Campochiaro P A, Lim J I
Wilmer Ophthalmological Institute, Johns Hopkins Hospital, Baltimore, Md.
Arch Ophthalmol. 1994 Jan;112(1):48-53. doi: 10.1001/archopht.1994.01090130058017.
Intravitreous aminoglycosides are widely used for the treatment and prophylaxis of endophthalmitis. Because the toxicity of 0.4 mg of gentamicin sulfate is well documented, many surgeons now use amikacin sulfate or low-dose gentamicin to reduce the risk of macular infarction. A survey of retinal specialists has suggested that amikacin or low-dose gentamicin can also cause macular toxic side effects. To further investigate this issue, the critical details of the case histories, findings, and course of 13 patients who received intravitreous injections of 0.2 to 0.4 mg of amikacin sulfate or 0.1 to 0.2 mg of gentamicin sulfate for prophylaxis or treatment of endophthalmitis are summarized. For several patients, complete case histories and a fluorescein angiogram are provided.
These cases suggest that amikacin and low-dose gentamicin, similar to gentamicin sulfate at a dose of 0.4 mg, can cause macular infarction. The causative dose cannot be ascertained in any of the cases, but doses were prepared by hospital pharmacists using typewritten protocols, a practice that helps to prevent dilution errors. Several of these cases differ from previously reported cases of aminoglycoside toxicity in that the involvement of the macula was quite discrete. Most of the patients suffered severe visual loss, but two patients, in whom most of the nonperfusion was adjacent to the macula and in whom some of the perifoveal capillaries were spared, recovered 20/50 visual acuity.
These cases emphasize the potential hazards of the intravitreous use of aminoglycosides. A toxic reaction can occur even when injection of low doses is intended and precautions are made to avoid dilution errors. A localized increase in concentration in dependent areas of the retina may play a role in aminoglycoside toxicity. If some of the perifoveal capillaries are spared, retention of some central vision is possible. Consideration should be given to substituting ceftazidime for aminoglycosides for the treatment and prophylaxis of endophthalmitis.
玻璃体内注射氨基糖苷类药物广泛用于眼内炎的治疗与预防。鉴于0.4mg硫酸庆大霉素的毒性已有充分记录，许多外科医生现使用硫酸阿米卡星或低剂量庆大霉素以降低黄斑梗死风险。一项针对视网膜专家的调查表明，阿米卡星或低剂量庆大霉素也可引起黄斑毒性副作用。为进一步研究此问题，总结了13例接受玻璃体内注射0.2至0.4mg硫酸阿米卡星或0.1至0.2mg硫酸庆大霉素以预防或治疗眼内炎患者的病史、检查结果及病程的关键细节。为部分患者提供了完整病史及荧光素血管造影。
这些病例提示，阿米卡星和低剂量庆大霉素与0.4mg硫酸庆大霉素相似，可导致黄斑梗死。在任何病例中均无法确定致病剂量，但剂量由医院药剂师根据打印的方案配制，这种做法有助于防止稀释错误。这些病例中有几例与先前报道的氨基糖苷类毒性病例不同，黄斑受累相当局限。大多数患者视力严重丧失，但有两名患者，其大部分无灌注区紧邻黄斑且部分中心凹周围毛细血管未受累，视力恢复至20/50。
这些病例强调了玻璃体内使用氨基糖苷类药物的潜在危害。即使旨在注射低剂量并采取预防措施避免稀释错误，仍可能发生毒性反应。视网膜依赖区浓度的局部升高可能在氨基糖苷类毒性中起作用。如果部分中心凹周围毛细血管未受累，则有可能保留部分中心视力。在眼内炎的治疗和预防中，应考虑用头孢他啶替代氨基糖苷类药物。
