ENDOPHTHALMITIS AFTER 25-GAUGE PARS PLANA VITRECTOMY Larissa Magosso, MD, Andre´ Maia, MD, Mauricio Maia, MD, Michel Eid Farah, MD, Octaviano Magalha˜es Jr, MD
Background: Twenty-five– gauge vitrectomy is a sutureless procedure that allows surgery performed thorough transconjunctival incisions, but the possibility of intraocular infection exists. Methods: We report a case of endophthalmitis after minimally invasive vitrectomy and discuss the possible mechanisms of this complication. Results: Twenty-five– gauge vitrectomy was performed to treat a patient with proliferative diabetic retinopathy. On the third postoperative day, infectious endophthalmitis was diagnosed, and the patient immediately underwent surgery. After conjunctival dissection, “mushroom-shaped” tissue and purulent discharge were observed at the sclerotomy sites. On the third day after reoperation, visual acuity was no light perception, and the patient underwent evisceration. Conclusion: We believe that vitreous incarceration after 25-gauge vitrectomy is an additional risk factor for intraocular infection. It is important to exclude vitreous incarceration after removal of the trocar in addition to conjunctival displacement prior to trocar insertion and beveled incision. Instillation of trypan blue stains the extruded vitreous, pointing out the tissue to be removed at the end of the procedure and minimizing the possibility of intraocular infection. Other risk factors include immunossupresion, long duration of the procedure, and multiple instrument entry through the sclerotomy. RETINAL CASES & BRIEF REPORTS 1:185–187, 2007
From the Department of Ophthalmology, Paulista School of Medicine, Federal University of Sa˜o Paulo, IPEPO, Sa˜o Paulo, Brazil.
Case Report A 63-year-old diabetic woman had decreased visual acuity in the right eye for 6 months. Best-corrected visual acuity was hand movements. She had a vitreous hemorrhage due to proliferative diabetic retinopathy. After discussion of the surgical possibilities, 25-gauge vitrectomy was elected, and the surgical technique used was preoperative conjunctival instillation of povidone (5%) followed by washout. The conjunctiva was displaced, and the three-trocar system was inserted perpendicularly to the sclera. Near-complete vitrectomy was performed via a standard three-port pars plana approach, and the posterior hyaloid was easily detached. At the end of the surgical procedure, 800 endophotocoagulation burns were performed. At the time of the surgical procedure, the blood glucose level was 180 mg/dL, and the patient was instructed to use topical eyedrops (ciprofloxacin and dexamethasone) every 3 hours during the postoperative period. The entire procedure was performed with a sterile 25-gauge system kit (Alcon, USA) that had not been previously resterilized. On the first day after surgery, anterior chamber examination disclosed minimal flare, and fundus evaluation demonstrated no vitreous hemorrhage. Visual acuity was 20/60. The patient reported a painful red eye and decrease in visual acuity by the third day after the surgical procedure. Visual acuity was light perception. Anterior chamber examination disclosed corneal melting and hypopyon
V
itrectomy using the 25-gauge system is a surgical procedure that allows sutureless vitreoretinal surgery performed through small transconjunctival incisions.1 Although an easy surgical procedure may be performed using this technique, there are concerns about its efficiency in complicated cases as well as the possibility of intraocular infection after this procedure. In addition, 23-gauge vitrectomy has been used as a sutureless procedure.2 We describe a case of endophthalmitis after minimally invasive vitrectomy in a diabetic patient and discuss the possible mechanisms of this complication.
Reprint requests: Michel Eid Farah, MD, Vision Institute, Paulista School of Medicine, Federal University of Sa˜o Paulo, 822 Botucatu Street, Sa˜o Paulo, SP-04023-062, Brazil; e-mail: [email protected]
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Fig. 1. Postoperative photograph showing endophthalmitis characterized by red eye, corneal melting, and hypopyon.
(Fig. 1). Fundus examination could not be performed. Infectious endophthalmitis was diagnosed, and surgery was immediately performed. After conjunctival dissection, a “mushroom-shaped” prominent tissue was observed at the superior sclerotomy sites. This tissue was removed, and purulent discharge was observed through the sclerotomies (Fig. 2). A specimen was immediately collected for analysis, which was positive for Staphylococcus aureus. Twenty-gauge three-port pars plana vitrectomy was performed, but the retina was pale at this time. At the end of the surgical procedure, 2.0 mg of vancomycin and 2.0 mg of ceftazidime were injected into the vitreous cavity, and the 20-gauge sclerotomies were closed by polyglactin 910 7-0 sutures. The patient developed total corneal opacification, and on the third day after the reoperation, visual acuity was no light perception. Evisceration was then performed.
