Abstract: Endophthalmitis justifiably is appreciated as an abscess, an intracavitary accumulation of purulent material. The volatile mixture of organism(s), endotoxins and exotoxins, cell wall, and various harmful enzymes is in direct contact with the retina, and even if intravitreal antibiotics kill the bacteria, continual damage can be inflicted by the inflammatory debris that remain in the eye. Although the retina does not necessarily become necrotic, functional recovery may be severely limited by pathologies such as cystoid macular edema. Becoming widely available in the early 1980s, vitrectomy increasingly was utilized to treat patients with postoperative endophthalmitis.1Chen C.J. Management of infectious endophthalmitis by combined vitrectomy and intraocular injection.Ann Ophthalmol. 1983; 15 (, 977–9): 968-974PubMed Google Scholar The surgical approach, however, rarely has been mentioned in publications after the Endophthalmitis Vitrectomy Study (EVS).2Endophthalmitis Vitrectomy Study GroupResults of the Endophthalmitis Vitrectomy Study a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis.Arch Ophthalmol. 1995; 113: 1479-1496Crossref PubMed Scopus (1342) Google Scholar This prospective randomized trial involving 420 eyes found no statistically significant benefit from vitrectomy, unless the visual acuity (VA) deteriorated to light perception (LP). Bacterial endophthalmitis is characterized properly as early and advanced,3Morris R. Witherspoon C.D. Kuhn F. Bryne J.B. Endophthalmitis.in: Roy F.H. Rindall Master Techniques in Ophthalmic Surgery. Williams and Wilkins, Baltimore1995: 560-572Google Scholar reflecting the condition's ability to progress rapidly. Intervention early rather than late, and complete rather than partial, reasonably is expected to offer prevention of further retinal damage, irrespective of the VA. Our choice of treatment is determined by the clinical picture and course, not whether the VA is LP versus hand movements or better. We choose intravitreal injection (vancomycin, ceftazidime, and dexamethasone, in addition to topical and oral antibiotics such as ciprofloxacin) only if the retina can be visualized or there is an excellent red reflex. If, however, no retinal detail can be seen or the red reflex is poor, or if there is no improvement within 24 hours after injection—during which time we monitor the patient very closely,3Morris R. Witherspoon C.D. Kuhn F. Bryne J.B. Endophthalmitis.in: Roy F.H. Rindall Master Techniques in Ophthalmic Surgery. Williams and Wilkins, Baltimore1995: 560-572Google Scholar we offer surgery as an alternative to observation. Most patients, understanding the risks and benefits of surgery versus injection alone, opt for vitrectomy. Our goal is complete vitrectomy, and we systematically advance from anterior to posterior. The corneal epithelium almost always is scraped, followed by cleansing of the anterior chamber, typically through a paracentesis. Occasionally, it is necessary to wipe the anterior surface of the intraocular lens. Irrigation of the bag is allowed by the creation of a large capsulectomy. Removal of the vitreous starts behind the lens and gradually proceeds deeper. We found that the posterior vitreous cortex is usually attached; we carefully detach it and vacuum the macular surface. In the periphery, we are conservative: the vitreous skirt is only shaved, reducing the risk of a retinal break. Should a retinal injury be caused or large areas of necrosis be discovered, we prefer silicone oil injection,4Aras C. Ozdamar A. Karacorlu M. Ozkan S. Silicone oil in the surgical treatment of endophthalmitis associated with retinal detachment.Int Ophthalmol. 2002; 24: 147-150Crossref Scopus (29) Google Scholar but this is rarely necessary. In our consecutive series of 47 eyes, 91% achieved 20/40 or greater final VA (EVS, 53%; P<0.0001, Fisher exact test). No eye developed retinal detachment (nonsurgical group in the EVS, 7%), and only 1 eye required silicone oil implantation. Enucleation or phthisis has not occurred (EVS, 6%), and no revitrectomy was necessary (EVS, 6% in the nonsurgical group vs. 0% in the surgical group). The EVS compared the outcome of a small biopsy (vitreous specimen collection) to a larger biopsy: "If there was no posterior vitreous separation, no attempt was made to induce a vitreous detachment.… It was a goal of surgery to remove at least 50% of the vitreous." We performed a full biopsy, greatly aided by using wide-angle viewing, which provides vastly improved visualization even when the corneal stroma is hazy. Although no one should directly compare this limited retrospective series to the randomized prospective EVS, it seems from our study that early and complete vitrectomy is safe and beneficial for eyes with postoperative endophthalmitis. With the incidence of this devastating surgical complication on the rise again due to clear corneal cataract surgery,5Cooper B.A. Holekamp N.M. Bohigian G. Thompson P.A. Case-control study of endophthalmitis after cataract surgery comparing scleral tunnel and clear corneal wounds.Am J Ophthalmol. 2003; 136: 300-305Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar we suggest that the issue be revisited. CEVES (Complete and Early Vitrectomy for Endophthalmitis Study) should enroll approximately 100 patients to show a statistically significant (α = 0.05) improvement (80% of eyes with 20/40 or greater final vision) over EVS recommendations.
Publication Year: 2006
Publication Date: 2006-04-01
Language: en
Type: letter
Indexed In: ['crossref', 'pubmed']
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Cited By Count: 39
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