From the Department of Retina and Vitreous, Eye Hospital, the School of Optometry and Ophthalmology, Wenzhou Medical College, Wenzhou, China.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Bin Zheng, MD, Department of Retina and Vitreous, Eye Hospital, the School of Optometry and Ophthalmology, Wenzhou Medical College, 270 Xueyuan Road, Wenzhou, Zhejiang 325000, China.
Posttraumatic endophthalmitis accounts for approximately 10% to 30% of all cases of intraocular infection.1–3 Vitrectomy has been recommended because of the severity of injuries, severity of infection, and the more adverse outcome reported in these cases.4 However, conventional vitrectomy is always severely limited because the cornea and anterior chamber are totally opaque in severely infected eyes. Whereas early surgical intervention may be associated with a favorable outcome in serve endophthalmitis cases6 the limitations posed by poor visualization of the anterior segment have now been circumvented by the use of ophthalmic endoscopy to bypass visualization constraints during pars plana vitrectomy.5–7 The fingings of two patients, who were treated with endoscopic vitrectomy, with totally opaque anterior segment due to severe intraocular infection after trauma are reported herein.
Report of Cases
A 39-year-old man presented with a two-day history of an acutely painful red eye with decreased vision after primary repair of a corneal laceration. He had suffered penetrating trauma to his right eye 5 days previously. He was treated with topical antibiotics and steroids, and he received one subconjunctival injection of tebramycin at the end of the primary repair. At 3 days after primary repair, clinical deterioration was evidenced by the visual acuity in the right eye, which was no perception of light. Examination revealed pus in the anterior chamber and a dense fibrin plaque over the pupil. No fundal details or red reflex was visible. B ultrasoundgraphy and computerized tomography revealed the lens to be absent, a metal foreign body in the vitreous cavity, retinal detachment, and dense vitreous opacities. Pars plana vitrectomy using an ophthalmic endoscope was undertaken. The vitreous specimen was sent for microbiologic culture. Culture showed Bacillus spp sensitive to most of the tested antibiotics.
A 33-year-old man developed increasing inflammation with hypopyon one day after primary repair of a corneal laceration and removal of an iron foreign body with magnet on the left eye. The patient presented with dramatic visual loss, severe ocular pain, and hypopyon. Vision in the patient’s left eye was poor light perception. As there were severe corneal edema with ring infiltrates, hypopyon, and cataractous lens, fundus glow was absent. All findings of the right eye on examination were within normal limits. B ultrasoundgraphy revealed dense vitreous opacities and suspected retinal detachment. When intravitreal therapy with clindamycin and amikacin failed to elicit improvement, endoscopic vitrectomy with lensectomy was undertaken. Vitreous culture showed a heavy growth of methicillin-resistant Staphylococcus aureus.
Endoscopic vitrectomy was performed in a manner described in earlier studies.5–7 Both patients underwent standard three-port pars plana vitrectomy. The essential surgical procedure was carried out as follows. The endoscope (Polydiagnost Inc., Germany) was first introduced into vitreous cavity and monitored through an operating microscope. After the tip of endoscope was visible as a fuzzy light source posterior to the intraocular lens, the vitrectomy cutter was introduced. A small core sample of the vitreous was aspirated for culturing and Gram staining. The opaque crystalline lens was removed to facilitate visualization in Case 2. The central portion of vitreous gel was excised first to create a central fluid space, then the remaining vitreous gel and the posterior vitreous surface was excised. Retinal structures were then gradually identifiable. The lens had dropped into the vitreous cavity overlying the posterior pole in Case 1 and was completely excised by a vitrectomy cutter. A piece of wedge-shaped iron foreign body 2mm × 3mm × 0.5mm was visualized in the 6-o’clock meridian near the equator retina in Case 1, and removed through pars plana incision with an intraocular forcep. A giant retinal tear of 180 degrees along the posterior margin of the vitreous base occurred in Case 2, probably induced by removal of the metallic foreign body with a magnet. Other findings of endoscopic view included intense purulent exudates covering the surface of retina and the ciliary processes, a total retinal detachment, peripheral retinal necrosis, and scattered retinal hemorrhage in both injured eyes. After the infectious vitreous was completely excised, the exudative membranes on retina surface were peeled off. Perflurorocarbon liquid was used to flatten the detached retina, and then the retinal tears were treated by photocoagulation. After air-fluid exchange, silicon oil was used to fill the vitreous cavity for long-term internal tamponade in both cases. A basal iridectomy was performed inferiorly to prevent pupillary block induced by silicone oil. All intraocular manipulations were under endoscopic direct visualization (Fig. 1).