Discussion Although 25-gauge vitrectomy has been recognized as an alternative procedure especially useful for treating macular diseases such as macular holes, epiretinal
Fig. 2. Intraoperative view showing purulent discharge through the sclerotomy site.
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membranes, vitreoretinal traction syndrome, and vitreous opacities, there have been concerns about the possibility of intraocular infection after this surgical procedure due to the sutureless sclerotomies.3 The incidence of endophthalmitis after 20-gauge vitrectomy is ⬍0.1%, and risk factors for intraocular infection are blepharitis, diabetes, and systemic diseases, which result in immunosuppression.3,4 Although our patient had type 1 diabetes, there was no preoperative blepharitis, meibomitis, or dacryocystitis, and the diabetes was apparently under control. In addition, good compliance during postoperative care regarding the use of eyedrops was reported by the patient, and infectious prophylaxis was applied with preoperative conjunctival povidone instillation. Although the incidence of endophthalmitis after 20-gauge system vitrectomy is low and no other risks for endophthalmitis were present in this case except diabetes, we think that 25-gauge vitrectomy may have resulted in peripheral vitreous incarceration through the conjunctiva and sclera. We believe that the vitreous sealed the sclerotomy but had protruded through the conjunctiva, creating a contiguous communication between the vitreous cavity and the conjunctiva. Because the sclerotomy healing process may be delayed by this surgical technique, we hypothesized, based on the outcome of this case, that bacteria gained access to the vitreous cavity.1,3,4 In a rabbit model, we also observed the possibility of vitreous incarceration through the conjunctiva and intraocular infection followed by bacteria instillation at the conjunctiva after 25-gauge incisions and no conjunctival displacement (authors’ unpublished data) We strongly advise that care should be taken in the selection of patients for 25-gauge vitrectomy. We also believe that additional care should be used during conjunctival displacement before the trocar insertion and beveled incision; it is important to observe the conjunctival incisions to exclude vitreous incarceration through the conjunctiva after the removal of the trocar to minimize the possibility of intraocular infection.1,3 We are currently using conjunctival instillation of trypan blue at the end of vitreoretinal surgery using the 25-gauge system; this dye stains the vitreous in case it is extruded and incarcerated through the conjunctiva (Fig. 3), pointing out the tissue to be removed using the vitreous cutter probe at the end of surgery. It is also important to be aware that additional risk factors for intraocular infection after vitrectomy include immunologic diseases, long duration of the procedure, and entry of multiple instruments through the sclerotomy during 25-gauge vitreoretinal surgery of a diabetic patient. The value of systemic prophylaxis with antibiotics such as fourth-generation quinolones
187
ENDOPHTHALMITIS AFTER 25-GAUGE VITRECTOMY
In summary, we describe the possibility of endophthalmitis after 25-gauge pars plana vitrectomy and discuss concerns about the risk of this complication after this novel surgical approach. Key words: diabetes, endophthalmitis, minimally invasive vitrectomy, vitreoretinal surgery.
References 1.
2. Fig. 3. Intraoperative maneuver using trypan blue to stain the vitreous incarcerated through the conjunctiva.
3. 4.
in specific cases as well as the safety of vitrectomy using the 25-gauge system must be better evaluated in the future to optimize the results of this innovative surgical technique.5
5.
Fujii GY, De Juan Jr, E Humayun MD, et al. Initial experience using the transconjunctival sutureless vitrectomy for vitreoretinal surgery. Ophthalmology 2002;109:1814–1820. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy. Retina 2005;25:208–211. Taylor SR, Aylward GW. Endophthalmitis following 25gauge vitrectomy. Eye 2005;19:1228–1229. Eifrig CW, Scott IU, Flynn HW, et al. Endophthalmitis after pars plana vitrectomy: incidence, causative organisms, and visual acuity outcomes. Am J Ophthalmol 2004;138:799–802. Fuller JJ, Marcus DM. Vitreous and aqueous penetration of orally administered gatifloxacin in humans. Arch Ophthalmol 2004;122:1408–1409.
