Blinding Endophthalmitis from Orthodontic Headgear
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《新英格兰医药杂志》
To the Editor: Intraocular infection (endophthalmitis) is a serious risk after a penetrating injury to the eye and may result in blindness. We report a severe intraocular infection from an eye injury caused by an orthodontic extraoral traction device (orthodontic headgear). A 12-year-old boy who was being treated for malocclusion with orthodontic headgear without safety features had an accidental release of the device, which apparently struck his right eye while he was sleeping. The patient reported pain in his right eye on awakening. His visual acuity was 20/60. A corneal laceration was found. The posterior segment of the eye appeared normal.
Treatment with intravenous cefazolin sodium (500 mg three times a day) was initiated, and repair of the wound was performed. The following morning, the patient's visual acuity was reduced to uncertain light perception. The intravenous antibiotic treatment was changed to vancomycin hydrochloride (500 mg three times a day) and ceftazidime (800 mg three time a day), and topical treatment with vancomycin hydrochloride (50 mg per milliliter) and ceftazidime (100 mg per milliliter) was administered every hour. The patient underwent vitrectomy, lensectomy, and intravitreal injection of vancomycin hydrochloride (1 mg) and ceftazidime (2.5 mg). Dense inflammatory debris that filled the vitreous cavity was found during surgery. The direct application of Gram's stain revealed gram-negative bacilli. Viridans streptococci sensitive to vancomycin were isolated. The patient's visual acuity remained unchanged.
Cases of endophthalmitis associated with orthodontic headgear have previously been reported1,2,3 after injuries sustained while playing with the headgear or improperly removing the device or resulting from the inadvertent release of the device during sleep. The visual acuity of the patients was limited to counting fingers or less in these reported cases. Cultures revealed mixed oral flora (including streptococci sensitive to vancomycin). The corneas became opaque and necrotic, and the vitreous cavity was filled with atypical solid inflammatory material. Total loss of vision in all cases was a result of infection with mixed flora.
The reports of these devastating injuries from orthodontic headgear encouraged the introduction of safety measures, such as a rigid safety strap that helps to prevent the face bow from being dislodged and face bows with recurved ends that form a safety guard over the sharp end of the intraoral bow.2 To minimize the risk of injury, orthodontists should caution patients against pulling the device out before releasing the elastic head straps. The device should be equipped with safety features that decrease the risk of inadvertent release and ocular penetration if it should strike the eye. Ophthalmologists should treat these injuries immediately and aggressively, even in the absence of intraocular inflammation, and patients should be monitored closely.
Tami Blum-Hareuveni, M.D.
Uri Rehany, M.D.
Shimon Rumelt, M.D.
Western Galilee–Nahariya Medical Center
22100 Nahariya, Israel
References
Holland GN, Wallace DA, Mondino BJ, Cole SH, Ryan SJ. Severe ocular injuries from orthodontic headgear. Arch Ophthalmol 1985;103:649-651.
Samuels RH, Jones ML. Orthodontic facebow injuries and safety equipment. Eur J Orthod 1994;16:385-394.
Zamir E, Hemo Y, Zauberman H. Traumatic Streptococcus viridans endophthalmitis after penetrating ocular injury from orthodontic headgear. J Pediatr Ophthalmol Strabismus 1999;36:224-225.
Treatment with intravenous cefazolin sodium (500 mg three times a day) was initiated, and repair of the wound was performed. The following morning, the patient's visual acuity was reduced to uncertain light perception. The intravenous antibiotic treatment was changed to vancomycin hydrochloride (500 mg three times a day) and ceftazidime (800 mg three time a day), and topical treatment with vancomycin hydrochloride (50 mg per milliliter) and ceftazidime (100 mg per milliliter) was administered every hour. The patient underwent vitrectomy, lensectomy, and intravitreal injection of vancomycin hydrochloride (1 mg) and ceftazidime (2.5 mg). Dense inflammatory debris that filled the vitreous cavity was found during surgery. The direct application of Gram's stain revealed gram-negative bacilli. Viridans streptococci sensitive to vancomycin were isolated. The patient's visual acuity remained unchanged.
Cases of endophthalmitis associated with orthodontic headgear have previously been reported1,2,3 after injuries sustained while playing with the headgear or improperly removing the device or resulting from the inadvertent release of the device during sleep. The visual acuity of the patients was limited to counting fingers or less in these reported cases. Cultures revealed mixed oral flora (including streptococci sensitive to vancomycin). The corneas became opaque and necrotic, and the vitreous cavity was filled with atypical solid inflammatory material. Total loss of vision in all cases was a result of infection with mixed flora.
The reports of these devastating injuries from orthodontic headgear encouraged the introduction of safety measures, such as a rigid safety strap that helps to prevent the face bow from being dislodged and face bows with recurved ends that form a safety guard over the sharp end of the intraoral bow.2 To minimize the risk of injury, orthodontists should caution patients against pulling the device out before releasing the elastic head straps. The device should be equipped with safety features that decrease the risk of inadvertent release and ocular penetration if it should strike the eye. Ophthalmologists should treat these injuries immediately and aggressively, even in the absence of intraocular inflammation, and patients should be monitored closely.
Tami Blum-Hareuveni, M.D.
Uri Rehany, M.D.
Shimon Rumelt, M.D.
Western Galilee–Nahariya Medical Center
22100 Nahariya, Israel
References
Holland GN, Wallace DA, Mondino BJ, Cole SH, Ryan SJ. Severe ocular injuries from orthodontic headgear. Arch Ophthalmol 1985;103:649-651.
Samuels RH, Jones ML. Orthodontic facebow injuries and safety equipment. Eur J Orthod 1994;16:385-394.
Zamir E, Hemo Y, Zauberman H. Traumatic Streptococcus viridans endophthalmitis after penetrating ocular injury from orthodontic headgear. J Pediatr Ophthalmol Strabismus 1999;36:224-225.