia. Any of the clinical features such as decreased visual acuity, chemosis, external oph‐ thalmoplegia, along with radiological evidence of endophthalmitis may require prompt action. Factors responsible for endophthalmitis which may affect the outcome include, dem‐ ographic such as age, gender, recent and past medical or surgical history and any underly‐ ing conditions which might have contributed to the onset of endophthalmitis. In particular, presence of diabetes, cardiac disease, renal disease, organ transplantation, immunodeficien‐ cy status and malignancy may enhance chances of having endogenous endophthalmitis. Other risk factors for endophthalmitis include, a recent ocular surgery, trauma, a recent den‐ tal procedure, intravenous drug administration, intravenous catheters or indwelling devi‐

ces. Endophthalmitis is a complex disease and can be caused by a large number of bacterial species, requiring a rapid identification of the causative organism along with the primary infected site. In some cases, the culture of the vitreous samples may not grow any bacteria probably due to the effect of prior antibiotics, nevertheless vitreous biopsy should be consid‐ ered because a culture of the vitreous sample is more often useful for identifying the respon‐ sible bacteria. Visual prognosis of patients with endophthalmitis depends mainly on the underlying microorganisms, which is particularly poor in cases of infection with Gram-posi‐ tive bacteria or Aspergillus species. There is a trend toward early vitrectomy because of the advancement of vitreous surgery. While the roles of intra-vitreal antibiotics and vitrectomy are evolving and may become more widely accepted as therapeutic modalities in some cases of endogenous endophthalmitis, early antibiotic therapy remains the cornerstone of treat‐ ment. In the chapter, "Endophthalmitis: Experience from a Tertiary Eye Care Center," Drs. Chaudhry, Al-Dhibi, Al-Rashed, Al-Mezaine, Arat and Abdelghani, describe their expert opinion of diagnosing and treating endophthalmitis from different causes.

Rheumatoid arthritis is an autoimmune connective tissue disease that manifests itself mostly with symmetrical swelling of the joints characterized by the inflammation of the connective tissue, usually of autoimmunological origin. Although most of the symptoms of the rheu‐ matic diseases concern primarily musculoskeletal system, in many of these disorders patho‐ logical changes take also place in various other organs including the eye. Ocular adenxa and the eye may be affected secondary to vascular changes occurring in the course of the pri‐ mary inflammation or may be the result of complications arising from the therapy of the rheumatic disease. The rheumatoid arthritis and spondyloarthropathies are the most com‐ mon inflammatory rheumatic diseases. Significantly less frequently juvenile idiopathic ar‐ thritis, Sjögren's syndrome, systemic lupus erythematosus and other less frequent connective tissue diseases as scleroderma, dermato-and polymiositis, recurrent inflamma‐ tion of the cartilage and systemic vasculitis are observed. Patients with different autoim‐ mune disorders may present with conjunctivitis, episcleritis, scleritis, keratitis and uveitis. Impaired secretion of tears occur in all patients with Sjögren's syndrome - either in the initial or more advanced stages of the disease - and constitute one of to the diagnostic criteria. Treatment is based on the use of both symptomatic drugs - moistening eyes and mouth and of immunosuppressants. Patients with scleroderma may develop secondary Sjorgren's syndrome and symptoms of dry eye. In the course of systemic vasculitis such as polyarteri‐ tis nodosa, Churga-Strauss syndrome, Wegener's granulomatosis, Behçet's disease, Takaya‐ su disease, giant cell arteritis and Cogan syndrome there are changes in the eye and ocular adenxa may occur due to vascular changes. The ocular changes in the course of inflamma‐ tion of the large vessels, such as giant cell arteritis, are mainly associated with ischemia of optic nerve or retina. The treatment of all systemic vasculitis requires aggressive immuno‐ suppressive therapy and high doses of glucocorticoids. Chronic glucocortycoid therapy of‐ ten leads to cataracts, and glaucoma. In the course of the infection with Chlamydia trachomatis, chronic conjunctivitis may occur in some patients. Clinical symptoms of chla‐ mydial conjunctivitis in reactive arthritis are characterized by moderate redness of an eye, tearing, photophobia and decreased vision. Bacterial keratitis in rheumatic diseases often is a complicated by erosive lesions of the cornea most commonly associated with primary and secondary Sjögren's syndrome. In recent days, many biological drugs have proved effective in the treatment of ocular manifestations of many rheumatic diseases and the exclusion of potential infection is particularly important for the choice of treatment and safety of therapy. In their chapter, "Eye Infection Complications in Rheumatic Diseases," Drs. Kwiatkowska

and Maślińska discuss kinds of eye and adnexal complications as a result of various rheu‐ matological disorders.

ces. Endophthalmitis is a complex disease and can be caused by a large number of bacterial species, requiring a rapid identification of the causative organism along with the primary infected site. In some cases, the culture of the vitreous samples may not grow any bacteria probably due to the effect of prior antibiotics, nevertheless vitreous biopsy should be consid‐ ered because a culture of the vitreous sample is more often useful for identifying the respon‐ sible bacteria. Visual prognosis of patients with endophthalmitis depends mainly on the underlying microorganisms, which is particularly poor in cases of infection with Gram-posi‐ tive bacteria or Aspergillus species. There is a trend toward early vitrectomy because of the advancement of vitreous surgery. While the roles of intra-vitreal antibiotics and vitrectomy are evolving and may become more widely accepted as therapeutic modalities in some cases of endogenous endophthalmitis, early antibiotic therapy remains the cornerstone of treat‐ ment. In the chapter, "Endophthalmitis: Experience from a Tertiary Eye Care Center," Drs. Chaudhry, Al-Dhibi, Al-Rashed, Al-Mezaine, Arat and Abdelghani, describe their expert

