3736

Dr. Koushik Tripathy, Dr.Pradeep Venkatesh

Dr. R.P Centre for Ophthalmic Sciences, All India Institute of

Medical Sciences, New Delhi

Surgical management of endophthalmitis

Endophthalmitis is a purulent inflammation involving the

intraocular fluids (vitreous and aqueous) and their adjacent

structures, usually due to infection. It denotes an acute

ophthalmic emergency in which eyes may become blind.

Prevention of post-surgical endophthalmitis by sterile

aseptic techniques and standard maintenance of the

operation theatre is of utmost importance.

The goals of surgery in a case of endophthalmitis are

1. To decrease the infective load (organisms, toxins,

inflammatory debris) in the vitreous.

2. To obtain vitreous for microbiological evaluation.

Undiluted vitreous yielded a higher percentage of

confirmed positive cultures and higher colony [1] counts than aqueous.

3. To make the ocular media clear

4. Block the inflammatory chain of events and their

effects on the eye

5. Treat the complications of endophthalmitis (retinal

detachment)

6. Minimize complication from the disease or the

treatment itself.

7. Direct delivery of antibiotics- better diffusion and

penetration of antibiotics.

[2] Endophthalmitis Vitrectomy Study (EVS) evaluated 420

cases of endophthalmitis following cataract surgery and

implantation of secondary intraocular lens implantation

(IOL). The EVS only included patients with at least a

perception of light and (LP) and a visual acuity of ≤ 20/50.

Other inclusion criteria were clarity of cornea and anterior

chamber to allow visualization of 'at least some part of the

Goals

Indications

iris'; a corneal clarity enough for vitrectomy; and media

haze which obscured a view of second-order retinal

arterioles. Exclusion criteria were previous ocular condition

limiting the visual potential of the eye to ≤ 20/100, and

previous intraocular surgeries other than cataract surgery

or secondary IOL implantation within 6 week.

Eyes with previous intravitreal antibiotic injection, and

retinal detachment or choroidal detachment of moderate

height on indirect ophthalmoscopy or ultrasonography

were also excluded. Patients with strong suspicion of fungal

endophthalmitis, unsuitable for surgery and age younger

than 18 years were excluded. Thus, very poor prognosis

acute post-operative endophthalmitis cases were also

excluded. The patients were then randomized to vitrectomy

(VIT, with intravitreal antibiotics) or vitreous tap and biopsy

(TAP, with intravitreal antibiotics) and systemic treatment

with or without intravenous antibiotics (ceftazidime and

amikacin).

The TAP group patients were allowed to undergo vitrectomy

with reinjection of intravitreal antibiotics (vancomycin and

amikacin) if the eye responded poorly 36-60 hours after the

TAP. These eyes had a visual acuity of at least LP and

<5/200, the red reflex was absent or media haze increased,

and vitreous culture showed a minimum of an equivocal

growth.

At least one of the following criteria was also required:

increase of hypopyon size of at least 1 mm, a ring infiltrate

in the cornea or deteriorating pain. However, in the

background of current advances in vitreoretinal procedure,

Kuhn F and colleagues have advocated a 'complete and

early vitrectomy for endophthalmitis (CEVE)' in which

clinical picture and course rather than visual acuity was the [3] criteria for vitrectomy. They used intravitreal antibiotics

(vancomycin, ceftazidime and dexamethasone) only in

cases with visible retina and an 'excellent red reflex'.

CEVE was offered to patients with poor red reflex, absent

visualization of retinal details, and patient with no

improvement within 24 hours of injection of intravitreal

antibiotics. Silicone oil was injected in cases with an

5

3938

iatrogenic retinal break or extensive areas of retinal

necrosis. The European Society for Cataract & Refractive

Surgeons' (ESCRS) gold standard is a diagnostic and

therapeutic vitrectomy in most cases of postoperative [4] endophthalmitis.

In cases of delayed onset postoperative endophthalmitis

(occurring more than 6 weeks after surgery) pars plana

vitrectomy (PPV) can be combined with intraocular

antibiotic (IOAB) alone, IOAB with partial capsulectomy, or

IOAB with complete capsulectomy and IOL explant or [5] exchange. IOAB can be given intravitreally, into the

capsular bag or both intracamerally and intravitreally. Mild

clinical presentations and endophthalmitis caused by

Staphylococcus epidermidis may be managed with IOAB

alone.

