Author: KRISHNENDU NANDI (India)
Co-authors:
Purpose
To study the clinical profile and outcome of patients developing endophthalmitis after vitrectomy
Setting/Venue
Tertiary Eye Care Centre
Methods
The study was initiated after approval from the Institutional Ethics Committee to retrospectively analyze the data from a series of 3100 consecutive vitrectomy surgeries performed from January 2015 to January 2109. The tenets of the Declaration of Helsinki were followed and informed consent was obtained from the patients` for use of their data from medical records for research purpose. Endophthalmitis developing after vitrectomy was defined as presence of unusual inflammation in the vitreous cavity or anterior chamber within a period of 6 weeks after surgery along with microbiological evidence of bacterial/fungal infection.(2) All cases of endophthalmitis in this study was culture-positive. All patients taken up for vitrectomy were prescribed antibiotic eye drops (gatifloxacin 0.3%) 4 times per day for application from 3 days prior to surgery. Pre-operatively 5% povidone-iodine solution was instilled in the conjunctival sac and was allowed a contact period of 3 minutes followed by periocular cleaning with 1% povidone iodine solution before draping. Following the surgery the patients were put on oral antibiotics and anti inflammatory agents, topical antibiotics and topical steroids routinely. The cases were followed up the very next day before being called for the next follow up at 1 week interval. For the patients who developed endophthalmitis data such as age of the patient, sex of the patient, indication for surgery, which eye was operated, interval of onset of symptoms from the date of surgery, symptoms of the patient, pre-operative vision, vision on presentation, result of ultrasound evaluation, results from culture of sample obtained, what intervention was carried out, post op vision, eventual outcome of the condition was noted. If the patient was suspected to have developed endophthalmitis, a gentle and sterile ultrasound examination was performed to evaluate the ocular structures and the extent of involvement. Anterior chamber tap was done for patients who were not planned for vitrectomy (for endophthalmitis) and the sample collected were sent for microbiological investigation. For the patients for whom repeat vitrectomy was planned sample for microbiological evaluation was collected by vitreous tap before initiating irrigating fluids. All the samples were sent to an accredited lab the same day for investigations such as Gram staining, KOH Mount, culture and sensitivity, PCR (Polymerase Chain Reaction) for eubacterial genome and pan-fungal genome. Optimal structural outcome was defined as Normal intraocular pressure with no retinal detachment after 3 months of follow up. Parametric and non-parametric tests were performed for contiguous and non-contiguous variables. A p value of <0.05 was considered to be significant
Results
In our series of 3100 consecutive vitrectomies 8 patients (0.26%) developed endophthalmitis in the post-operative period. All of them developed the dreaded complication within a period of 15 days from the vitrectomy surgery. All the surgeries performed in our series were 23 Gauge trans conjunctival vitrectomies. The indication for surgery in the cases which developed endophthalmitis were proliferative diabetic retinopathy (PDR) in 3 cases (37.5 %), traumatic vitreous haemorrhage in 2 cases (25 %), vasculitis related vitreous haemorrhage in 2 cases (25 %) and a traumatic retinal detachment in 1 case (12.5 %). The mean visual acuity on presentation was 1.4 LogMAR. Six of the patients were male (75 %) and 2 were female (25 %). The mean age of the patients were 21.12 years. The mean interval from surgery to diagnosis of endophthalmitis was 7.37 days. 3 of the patients were known diabetics (37.5 %). One patient was on oral steroids for associated systemic illness (12.5 %). Two of the patients presented with ocular motility restriction along with the acute signs of inflammation (25 %). Ultrasound evaluation revealed retinal detachment in 4 cases (50 %) and choroidal detachment was also noted in a few. Intravitreal injection of antibiotics vancomycin and amikacin was given to 2 patients (25 %) and 1 patient received a combination of the above antibiotics and steroid intravitreal injection (12.5 %). Repeat vitrectomy was performed for 4 (50 %) of the cases with 1 patient out of them having to undergo evisceration following worsening of the condition after vitrectomy. Three patients had to undergo evisceration as their eye could not be salvaged (evisceration – 4 eyes out of 8 – 50%). Samples from all the cases were sent for microbiological evaluation and all of them came out to be culture positive, with all of them showing evidence of bacterial infection, which correlates with the early presentation of the cases following surgery. Four of the samples came back positive for Staphylococcus epidermidis (50 %), 1 each for Pseudomonas sp (12.5%) Escherichia coli (12.5 %), Enterobacter sp (12.5 %), Acinetobacter sp (12.5 %). Two patients ended up with LogMAR acuity of 1.0 (25%), 2 patients with Perception of Light (25%), and the ones eviscerated were No PL (50%). The structural outcome in 4 cases (50%) were favorable with normal IOP and no retinal detachment. The follow up duration of the patients ranged from 3 months to 30 months post operatively with mean follow up being of 12 months
Conlusions
Endophthalmitis after vitrectomy, though rare, usually ends in a grave clinical picture with very poor visual and structural prognosis. Extreme caution with regard to asepsis in the peri-operative period is essential to reduce the incidence and morbidity of this condition
Financial Disclosure
Not Applicable
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