Rheumatoid arthritis is an autoimmune connective tissue disease that manifests itself mostly with symmetrical swelling of the joints characterized by the inflammation of the connective tissue, usually of autoimmunological origin. Although most of the symptoms of the rheu‐ matic diseases concern primarily musculoskeletal system, in many of these disorders patho‐ logical changes take also place in various other organs including the eye. Ocular adenxa and the eye may be affected secondary to vascular changes occurring in the course of the pri‐ mary inflammation or may be the result of complications arising from the therapy of the rheumatic disease. The rheumatoid arthritis and spondyloarthropathies are the most com‐ mon inflammatory rheumatic diseases. Significantly less frequently juvenile idiopathic ar‐ thritis, Sjögren's syndrome, systemic lupus erythematosus and other less frequent connective tissue diseases as scleroderma, dermato-and polymiositis, recurrent inflamma‐ tion of the cartilage and systemic vasculitis are observed. Patients with different autoim‐ mune disorders may present with conjunctivitis, episcleritis, scleritis, keratitis and uveitis. Impaired secretion of tears occur in all patients with Sjögren's syndrome - either in the initial or more advanced stages of the disease - and constitute one of to the diagnostic criteria. Treatment is based on the use of both symptomatic drugs - moistening eyes and mouth and of immunosuppressants. Patients with scleroderma may develop secondary Sjorgren's syndrome and symptoms of dry eye. In the course of systemic vasculitis such as polyarteri‐ tis nodosa, Churga-Strauss syndrome, Wegener's granulomatosis, Behçet's disease, Takaya‐ su disease, giant cell arteritis and Cogan syndrome there are changes in the eye and ocular adenxa may occur due to vascular changes. The ocular changes in the course of inflamma‐ tion of the large vessels, such as giant cell arteritis, are mainly associated with ischemia of optic nerve or retina. The treatment of all systemic vasculitis requires aggressive immuno‐ suppressive therapy and high doses of glucocorticoids. Chronic glucocortycoid therapy of‐ ten leads to cataracts, and glaucoma. In the course of the infection with Chlamydia trachomatis, chronic conjunctivitis may occur in some patients. Clinical symptoms of chla‐ mydial conjunctivitis in reactive arthritis are characterized by moderate redness of an eye, tearing, photophobia and decreased vision. Bacterial keratitis in rheumatic diseases often is a complicated by erosive lesions of the cornea most commonly associated with primary and secondary Sjögren's syndrome. In recent days, many biological drugs have proved effective in the treatment of ocular manifestations of many rheumatic diseases and the exclusion of potential infection is particularly important for the choice of treatment and safety of therapy. In their chapter, "Eye Infection Complications in Rheumatic Diseases," Drs. Kwiatkowska

opinion of diagnosing and treating endophthalmitis from different causes.

XII Preface

Trachoma is the leading infectious cause of preventable blindness in the world which is dis‐ tributed primarily in tropical developing countries including North and sub-Saharan Africa, the Middle East, and the Northern Indian subcontinent. The infection is caused by Chlamy‐ dia trachomatis, an obligate intracellular parasite. Children and young women of childbear‐ ing age in the low socioeconomic status in areas of poor hygiene are considered to be the primary source of recurrent infections by C. trachomatis. Trachoma has been classified by WHO into 5 classes depending on the severity of the infection. For example in the active stage of the disease (TF), only follicles can be seen in the tarsal conjunctiva, in the trachoma‐ tous inflammation (TI), pronounce inflammatory thickening of upper tarsal conjunctiva can be noticed, in the trachomtous scarring (TS), scarring of the tarsal conjunctiva in the form of white band can be noticed, in the trachomatous trichiasis (TT), eye lashes rub the eyeball and in the corneal opacity (CO) stage, one can easily see a visible corneal scar. A presump‐ tive diagnosis of trachoma can be made based on clinical features, especially in an area where trachoma is considered to be present. The World Health Assembly has resolved to eliminate blinding trachoma by the year 2020. To this, the Global Alliance for the Elimina‐ tion of Blinding Trachoma (GET2020) was formed in 1998. Control activities focus on the implementation of the SAFE strategy, surgery for trichiasis, antibiotics for infection, facial cleanliness (hygiene promotion) and environmental improvements, to reduce transmission of the organism. Each of these components tackles the pathway to blindness at different stages. Antibiotics for treatment of active trachoma may be given locally or systematically, but topical treatment is preferred because: It is cheaper, there is no risk of systemic side-ef‐ fects, and Local antibiotics are also effective against bacterial conjunctivitis which may be associated with trachoma. Transmission of trachoma is closely associated with personal hy‐ giene and environmental sanitation. In the chapter, "Trachoma and Inclusion Conjunctivi‐ tis," the authors nicely outline detailed clinical features, diagnostic strategies with available testing and the effectiveness of the current treatment strategies in the management of tra‐ choma.

#### **Imtiaz A. Chaudhry, MD PhD FACS**

Houston Oculoplastics Associates Memorial Hermann Medical Plaza Texas Medical Center Houston, Texas, United States of America