For more severe cases, suspected fungal and

Propionibacterium acnes cases, and recurrent cases

following IOAB a PPV with antibiotic and/or antifungal may

be appropriate. Specifically P acnes is known to recur after

IOAB alone. PPV with total capsulectomy and IOL explant/

exchange has the least recurrence rate among the

surgeries described for chronic post-operative

endophthalmitis.

The Collaborative Bleb-related infection incidence and [6] treatment study group used a staging of bleb-related

infections (Table 1) in which stage IIIb cases received

immediate vitrectomy with intravitreal antibiotics along

with topical and systemic antibiotics. Early PPV with

intravitreal antibiotics has been shown to reduce risk of

final vision of no PL and improve final visual acuity in culture [7] positive bleb associated infections.

For endophthalmitis related to intravitreal injections of

anti-vascular endothelial growth factor (anti-VEGF) agents

and steroids, mild cases are managed by intravitreal

antibiotics alone. Streptococcus viridans endophthalmatis stis particularly fulminant presenting at 1 day after injection,

and all eyes had poor final vision of ≤ hand motions with

retinal detachment despite successful vitrectomy in a [8] study.

Traumatic endophthalmitis has a worse prognosis

compared to the post-operative variant due to virulent

organisms (Bacillus cereus), severe infection,

polymicrobial etiology, and associated retinal detachment

or intraocular foreign bodies. Immediate PPV with

intravitreal antibiotics is the mainstay of treatment in

traumatic endophthalmitis, though useful vision may not

always be salvaged. The associated intraocular foreign

body or retinal detachment can also be dealt with during

the PPV. Traumatic endophthalmitis is children is especially

aggressive and warrants early intervention.

Intravenous antibiotics and antifungals are the primary

mode of treatment in endogenous endophthalmitis. Search

for systemic focus of infection is crucial. Many patients are

systemically very ill with sepsis. Cases not responding to

systemic therapy and intravitreal antibiotics with loss of red

glow may be taken up for a PPV.

Timing of surgical intervention depends on cause of

endophthalmitis, clinical course, visual acuity, visibility of

retina, status of red glow, presence of relative afferent

papillary defect (RAPD), virulence of organism and others.

Early vitrectomy has the advantages of early control of

infection and inflammatory cascade, an early collection of

microbiological specimen, and avoidance of complications [9] (e.g., macular) of the infective process.

A vitrectomy procedure also increases retinal oxygenation,

allows definitive treatment even when the type, virulence

and sensitivity pattern of the organism are unknown. It

allows direct inspection of the retina and an opportunity to

manage any co-existing pathologies, reduces the duration

of the disease, and may expedite visual recovery. The

authors of CEVE also state that an early vitrectomy may

reduce iatrogenic damage by improved visibility and

reduced tissue fragility as the disease is treated before

progression.

However, entering in an acutely inflamed eye may have

higher chances of pain, hemorrhage, poor intraoperative

Timing

4140

visualization and iatrogenic retinal damage. On the other

hand delayed vitrectomy after one or more intravitreal

antibiotic injection may help better visualization, reduce

intraoperative hemorrhage, decrease pain and potentially

reduce iatrogenic retinal breaks.

The standard criteria for assessment of visual acuity has [2] been defined by the EVS. When a patient could not see

the largest letters on the ETDRS chart at 1m, ability to

count fingers is checked. In case of inability to do so,

hand motion is examined by blocking the fellow eye. A

light source like lamp used for near vision is then

directed from behind the patient to the examiner's

fingers situated at 60 cm from the eye.

The hand remained stationary or moved vertically or

horizontally at the rate of one motion per second. The

patient has to tell whether the hand is still or moving

sideways or up-down. If at least four correct responses

are received of a total of 5 hand motions, the visual

acuity is recorded as Hand motions. If hand motions

can't be elicited, a bright light using brightest intensity

of the indirect ophthalmoscope is directed to the eye

from 90 cm to detect the LP.