Figure 1. Endoscopic Views During Vitrectomy of Case 2: (A) Endoscopic Visualization of Cornea Showed a Central Corneal Laceration that Had Been Primary Repaired(arrow), and Opacification of Cornea. (B) Fibrins Formed in Vitreous Cavity Were Removed Under Endoscopic Visualization. (C) The Severely Infected and Rolled Edge of the Giant Retinal Tear Was Excised with a Vitrectomy Cutter. (D) There Were Scattered Necrotic Lesions (star) and Inflammatory Exudates (arrow) in Swollen Pigment Epithelium Layer. (E) The Retina Was Clearly Visualized After the Infectious Vitreous Was Completely Excised. (F) The Retinal Tears Were Treated by Photocoagulation.
Ceftazidime and vancomycin were injected in the eye at the end of the operation. Topical and systemic therapies with antibiotics and steroids were given after the vitrectomy.
One month after surgery, the eye was quiet with a best visual acuity of counting fingers at 1 m. Thereafter the patient lost follow-up.
Although initial improvement was encouraging with the best visual acuity at 6/60, deterioration of clinical sign was noticed with development of silicone oil keratopathy resulting in a final vision of hand motion. The patient was off all treatment because of financial problem.
Although there was a general agreement that the most severe endophthalmitis cases might benefit from vitreous surgery, there was no clear indication about when vitrectomy should be undertaken in acute posttraumatic endophthalmitis cases. Despite severe intraocular inflammation and poor initial visions, other preoperative findings, such as retinal detachment, iron foreign body in vitreous cavity, and ineffectiveness of intravitreal antibiotics suggested immediate vitrectomy in the cases reported in the study.
Both posttraumatic endopathalmitis cases in the study are characterized by visualization constraints and poor corneal conditions. Conventional pars plana vitrectomy cannot be performed safely because of inadequate or no visualization of posterior segment in these cases. Open-sky vitrectomy or temporary keratoprosthesis vitrectomy may be selected as a therapeutic option, however, both surgical approaches described above are limited when corneal transplantation is needed because of poor corneal conditions. The donor graft is not available at most times in our country. As there were large corneal laceration, severe corneal edema, and visualization constraints in both patients, we eventually selected endoscopic vitrectomy as a proper surgical approach. Since the cornea was spared during endoscopic vitrectomy, rapid recovery of corneal transparence was achieved in both injured eyes after surgery (Fig. 2).
Figure 2. The Corneas of Both Eyes Recovered Transparence at 1 Month Postoperatively.
Endoscopic vitrectomy enlarges the range of possibilities of conventional pars plana vitrectomy, by revealing “dead angles” of the eye or opacities of optical media. Thus this approach allows the surgeon to perform a more complete and safe vitrectomy, particularly in eyes with visualization constraints. Under direct endoscopic visualization, we excised infectious vitreous even on vitreous base and ciliary processes without any complications. This was difficult or impossible to accomplish in conventional vitrectomy and beneficial for the control of intraocular inflammation. It was also possible to deal easily with complications such as dropped lens and foreign body in vitreous cavity, as described in other studies.7–8
In conclusion, although posttraumatic endophthalmitis has a poorer prognosis which was partially contributed to by virulent infecting organisms,2,4 successful control of the intraocular inflammation in the eyes infected by Bacillus spp or Staphylococcus aureus after prompt vitrectomy. With proper attention to details, severely infected eyes with poor corneal condition and visualization constraints in anterior segment may be salvaged using endoscopic vitrectomy techniques. Many of these eyes would otherwise be lost because of delayed or no vitreous surgery.
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- Foster PK, Abbott RL, Gelender H. Management of infectious endophthalmitis. Ophthalmology. 1980;87:313–318.
- Affeldt JC, Flynn HW Jr, Forster PK, et al. Microbial endophthalmitis resulting from ocular trauma. Ophthalmology. 1987;94:407–413.
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