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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
Moharram
IOL PRESERVATION IN ENDOPHTHALMITIS
By
Hossam M. Moharram, MD.
Department of Ophthalmology,
Minia Faculty of Medicine
ABSTRACT:
Purpose: Is to study IOL preservation PVD and extensive vitrectomy in cases of
endophthalmitis.
Patients and methods: 28 eyes of post cataract extraction endophthalmitis were
undergone vitrectomy without IOL extraction, PVD was done in all cases with
extensive core vitrectomy.
Post-operative follow up regarding V/A, anterior and posterior segment inflammation
were observed for a period of 6 months.
Results: The overall results revealed better postoperative visual acuity and success
rate in comparison with IOL extraction and only core vitrectomy.
KEY WORDS:
Endophthalitis
Vitrectomy
IOL
well as immediately if the patient
complains of pain or decreased vision.
Once endophthalmitis is suspected, one
should examine the patient often and
take definitive action when indicated.
Although the more common signs of
endophthalmitis are well known by
physicians, one should make attention
of less frequent signs. These include
chemosis, lid edema, membrane
formation on the intraocular lens
(IOL), and retinal hemorrhages3.
INTRODUCTION:
A
broad
definition
of
endophthalmitis includes any severe
intraocular inflammation. Toxic substances, necrotic tumors, noninfec-tious
uveitis, and infarction can create the
clinical picture of vitritis, hypopyon,
and ocular pain1.
Infectious endophthalmitis can
be of bacterial, fungal, or parasitic
etiology. Vitreous surgery decreases
the number of organisms, reduces
inflammatory components, enhances
the penetration and diffusion of
antibiotics, and aids in identification of
the pathogen. Late complications
related to cellular proliferation on the
vitreous matrix are reduced as well2.
Early surgical intervention is
advantageous
since
it
allows
immediate treatment of all treatable
pathologies, it serves as a prophylactic
measure, preventing complications that
would occur with a prolonged disease
process, and it reduces the risk of
surgery via improved visibility and
decreased tissue fragility3.
Early diagnosis and treatment
are of paramount importance when
managing a patient with endophthalmitis. It is strongly recommended that
all ocular surgery patients be examined
on the first postoperative morning as
METHODS:
A prospective randomized
controlled trial of 28 cases of severe
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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
Moharram
post-cataract endophthalmitis as an
initial procedure was studied.
necrosis, atrophic holes and iatrogenic
tears.
Endophthalmitis
Vitrectomy
Study (EVS) criteria were conducted.
Intraocular antibiotic injections
(Ceftazidime 2.2 mg - Vancomycine 1
mg) were done in all eyes.
All patients underwent IOL
preservation, posterior capsulotomy,
extensive vitrectomy with PVD.
Postoperative
treatment
th
consisted of systemic 4 generation
quinolones, topical antibiotic and
steroid eye drops, subconjunctival
injections and anti-inflammatory drugs.
Surgical steps consisted of
cleaning anterior segment from membranes at the angle, over the iris and
over the IOL and viscoelastic injection
after silicone infusion cannula application (fig. 1,2).
Patients were followed up 1, 2,
4, 12 weeks and 6 months
postoperatively. Post-operative follow
up include V/A, anterior and posterior
segment inflammation.
Standered 3 ports vitrectomy
was done starting by cleaning the
anterior vitreous face and posterior
capsulomy (fig. 3).
RESULTS:
Better vision was achieved in
24 eyes (85%). 2 eyes ended with no
light perception, and vision was
stabilized in the rest 2 eyes. 2 eyes
needed a second operation because of
uncontrolled infection in one eye and
retinal detachment in the other.
Creation of PVD with caution in
all cases and extensive core vitrectomy
(fig. 4),
The macular surface should
always be vacuumed, even if there is
no apparent pus accumulation on it.
The silicone-tipped flute needle is used
with passive, not active, suction. Even
if larger pus fragments are present,
these tend to break up and can easily
exit the eye through the needle.
Alternatively, the vitrectomy probe’s
aspiration is utilized once the sticky
material has been mobilized from the
macular surface. It is rarely necessary
to meticulously vacuum the retinal
surface elsewhere.
As regarding AC reaction,
postoperative recovery within 2 weeks
was achieved in 80%.
Formation of inflammatory
membrane over the IOL was noticed in
most of cases by the second
postoperative day (50%) and resolved
by the end of 2 weeks.
Elevation of intraocular pressure was
encountered in 3 cases and controlled
by topical beta blocker in 2 cases and
by addition of dorzolamide in the
remaining case.
Endolaser was applied to the
healthy retina surrounding areas of
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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
Moharram
Fig 1
Fig 2
Fig 3
Fig 4
Fig 5
Fig 6
claim the obligation of immediate
complete pars plana vitrectomy. Even
though recent peer-reviewed literature
includes numerous publications about
the treatment of postoperative endophthalmitis, none of the papers offers a
DISCUSSION:
Once postcataract extraction
endophthalmitis is suspected vitreoretinal specialists all over the world are
divided into two camps: those who
avoid early vitrectomy and those who
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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
prospective, randomized study of
modern, complete pars plana vitrectomy versus vitreous tap and intravitreal antibiotics only.
Moharram
Nelsen
and
co-workers
described retinal detachment to occur
in 20 % of endophthalmitis patients
treated with vitrectomy and intraocular
antibiotics6,7.
In this study early complete
vitrectomy, IOL preservation and
posterior capsulectomy was done for
treating such cases.
In this study 85% of cases had
better V/A and only one case
developed retinal detachment. These
results may be due to preservation of
IOL and laser application.