IOP is measured using applanation tonometer. The

corneal surface may be irregular, and a non-contact

tonometer may show an error in such cases. A

hypotonous eye may denote an associated retinal

detachment, choroidal detachment or open globe

injury. A hypotonous small eye with LP alone and

chorioretinal thickening on ultrasound may denote a

pre-phthisical eye and surgery may better be avoided in

such eyes. In cases with high IOP, inflammatory

membrane blocking the anterior chamber angle should

be searched and removed.

Evaluation

Visual acuity

Intraocular pressure (IOP)

Slit lamp examination

Height of hypopyon, cellular reaction, inflammatory

membrane, and posterior synechia are important to

note progression. Rubeosis iridis denotes a poor

prognosis even after surgery.

Enough clarity of the cornea is the minimum

requirement for vitrectomy. Cases with severe corneal

haze, corneal abscess, and perforated cornea present

challenging scenario to perform a safe vitrectomy. Poor

or no visualization of the retina may lead to more

iatrogenic damage than the disease itself. Vitrectomy in

such cases should be avoided. An eye with painful end

stage endophthalmitis may require evisceration with

intraocular implants.

RAPD may not necessarily denote a poor final prognosis

as it may be caused by the toxins released by the

organisms and may be reversible after removal of the

infective load, inflammatory debris, and toxins.

The EVS classified media clarity using an indirect

ophthalmoscopy.

1. A 20/40 or better view to the retina

2. Clarity is worse than 1, but second order vessels

are visible

3. Worse than 2, but some retinal vessels visible

4. Worse than 3, but a red reflex is present

5. No red reflex

The media clarity was also assessed photographically in the

EVS. It included stereo photographs centering the midpoint

between the optic disc and the fovea, a 'single clearest

possible' image of the same area, and a stereoscopic pair of

the anterior segment.

In significant media opacity ultrasound should be

preferably performed by the surgeon himself. It gives

an idea of amount and thickness of the exudates. retinal

Cornea

Media opacity

Ultrasound

4342

detachment (RD), choroidal detachment (CD), foreign

bodies can also be detected. Areas of vitreoretinal

adhesion, subretinal abscess, can also be detected. EVS

excluded patients with RD or CD of moderate height.

Systemic evaluation and control of hypertension,

diabetes, coronary artery disease and others are

essential before any ocular surgery. All known cases

with systemic comorbidities should receive attention

and clearance from attending physician.

However, as endophthalmitis is a devastating

emergency vitrectomy may be an option if it is in the

best interest of the patient. However, in all such cases

patients should be informed adequately of their

condition and other options of management. A written

consent is a must before vitrectomy and may bear a

medico-legal implication. Systemic control of primary

infection is crucial in cases of endogenous

endophthalmitis.

is the preliminary and the minimum

requirement before any surgery including vitrectomy.

Chances of loss of LP, retinal detachment, phthisis,

glaucoma, sunken globe, whitening of the cornea,

aggravation of pain and redness, recurrence of infection

should be explained in patient's language.

guides the placement of cannula in the

presence of a CD or RD. The surgeon should avoid the

quadrant where the CD or RD is present. In such cases,

a 6 mm cannula should be used. It is important to

realize that in gross hypotony the dimensions of the

globe may be decreased significantly so that a cannula

at 3.5mm behind the limbus may be subretinal. Before

inserting the trocar cannula, the IOP can be built by

injecting the balanced salt solution' (BSS) into the

anterior chamber or the vitreous with a 26G needle. The

tip of the needle should be visible during injection.

The operating microscope should be in

working condition with good optics. The laser filter in

Surgery

Consent

Ultrasound

Prerequisites –

the operating microscope should be arranged, and the

inverter should be working. The contact lenses (wide

angle lens and irrigating plano concave lens), the

syringe for silicone oil injection, laser probe, silicone oil,

and PFCL should be in hand. Magnets, forceps (for

foreign body); slides and culture tubes for collection of

the sample should be arranged. The intravitreal

antibiotics to be injected after the PPV should be

arranged and reconstituted. Microvitreoretinal blade

(20G) is required for inserting the 6mm infusion cannula

and to make clear corneal incision for the removal of

membranes and exudates in the anterior chamber.

