Infection and inflammation - URGENT

[Nerka]

Hi, my hubby had penetrating injury to the right eye on 5th of october 2007. He almost lost his vision completaly in that eye.The doctors stitched the wound and sent him home for 5 days. Everything went well and his vision although blurred was fine otherwise. He was on systemic antibiotics and drops antibiotics,dilating drops and steroids drops for 5 days and had check up. The doctors said that there is still some inflammation inside the eye and continued with the steroids drops for next 4 days. When my husband stopped them as adviced, he developed severe pain in the eye and half of the head. He went to A&E and after 2 hours of agony they relieved pain with steroids injections in the white of the eye. They have given him some more drops and asked to come in 3 days time. His vision afterwards really deteriorated and when he came back for check up, they got him straight into the theater to take some biopsy from the inside of the eye and had given him 2 types of broad spectrum antibiotics and antifungals injections into the eye.They kept him in hospital and it has been 12 days since that day and he is still there. Over that time they have grown bacteria -Coagulase negative staphylococcus. They said its slowly growing one and is scanty. They were giving him loads of antibiotics and steroids (prednisolone 80mg for the first 4 days).Than they decided to stop the steroids suddenly as the eye become better, and over night my hybby's eye become painfull and more inflammed. They decided to do vitrectomy (3days ago) and they have also taken another biopsy and gave him more antibiotics into the eye (they already had sensitivity test and knew what exactly can kill it - they mentioned that the antibiotics were right from the very beginning anyway).His vision is really poor now and one day better and another worse- he only see colours and enough to walk around and not kill himself. He is back on steroids (60mg for 3 days, than they want to reduce to 40mg 3/7, 30mg 3/7, 20mg 3/7, and 15mg 3/7.I am worried that this inflammation will never go away, and if the treatment is right so why there is still so much inflammation in the eye? How do you know if all bacteria are killed? They have grown the same bacteria from the second biopsy. How much chance he has got to get his vision back to at least 80%, he used to be 20/20 before the accident.  Was the decision right to stop steroids so quickly? I know they can have serious side effects.Do you have any suggestions how to stop the inflammation? I am trying to get some supplements like blueberry extracts and vit.c etc. How long after vitrectomy you can expect some improvement?
Sorry for such a long letter but i thought that the more informations i can give you the better for you. This is really urgent, please for quick respond, ideally on my email if possible.
LONDON, UK

[John C Hagan III, MD, FACS, FAAO]

Your husband has a severe problem that is vision threatening. It seems to change frequently. It seems the main problems are infection and severe inflammation. I have no idea why they changed medication. That is not something we can determine in this forum.

In our practice (and if it were me) I would ask to be checked daily until things were stable. I would not wait till Wednesday to be rechecked.  I would try to see the Eye MD TODAY.

JCH III MD

[Nerka]

Hi, thanks for all your answers so far. My husband was sent home yesterday (Thursday 1/11) becouse his eye become better for last 2 days. In the morning IOP was 17, lens clear, clear cornea,and his vision improved on wednesday, and yesterday morning he could even see 2nd line of letters from the top from 6 metres.The eye was comfortable.
On Tue 30/10 he was still on many medications: Prednisolone tbl 30mg, Dexomethasone 0.1 % drops every 2 hours, Ofloxacin drops 4xday, Doxycycline 100mg tbl.1xday, Moxifloxacin 400mg tbl 1xday.
Yesterday 1/11 when he came back home he was very excited that his vision improved and maybe is not as bad as it looked. But in the evening his vision become worse and again he cannot see anything, only light, colours and some movements. What worries me is that his medications were changed dramatically: Prednisolone tbl. 20mg for the next 5 days, Maxitrol drops 4xday, Mydrilate 0.5 % drops (cyclopentolate hydrochloride), Ranitidine tbl 3xday.
The doctors on sending him home said that his vision maybe up and down so he shouldnt worry and he needs to come back next wednesday.But we dont know what to think, his eye is not comfortable and although he was given some pain killers to take home we still worry that maybe something wrong is going on. What do you think? Is it normal to have that amount of change in vision within few hours? Why did they change so much medications when things just started to looking up. Should we go to the doctors as soon as possible or should we wait until wednesday?  
Thanks in advanced.

[John C Hagan]

Ciliary body detachment and cilo-choroidal detachment are the same thing. The ciliary body is the focus muscle of the eye but it also produces the aqueous that fills the front of the eye and creates normal intraocular pressure. If there is blood or fluid or inflammation in the middle part of the eye (uveal tract) it can pull the ciliary body away from its normal position. When that happens the IOP of the eye drops (as in your friend). It will often reattach without treatment with time or steroids. If it doesn't reattach then a surgical procedure is usually done to drain the blood or fluid out of the middle part of the eye. That the IOP is going up indicates the ciliary body is starting to produce some fluid.

JCH III MD

[Nerka]

Hi its me again. Just wanted to ask about something else. My hubby is still in hospital and he developed very low IOP - 4mmHg. He experienced pain and dyscomfort and his vision really deteriorated. That was about 5 days ago but i didnt know until yesterday when i had a chance to read his medical notes. The IOP started to pick up every day and today is 13mmHg. His vision starting to improve today and he started to see his fingers but says he also see a lot of floaters. They also did some scans incl. ultrasound biomicroscopy and found out cilliary body detachment. What does it mean? Is it the same as ciliochoroidal detachment?  Is it something to worry about? We are waiting for the consultant to come to talk to us about that but they are not explaining enough, if anything really.There is still inflammation iside the eye, but his steroids tablets has been reduced to 20mg, and prednisolone drops every 2 hours. What do you think?
Thanks in advance.

[John C Hagan]

Removing the eye is not likely. My concern is how much sight it will have. The infection and inflammation will eventually stop but again what is left of the vision is another story.

With all these things the sooner the eye is closed the better, after closing the eye generally it would need to be seen the next day and every few days thereafter. If there is an possibility of an infection generally I would see the patient every day. That's about all I can say.

JCH III MD

[Nerka]

Thanks for your answer, do you think they will have to take his eye out ? Is this possible that they will not be able to stop the inflammation/infection? Could delay in the treatment have a serious effect on the complications? After his accident (05/10/2007 at 1pm) he had to wait in the hospital until the next day (10am) to have his repairing surgery becouse there wasnt any anaesthetist to do GA. He refused to stay although he had been offered money to stay but he had other commitments ?!? I am now very upset that there maybe some doctors fault in that. On A&E it was eye specialist who saw him as that was the eye hospital (apparently one of the best in London). I am Dental Hygienist and Therapist and have some medical knowledge. I do understand that doctors will always try to cover for the other one but this is my husband's health on the hand and would like to know what is your honest opinion please.
Thanks in advance.

[John C Hagan III, MD, FACS, FAAO]

Hello Nerka,  I can only give you some generalizations about cases similiar to your husband. The prognosis is very poor to recover good vision. An infection in the eye "enophthalmitis" is a common cause for complete blindness. I do not think the manipulation of the steroids had any thing to do with his problem. I'm not sure why arrangements were not made by the ER to see an eye specialist the next day.  Blueberry extracts are worthless.

Sometimes enophthalmitis clears up and leaves much less damage than expected. We can hope and pray such will be the case for your husband. Good luck and be sure he takes extreme care with his other eye including wearing glasses for protection all waking hours.

JCH III MD