Background: Twenty-five– gauge vitrectomy is a sutureless procedure that allows surgery performed thorough transconjunctival incisions, but the possibility of intraocular infection exists. Methods: We report a case of endophthalmitis after minimally invasive vitrectomy and discuss the possible mechanisms of this complication. Results: Twenty-five– gauge vitrectomy was performed to treat a patient with proliferative diabetic retinopathy. On the third postoperative day, infectious endophthalmitis was diagnosed, and the patient immediately underwent surgery. After conjunctival dissection, “mushroom-shaped” tissue and purulent discharge were observed at the sclerotomy sites. On the third day after reoperation, visual acuity was no light perception, and the patient underwent evisceration. Conclusion: We believe that vitreous incarceration after 25-gauge vitrectomy is an additional risk factor for intraocular infection. It is important to exclude vitreous incarceration after removal of the trocar in addition to conjunctival displacement prior to trocar insertion and beveled incision. Instillation of trypan blue stains the extruded vitreous, pointing out the tissue to be removed at the end of the procedure and minimizing the possibility of intraocular infection. Other risk factors include immunossupresion, long duration of the procedure, and multiple instrument entry through the sclerotomy. RETINAL CASES & BRIEF REPORTS 1:185–187, 2007
From the Department of Ophthalmology, Paulista School of Medicine, Federal University of Sa˜o Paulo, IPEPO, Sa˜o Paulo, Brazil.
Case Report A 63-year-old diabetic woman had decreased visual acuity in the right eye for 6 months. Best-corrected visual acuity was hand movements. She had a vitreous hemorrhage due to proliferative diabetic retinopathy. After discussion of the surgical possibilities, 25-gauge vitrectomy was elected, and the surgical technique used was preoperative conjunctival instillation of povidone (5%) followed by washout. The conjunctiva was displaced, and the three-trocar system was inserted perpendicularly to the sclera. Near-complete vitrectomy was performed via a standard three-port pars plana approach, and the posterior hyaloid was easily detached. At the end of the surgical procedure, 800 endophotocoagulation burns were performed. At the time of the surgical procedure, the blood glucose level was 180 mg/dL, and the patient was instructed to use topical eyedrops (ciprofloxacin and dexamethasone) every 3 hours during the postoperative period. The entire procedure was performed with a sterile 25-gauge system kit (Alcon, USA) that had not been previously resterilized. On the first day after surgery, anterior chamber examination disclosed minimal flare, and fundus evaluation demonstrated no vitreous hemorrhage. Visual acuity was 20/60. The patient reported a painful red eye and decrease in visual acuity by the third day after the surgical procedure. Visual acuity was light perception. Anterior chamber examination disclosed corneal melting and hypopyon
V
itrectomy using the 25-gauge system is a surgical procedure that allows sutureless vitreoretinal surgery performed through small transconjunctival incisions.1 Although an easy surgical procedure may be performed using this technique, there are concerns about its efficiency in complicated cases as well as the possibility of intraocular infection after this procedure. In addition, 23-gauge vitrectomy has been used as a sutureless procedure.2 We describe a case of endophthalmitis after minimally invasive vitrectomy in a diabetic patient and discuss the possible mechanisms of this complication.
Reprint requests: Michel Eid Farah, MD, Vision Institute, Paulista School of Medicine, Federal University of Sa˜o Paulo, 822 Botucatu Street, Sa˜o Paulo, SP-04023-062, Brazil; e-mail: [email protected]
185
RETINAL CASES & BRIEF REPORTSℜ
186
Fig. 1. Postoperative photograph showing endophthalmitis characterized by red eye, corneal melting, and hypopyon.
(Fig. 1). Fundus examination could not be performed. Infectious endophthalmitis was diagnosed, and surgery was immediately performed. After conjunctival dissection, a “mushroom-shaped” prominent tissue was observed at the superior sclerotomy sites. This tissue was removed, and purulent discharge was observed through the sclerotomies (Fig. 2). A specimen was immediately collected for analysis, which was positive for Staphylococcus aureus. Twenty-gauge three-port pars plana vitrectomy was performed, but the retina was pale at this time. At the end of the surgical procedure, 2.0 mg of vancomycin and 2.0 mg of ceftazidime were injected into the vitreous cavity, and the 20-gauge sclerotomies were closed by polyglactin 910 7-0 sutures. The patient developed total corneal opacification, and on the third day after the reoperation, visual acuity was no light perception. Evisceration was then performed.