Polyglactin (Vicryl) 7-0 and monofilament nylon 10-0

may be required to close scleral and corneal wound

respectively. The pressure of the cylinder should be

optimum before starting the surgery.

The surgery is done under peribulbar

anesthesia (bupivacaine and lignocaine) in adults

without significant medical illness. For medically ill

patients and those having cardiac diseases written

clearance for ocular surgery should be obtained from

the physician before the surgery. Children and mentally

challenged patients are taken under general

anesthesia.

The patients' surgical field is

cleaned with standard norms using povidone iodine. A

sterile surgical drape is applied to keep the eyelashes

away from the surgical field.

When intravitreal location of the tip

of infusion cannula may not be confirmed

intraoperatively, a 20G 6mm cannula is preferred. Such

instances include aphakic and pseudophakic eyes with

small pupils, hypotony, CD, RD, and severe media

opacity in the anterior segment. The quadrant of CD or

RD should be avoided during placement of the cannula.

First, a localized peritomy is done, and a stay suture of

polglactin 910 7-0 is put 3 or 3.5 mm behind the limbus

in aphakic and pseudophakic eyes respectively. When

Anesthesia-

Patient Preparation:

Infusion cannula-

4544

media permits visualization of the tip of cannula 23G or

25G infusion can be used along with the other 2

(superoonasal and superotemporal). However, in all

cases infusion should be started only after confirmation

of the intravitreal position of the cannula.

Encirclage- Band (type 240- 2.5mm wide) may be put in

cases of retinal detachment. It may support the

peripheral retina where removal of vitreous may be

hazardous.

should be done before starting the

infusion to avoid dilution of the sample. A syringe is

attached to the aspiration tube from the vitrectomy

cutter. The mouth of the cutter should be visible.

Suction on the syringe is applied only when the cutter is

on with high cut rate. ESCRS recommends a collection

of at least 0.5ml of undiluted vitreous.

The endpoint mentioned is softening of the eye ball and

disappearing of the cutter from the view. We consider

using the latter endpoint as being hazardous. After

ensuring that the tip of the infusion cannula is in the

vitreous cavity and not covered by any membrane, the

infusion is started. After the globe is formed the cutter is

removed. A total of 0.5- 2 ml undiluted vitreous is

collected, which is then sent for evaluation. The EVS

obtained 0.1 ml of the aqueous sample using 25 G or 27

G needle. Vitreous gel (0.2- 0.5) was removed from the

mid-vitreous.

For adequate

intraoperative visibility, the anterior segment media

opacity needs to be cleared as much as possible. The

corneal clarity can be improved by deturgescence

rolling a dry swab firmly over the cornea. In extreme

cases, the epithelium may need to be scraped. The

epithelium near the limbus should not be scraped as it

may lead to limbal stem cell loss and delay in corneal

healing.

In severe corneal haze with endophthalmitis involving

an only seeing eye, surgery using temporary

Vitreous biopsy

Dealing with corneal haze-

keratoprosthesis (KPro), vitrectomy and then corneal

graft may be tried. Difficulty in inserting the trocar and

cannula and repeated episode of Globe collapse are

common during vitrectomy using a temporary KPro.

There may be a problem to use a contact wide angle

viewing lens, due to leaking at the side of temporary

keratoprosthesis, and poor visibility can hamper an

optimal surgery. The functional and anatomical

outcome in such cases remains dismal despite recent

advances in ophthalmic surgery. However, globe

salvage rate of 38% has been reported in the literature [11] using temporary KPro for endophthalmitis.

The hypopyon, inflammatory

membrane, and debris can be removed by wash with

balanced salt solution, internal limiting membrane forceps,

end-grasping forceps, vitrectomy cutter (with infusion

through corneal wound) and other instruments. The angle

of the anterior chamber should be made free of membranes

and debris at they may lead to IOP rise later.

The membrane over iris and the pupillary zone can

sometimes be removed in toto using a vitrectomy forceps.

The materials collected from the anterior chamber can be

sent for microbiological review. The vitrectomy cutter

through the sclerotomy can be used to create a large

peripheral iridectomy (PI) in pseudophakic eye avoiding the [12]IOL haptics.