A large capsulectomy with the
vitrectomy probe was done in all cases
to allow the intravitreal infusion fluid
to irrigate the capsular bag it also
improves visualization4.
The EVS group deserve a lot of
credit for introducing a systematic,
statistically well analyzed approach to
the management of eyes with acute
postoperative
endophthalmitis.
Because of the fear of iatrogenic retinal
damage during an operation where
visibility is a serious problem,
however, the EVS protocol called for a
vitrectomy that was not radical.
Indeed, the EVS compared eyes with
no vitrectomy (small, diagnostic
biopsy) with eyes with limited vitrectomy (medium biopsy). As a result,
the EVS was unable to demon-strate
any difference between surgical and
nonsurgical treatment, except in eyes
that were in their final stage of
damage8.
The posterior vitreous should
be detached and removed over retina
that is not necrotic. The retinal
appearance instantly changes to a clear
image once the vitreous “veil” has
been lifted. The central vitreous must
be completely removed to minimize
the bacterial load (“reservoir”) inside
the eye.
Detachment of the hyaloid
anterior to the equator should not be
aggressively pursued as this increases
the risk of iatrogenic retinal tear
formation.
Only
trimming
is
recommended in the periphery to
reduce the incidence of iatrogenic
retinal injury. Careful trimming is
sufficient to reduce the volume of the
infected medium while keeping the
retinal injury risk at an acceptably low
level.
Better understanding of the
pathophysiology, safer vitrectomy
machines, improved intraoperative
visualization technologies, increasingly
efficacious techniques of retinal
reattachment, new antibiotics (9) (more
effective/ potent and able to penetrate
the blood–retina barrier in higher
concentrations) are now available;
consequently, it is time to reevaluate
the role of vitrectomy in the treatment
of eyes with acute postoperative
endophthalmitis.
In the literature, endophthalmitis is suspected to increase the risk
of retinal detachment. EVS5 reported 6
cases of retinal detachment in the
vitrectomy group (2.8% of 218
patients) and improved V/A in 54%1.
In the no vitrectomy group EVS
reported that 7.2% of cases developed
retinal detachment and V/A was
improved in 52% of cases.
CONCLUSION:
IOL preservation, posterior
capsulectomy, PVD and extensive core
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EL-MINIA MED., BULL., VOL. 18, NO. 2, JUNE, 2007
vitrectomy seems to improve both the
anatomical and functional outcomes.
Moharram
vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis.
Arch Ophthalmol. 1995; 113: 14791496.
(6) Nelsen P.T., Marcus D.A.,
Bovino J.A. Retinal detachment
following endophthalmitis. Ophthalmology 1985; 92:1112-17.
(7) Doft BM, Kelsey SF,
Wisniewski SR. Retinal detachment in
the endophthalmitis vitrectomy study.
Arch Ophthalmol 2000; 118:1661–
1665
(8) Kuhn F, Gini G. Ten years
after…are
findings
of
the
Endophthalmitis Vitrectomy Study still
relevant today? Graefes Arch Clin Exp
Ophthalmol 2005; 243:1197–1199
(9) Hariprasad SM, Shah GK,
Mieler WF, Feiner L, Blinder KJ,
Holekamp NM, Gao H, Prince RA.
Vitreous and aqueous penetration of
orally administered moxifloxacin in
humans. Arch Ophthalmol 2006; 124:
178–182
REFERENCES:
(1) Kresloff M.S., Castellarin A.A.,
Zarbin M.A. Endophthalmitis. Surv.
Ophthalmol. 1998; 43:193-224.
(2) CalleganMC, Kane ST,
Cochran DC, et al., Bacillus
endophthalmitis: roles of bacterial
toxins and motility during infection.
Invest Ophthalmol Vis Sci 2005;
46:3233–3238
(3) Taban M, Behrens A,
Newcomb RL, et al., Acute endophthalmitis following cataract surgery: a
systematic review of the literature.
Arch Ophthalmol 2005; 123:613–620
(4) Burillon C, Kodjikian L, Pellon
G, et al., In-vitro study of bacterial
adherence to different types of
intraocular lenses. Drug Dev Ind
Pharm 2002;28:95–99
(5) Endophthalmitis Vitrectomy
. Results of the
Endophthalmitis Vitrectomy Study: a
randomized trial of immediate
‫الحفاظ على العدسات داخل العين فى األلتهاب الصديدى داخل العين‬
‫حسام محرم‬
‫قسم الرمد – كلية طب المنيا‬
‫الغرض من البحث‬
‫دراسة الحفاظ على العدسات داخل العين فى األلتهاب الصديدى داخل العين‬
‫المرضى والوسائل‬
‫تم استئصال الجسم الزجاجى بدون نزع العدسات داخل العين فى ثمانية وعشرون عينا ً بها‬
‫ألتهاب صديدى داخل العين بعد ازالة المياه البيضاء مع عمل فتحة بالحافظة الخلفية و فصل‬
‫الوجه الخلفى للجسم الزجاجى فى جميع الحاالت مع استئصال معظم الجسم الزجاجى‬
‫تمت المتابعة بعد العملية مشتملة حدة األبصار ومالحظة وجود ألتهاب بالقطعة األمامية والخلفية‬
‫لمدة ستة أشهر‬
‫النتائج‬
‫أظهرت جميع النتائج فيما بعد العملية عن حدة أبصار أفضل ومعدل نجاح مقارنةً بنزع‬
.‫العدسات داخل العين ومجرد ازالة الجزء المركزى للجسم الزجاجى‬
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