Ophthalmic Surgery, Lasers and Imaging Retina

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Case Report 

Post-Pneumatic Retinopexy Endophthalmitis: Management of Infection and Persistent Retinal Detachment

Tarun Sharma, MD, FRCSEd

Abstract

Pneumatic retinopexy is an invasive procedure and requires all asepsis precautions to be followed, possibility of infective endophthalmitis to be kept in mind in clinical settings. This case report illustrates this important complication. A patient underwent pneumatic retinopexy to repair superior half retinal detachment caused by a single horseshoe-shaped tear. Two days later, he developed all signs of infective endophthalmitis. He was managed with intravitreal antibiotics and later vitreous surgery and gas tamponade to repair persistent retinal detachment. At one and half year of follow-up, his vision was 6/9, attached retina and no evidence of recurrence of infection.

Abstract

Pneumatic retinopexy is an invasive procedure and requires all asepsis precautions to be followed, possibility of infective endophthalmitis to be kept in mind in clinical settings. This case report illustrates this important complication. A patient underwent pneumatic retinopexy to repair superior half retinal detachment caused by a single horseshoe-shaped tear. Two days later, he developed all signs of infective endophthalmitis. He was managed with intravitreal antibiotics and later vitreous surgery and gas tamponade to repair persistent retinal detachment. At one and half year of follow-up, his vision was 6/9, attached retina and no evidence of recurrence of infection.

Post-Pneumatic Retinopexy Endophthalmitis: Management of Infection and Persistent Retinal Detachment

From the Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, India.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Tarun Sharma, MD, FRCSEd, Director, VR Services, 18 College Road, Chennai-600006, Tamil Nadu, India.

Accepted: November 01, 2008
Posted Online: March 09, 2010

Introduction

Pneumatic retinopexy is one of the surgical options to treat selected retinal detachments.1–3 While endophthalmitis can occur following any intraocular surgery, its occurrence following pneumatic retinopexy is rare (less than 1%).4 In a case report of endophthalmitis after pneumatic retinopexy described by Claus, the organism isolated was Staphylococcus epidermidis. During vitrectomy that this patient underwent, the retina was still attached.5

We report a case of endophthalmitis and persistent retinal detachment following pneumatic retinopexy that was managed with vitreous surgery and gas tamponade.

Case Report

A 58-year-old man gave a history of having undergone phacoemulsification with foldable intraocular lens (IOL) about a month back; intraoperatively anterior vitrectomy was performed following a rent in the posterior capsule. Four weeks following cataract surgery, he developed superior half retinal detachment caused by a large horse-shoe shaped tear at 12-o’clock meridian. He underwent pneumatic retinopexy using 0.4 mL of perfluoropropane gas withdrawn through a Millipore filter. No retinopexy was done at the time of surgery hoping that laser photocoagulation would be performed after the reattachment of the retina in the postoperative period.

On day one, most of the retina flattened. However, persistence of fluid did not permit laser treatment around the retinal break; only mild vitreous haze was observed. On day 2, he developed signs of infectious endophthalmitis such as hypopyon and intense vitreous haze with no clear view of the retina. Anterior chamber tap showed gram negative bacilli on smear examination, though subsequent culture was negative. Intravitreal injection of Vancomycin and Ceftazidime was given along with topical antibiotics, steroids and cycloplegics. He was then referred to our center for further management.

At the initial evaluation, his best-corrected visual acuity was hand motions. Slit-lamp examination showed persistent hypopyon and severe vitreous haze and no visible retinal details. B scan ultrasound showed membranous echoes in the mid and posterior vitreous cavity, reverberations due to IOL and gas, and thickened choroid. Subsequently, he received one more intravitreal injection (Vancomycin + Ceftazidime) along with oral steroids. Gradually, his vitreous clarity improved and underlying retinal detachment could be seen. About a week after he was examined by us, he underwent pars plana vitrectomy to clear the inflammatory membranes and debris along with #240 encircling band and gas tamponade and cryopexy to retinal break. No intraoperative complication occurred. Vitreous tap did not show growth of organism.

His immediate postoperative period was uneventful. Two months later, his visual acuity improved to 20/30, vitreous cavity was clear, and the retina attached. A year and half later, visual acuity of 20/30 was maintained with well-attached retina. No recurrence of inflammation or infection or detachment was observed throughout the follow-up.

Discussion

Occurrence of endophthalmitis after pneumatic retinopexy, though rare, should be suspected if the vitreous haze increases more so in the immediate postoperative period. Though smear showed bacterial organism, culture remained negative in this case suggesting that the load of infective agent in the anterior chamber was not adequate to grow in culture. Even vitreous tap was negative later, suggesting low virulence of infective agents probably responding to intravitreal antibiotics. Recovery of excellent vision suggested that early start of intravitreal antibiotics negated the effect of toxins on the retina. This case illustrated that vitreous surgery not only did allow clearing of the infective or inflammatory debris but also permitted successful reattachment of the retina.

References

  1. Sharma T, Gopal L. Recent developments in vitreoretinal surgery. J Indian Med Assoc. 2000;12:754–758,760–762.
  2. Sharma T. Posterior extension of retinal break following pneumatic retinopexy. Ann. Ophthalmol. 2002;34:47–48. doi:10.1007/s12009-002-0059-8 [CrossRef]
  3. Sharma T, Badrinath SS, Mukesh BN, Gopal L, Shanmugam MP, Bhende P, Bhende M, Shetty NS, Agrawal R. A multivariate analysis of anatomic success of recurrent retinal detachment treated with pneumatic retinopexy. Ophthalmology. 1997;104:2014–2017.
  4. Tornambe PE, Hilton GF: Pneumatic retinopexy. A multicenter randomized controlled clinical trial comparing pneumatic retinopexy with scleral buckling. The Retinal Detachment Study Group. Ophthalmology. 1989;96:772–783.
  5. Eckardt C. Staphylococcus epidermidis endophthalmitis after pneumatic retinopexy. Am J Ophthalmol. 1987;103:720–721.
Authors

From the Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, India.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Tarun Sharma, MD, FRCSEd, Director, VR Services, 18 College Road, Chennai-600006, Tamil Nadu, India.

10.3928/15428877-20100215-22

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