Through this PI, the debris in the anterior chamber can be

removed using the cutter. Recombinant tissue plasminogen

activator (rt-PA) has been used to dissolve the

inflammatory debris. In case of bleeding epinephrine or a

viscoelastic may be used to fill the anterior chamber and to

provide a tamponade.

(Sodium hyaluronate 1%) is an important

adjuvant in the psudophakic and aphakic eyes. After

clearance the anterior segment of infective debris,

healon may be used to fill the anterior chamber. It

maintains the anterior chamber and ensures media

clarity during the surgery. It prevents intraoperative

reaccumulation of blood or inflammatory debris, keeps

The anterior chamber:

Healon

4746

the anterior chamber formed, reduces Descemet's

folds, and maintains papillary dilation. However, there is

a risk of increased IOP and so patient should be

monitored for an elevation of IOP.

needs to be dilated at least 3mm for

adequate view through a wide angle contact lens. For

mydriasis intracameral adrenaline, viscoelastics,

removal of pupillary membrane, iris hooks, and

sphincterotomy may be used.

(in traumatic and endogenous

endophthalmitis cases) may need to be sacrificed if

cataract hampers an adequate clearance of the

infection. Lens can be removed using the vitrectomy

cutter (lensectomy), the irrigation-aspiration probe in

young patients (lens aspiration) or phacoemulsifier. The

deposits over the IOL may be removed by a jet of BSS

over the lens, or gentle rubbing by the silicone tip of the

extrusion cannula.

A central membranectomy to remove the posterior

capsule may be required for visualization of the

posterior segment in aphakes and psuedophakes. It

also helps the irrigation of the capsular bag with

antibiotics (in delayed postoperative endophthalmitis)

or infusion fluid. A large capsulectomy may lead to an

unstable IOL and even IOL drop, and may complicate

the surgery. In recurring cases of delayed postoperative

endophthalmitis the IOL along with the capsular bag

may need to be explanted.

After the vitreous biopsy is taken, the syringe

is removed from the aspiration tubing of the cutter, which is

now connected with the vitrectomy machine via a tube. The

vitrectomy is performed from anterior to posterior, clearing

the opacity behind the pupil first and then proceeding

posteriorly with care (especially looking for any membrane

with dichotomously branching vessels that may denote

retina).

An active bleeding in the posterior segment is usually an

The pupil

The crystalline lens

Vitrectomy:

indication that the retina or choroid has been damaged.

Careful preoperative ultrasound may make the surgeon

alert of a possible retinal detachment. The EVS did not

advocate induction of posterior vitreous separation when it

was not already present. Aggressive removal of the

posterior hyaloid was not done. The goal of surgery was to

remove at least 50% of vitreous in eyes with no posterior

vitreous detachment.

Conventionally aim of endophthalmitis vitrectomy has been

only to perform a core vitrectomy. Usually, high cut rate and

low suction is used as the infected retina is necrotic and

there may be inadvertent vitreous traction with an

iatrogenic retinal injury. Conventionally the end point of

vitrectomy is when the posterior pole with the optic disc and

the arcade vessels are seen.

The inflammatory debris (macular hypopyon) collects

posterior to the posterior hyaloid at the posterior pole as [9] the patients lie supine. This causes the macular

complications like cystoid macular edema, stress

hemorrhage, and epimacular proliferations. A 'proportional

pars plana vitrectomy' (PPPV) has been described by Morris [11] R E and colleagues. The extent of vitrectomy is

proportional to safe visibility, the expertise of the surgeon

and the retinal condition.

It varies from minimum diagnostic vitrectomy (MDV) to

total pars plana vitrectomy (TPPV) with the cleaning of the

posterior retinal surface. In 'complete and early vitrectomy

for endophthalmitis (CEVE)' a nasal vertical well is dug with

the opaque vitreous. The posterior vitreous face is then

identified as it is 'opaque' or by the deposits of infective

colonies over it as yellowish or white dots. A drop of

triamcinolone may also be used to delineate the posterior

vitreous clearly. The posterior vitreous detachment (PVD)

is then induced using suction of the cutter.