Discussion Although 25-gauge vitrectomy has been recognized as an alternative procedure especially useful for treating macular diseases such as macular holes, epiretinal
Fig. 2. Intraoperative view showing purulent discharge through the sclerotomy site.
●
2007
●
VOLUME 1
●
NUMBER 3
membranes, vitreoretinal traction syndrome, and vitreous opacities, there have been concerns about the possibility of intraocular infection after this surgical procedure due to the sutureless sclerotomies.3 The incidence of endophthalmitis after 20-gauge vitrectomy is ⬍0.1%, and risk factors for intraocular infection are blepharitis, diabetes, and systemic diseases, which result in immunosuppression.3,4 Although our patient had type 1 diabetes, there was no preoperative blepharitis, meibomitis, or dacryocystitis, and the diabetes was apparently under control. In addition, good compliance during postoperative care regarding the use of eyedrops was reported by the patient, and infectious prophylaxis was applied with preoperative conjunctival povidone instillation. Although the incidence of endophthalmitis after 20-gauge system vitrectomy is low and no other risks for endophthalmitis were present in this case except diabetes, we think that 25-gauge vitrectomy may have resulted in peripheral vitreous incarceration through the conjunctiva and sclera. We believe that the vitreous sealed the sclerotomy but had protruded through the conjunctiva, creating a contiguous communication between the vitreous cavity and the conjunctiva. Because the sclerotomy healing process may be delayed by this surgical technique, we hypothesized, based on the outcome of this case, that bacteria gained access to the vitreous cavity.1,3,4 In a rabbit model, we also observed the possibility of vitreous incarceration through the conjunctiva and intraocular infection followed by bacteria instillation at the conjunctiva after 25-gauge incisions and no conjunctival displacement (authors’ unpublished data) We strongly advise that care should be taken in the selection of patients for 25-gauge vitrectomy. We also believe that additional care should be used during conjunctival displacement before the trocar insertion and beveled incision; it is important to observe the conjunctival incisions to exclude vitreous incarceration through the conjunctiva after the removal of the trocar to minimize the possibility of intraocular infection.1,3 We are currently using conjunctival instillation of trypan blue at the end of vitreoretinal surgery using the 25-gauge system; this dye stains the vitreous in case it is extruded and incarcerated through the conjunctiva (Fig. 3), pointing out the tissue to be removed using the vitreous cutter probe at the end of surgery. It is also important to be aware that additional risk factors for intraocular infection after vitrectomy include immunologic diseases, long duration of the procedure, and entry of multiple instruments through the sclerotomy during 25-gauge vitreoretinal surgery of a diabetic patient. The value of systemic prophylaxis with antibiotics such as fourth-generation quinolones
187
ENDOPHTHALMITIS AFTER 25-GAUGE VITRECTOMY
In summary, we describe the possibility of endophthalmitis after 25-gauge pars plana vitrectomy and discuss concerns about the risk of this complication after this novel surgical approach. Key words: diabetes, endophthalmitis, minimally invasive vitrectomy, vitreoretinal surgery.
References 1.
2. Fig. 3. Intraoperative maneuver using trypan blue to stain the vitreous incarcerated through the conjunctiva.
3. 4.
in specific cases as well as the safety of vitrectomy using the 25-gauge system must be better evaluated in the future to optimize the results of this innovative surgical technique.5
5.
Fujii GY, De Juan Jr, E Humayun MD, et al. Initial experience using the transconjunctival sutureless vitrectomy for vitreoretinal surgery. Ophthalmology 2002;109:1814–1820. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy. Retina 2005;25:208–211. Taylor SR, Aylward GW. Endophthalmitis following 25gauge vitrectomy. Eye 2005;19:1228–1229. Eifrig CW, Scott IU, Flynn HW, et al. Endophthalmitis after pars plana vitrectomy: incidence, causative organisms, and visual acuity outcomes. Am J Ophthalmol 2004;138:799–802. Fuller JJ, Marcus DM. Vitreous and aqueous penetration of orally administered gatifloxacin in humans. Arch Ophthalmol 2004;122:1408–1409.