Induction of PVD is avoided over the necrotic retina, where

hyaloid is shaved as there is a chance of retinal break or

retinal detachment. In other areas, PVD is induced, and

vitreous is removed to decrease the infective load

optimally. However, detachment of vitreous anterior to the

4948

equator was not 'aggressively pursued', and peripheral

vitreous was trimmed carefully. Thus in CEVE posterior

hyaloid is removed contrary to the recommendation of the

EVS, though they retain same treatment philosophy

regarding peripheral vitrectomy.

The primary goal of the CEVE is to cure the infection and

vacuuming of the macular surface was always performed

using a silicone tip extrusion cannula (flute needle) with

passive suction. Aspiration by vitrectomy probe was done

once the sticky material was mobilized from the retinal

surface.

The ESCRS recommends that in acute endophthalmitis,

induction of PVD (in cases without a preexisting PVD)

should be reserved for experienced vitreoretinal surgeons.

After the vitrectomy is done, fluid air

exchange is done. Intravitreal antibiotics are then given.

EVS used Inj. Vancomycin hydrochloride 1mg in 0.1 ml and

Inj. Amikacin 400µg in 0.1ml. The ESCRS recommends half

of the usual dose of antibiotics if full vitrectomy has been

done. The injection is given into the mid-vitreous slowly

over 1-2 minutes, with the bevel of the needle up, aiming [4] away from the macula. Separate needles and syringes are

recommended by the ESCRS to avoid flocculation. The first

choice of antibiotic-combination of the ESCRS is

Vancomycin (1mg) and Ceftazidime (2.25mg) to cover both

Gram positive and negative organisms respectively.

The second choice combination is Vancomycin 1mg and

Amikacin 400µg especially in patients with allergy to beta-

lactam group of drugs. In acute postoperative

endophthalmitis, the ESCRS also recommends intravitreal

dexamethasone (preservative free) 400µg in 0.1ml to

reduce intraocular inflammation, though its role in

improving visual outcome is controversial.

The requirement of systemic steroids is avoided in elderly

patients. Piperacillin-Tazobactam is also being used in

bacterial endophthalmitis at a dose of 225µg in 0.1ml. It

has good activity against many Gram-positive and Gram-

negative bacteria including Pseudomonas aeruginosa. For

Intravitreal drugs-

fungal endophthalmitis Amphotericin B (5-10 µg) or

Voriconazole (100 µg) is used.

Silicone oil is an important tamponade

agent after vitreoretinal procedures. In an in vitro study, it

was shown to decrease the counts of colony forming units

of Staphylococcus epidermidis, Staphylococcus aureus,

Pseudomonas aeruginosa, Candida albicans, and [13] Aspergillus species. Possible mechanism may be

nutritional deprivation and toxicity. [14] Bacteria cannot multiply within silicone oil. It also

provides a clear media after surgery. It prevents or treats a [9]rhegmatogenous retinal detachment. Most surgeons use

silicone oil in endophthalmitis only if there is a retinal break,

a detached retina, or in cases with extensive areas of retinal

necrosis (potential areas of a retinal break).

In cases where adequate removal of vitreous has not been

done, implantation of silicone oil may compartmentalize

the bacterial load between the retina and the oil. This may

potentially allow retinal necrosis and a retinal detachment.

Intravitreal antibiotics are injected after silicone oil

injection.

These procedures are reserved for the painful blind eyes

with worst prognosis when symptomatic relief or

anatomical restoration of normal appearance cannot be

achieved with other modalities. A case of advanced

endophthalmitis with perforated corneal ulcer (or

impending corneal perforation) and extruding intraocular

contents; or with panophthalmitis may need an

evisceration. Psychological and medicolegal implications

are huge, and all patients should be adequately counseled

before the surgery.

The infusion cannula

should never be turned on without viewing its tip. The

anterior segment needs to be cleared, pupils enlarged and

the tip of the infusion cannula seen before the infusion is

started. In cases id inadvertent suprachoroidal or

Role of silicone oil:

During insertion of cannula-

Evisceration or Enucleation

Complications of surgery

5150

subretinal infusion, the involved sclerotomy should be

closed, a 6 mm cannula should be inserted away from the

site. In extreme cases infusion through a corneal wound

may be used. In hypotonous, aphakic eyes chances of the

detachment of pars plana/plicata is there during insertion

of blunt or used trocars.

The possibilities of retinal dialysis at the site of working

sclerotomies are there due to repeated insertion/

withdrawal of intravitreal instruments maneuvers and

potential vitreous traction at these locations. Hence,

before using large instruments like intraocular magnets or

foreign body forceps, the vitreous near the sclerotomy site

should be adequately cleared.

The retina may

be necrotic, and the break may arise from the infection or

be iatrogenic. The break is surrounded by 2-3 rows of the

laser of mild intensity intraoperatively in the surrounding

retina. Silicone oil is injected. The breaks may be lasered

postoperatively under silicone oil also.

Intraoperative laser carries the risk of laser induced break

as the retina is swollen and friable in acute

endophthalmitis. In case of occurrence of retinal

detachment, the vitreous and pus are cleared. Subretinal

fluid is drained though the break or a drainage retinotomy

and silicone oil is injected. The patient is advised strict

poisoning according to the location of the break.

A case of recurrent

endophthalmitis following an initial vitrectomy may be very

aggressive, and a repeat vitrectomy with removal of

vitreous membranes and silicone oil injection may be

required. No cases in EVS (VIT group) or CEVE study

required a revitrectomy in contract to the TAP group of EVS

(6%).

Suprachoroidal hemorrhage was

noted in 1.9% of VIT group and 4.9% of the TAP group of

EVS respectively. In general, this denotes a poor prognosis.

Retinal break and retinal detachment:

Uncontrolled infection:

Expulsive hemorrhage:

Anatomical and functional outcomes

Anatomical failure of treatment in endophthalmitis has

been defined as 'enucleation, evisceration or phthisis'. In

EVS phthisis occurred in 2% of the patients in VIT group

(4% in TAP).

The outcomes are poor in cases of virulent organisms, late

and advanced presentation, traumatic cases, and bleb

related endophthalmitis.

The EVS study found almost similar chances of achieving

good final visual acuity of at least 20/40 or 20/100; and of

losing visual acuity to <5/200 in TAP compared to the VIT

group in the cases with baseline vision better than LP. On

the other hand, thirty-three percent and 56% eyes with

only perception of light (LP) at presentation achieved a final

visual acuity of at least 20/40 and 20/100 respectively after

vitrectomy compared to 11% and 30% with TAP group. In

such cases, the risk of loss of visual acuity to <5/200 was

also reduced by immediate vitrectomy (20% versus 47%

with TAP). Most important cause of visual loss was the

macular abnormality. Thus, the EVS study recommended

early vitrectomy with intravitreal antibiotics in acute post-

cataract surgery bacterial endophthalmitis cases with only

LP. The CEVE study showed that 91% of 47 achieved final

visual acuity of 20/40, none developed phthisis or retinal

detachment or required enucleation. No revitrectomy was

needed (versus 0% in VIT and 6% in TAP group in EVS).

Endophthalmitis remains a devastating ocular infection

with the potential to cause vision loss and phthisis. In the

current advances in vitreoretinal surgery, more surgeons

are opting for early vitrectomy. However, the vitrectomy

should be done within the safety limit. However,

management should be individualized taking into

consideration results from several large scale studies and

overall systemic status and status of fellow eye of affected

patients.

Conclusion

5352

[1] M. Barza, P. R. Pavan, B. H. Doft, S. R. Wisniewski, L.

A. Wilson, D. P. Han, and S. F. Kelsey, "Evaluation of

microbiological diagnostic techniques in

p o s t ope ra t i ve endoph tha lm i t i s i n t h e

Endophthalmitis Vitrectomy Study," Arch.

Ophthalmol. Chic. Ill 1960, vol. 115, no. 9, pp. 1142-

1150, Sep. 1997.

[2] "Results of the Endophthalmitis Vitrectomy Study. A

randomized trial of immediate vitrectomy and of

intravenous antibiotics for the treatment of

postoperat ive bacter ia l endophthalmit is.

Endophthalmitis Vitrectomy Study Group," Arch.

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