520
AMERICAN JOURNAL OF OPHTHALMOLOGY E N D O P H T H A L M I T I S AFTER VITRECTOMY
D O N A L D R. M A Y , M.D., PEYMAN,
AND G H O L A M A. M.D.
Chicago, Illinois The incidence of endophthalmitis re ported after vitrectomy is extremely low. Machemer did not report a single case in his series 1,2 ; in a recent series of 100 cases Michels and Ryan 3 reported one case of endophthalmitis. Of 250 vitrectomies performed here, we have encountered only one case of endophthalmitis. CASE REPORT A 29-year-old white man with growth-onset diabe tes, controlled with 50 units of NPH insulin daily, first noted a subjective decrease in vision one year before hospital admission in April 1974. He was examined for diabetic retinopathy, and over the next month, received 360-degree argon laser peripheral ablation in both eyes. Within one month after treat ment, he experienced bilateral vitreous hemorrhages that recurred for the next ten months. On admission in April 1975, his best corrected visual acuity was R.E.: hand motions, and L.E.: counting fingers at 1 foot. Intraocular pressure by applanation tonometry was 14 mm Hg in each eye. Dense fresh and old blood in the vitreous humor of both eyes obscured the view of the fundus. Ultra sound examination showed no evidence of retinal detachment. In May he underwent an uncomplicat ed pars plana vitrectomy with partial lysis on the vitreous traction bands in the right eye. The day after vitrectomy, we noted a dense vitreous hemor rhage that did not clear. Ten weeks later, the patient had a vitreous lavage with the vitrophage. A moderate vitreous haze, pre sent at the end of the operation, persisted 24 hours after operation, and the anterior chamber had 1 to 2 + flare and several cells. The patient complained of moderate pain in the eye and reported episodes of intermittent chills and loss of appetite. Thirty-six hours after surgery, the appearance of the eye was unchanged, but the pain was more severe. The patient was afebrile. Forty-eight hours after the operation, the patient reported that he had had severe pain during the preceding night, and he had marked inflammation and edema of the conjunctiva From the Department of Ophthalmology, Univer sity of Illinois Eye and Ear Infirmary, Chicago, Illinois. This study was supported in part by Public Health Service grant 1107-03, and in part by the Lions of Illinois Foundation. Reprint requests to Donald R. May, M.D., Univer sity of Illinois Eye and Ear Infirmary, 1855 W. Taylor St., Chicago, IL 60612.
APRIL, 1976
and eyelids. The anterior chamber showed a 2-mm hypopyon with 3+ cells; the vitreous cavity was hazy. Because we thought the infecting organism might be gentamicin-resistant, we administered parenteral kanamycin, 150 mg, and oxacillin, 500 mg. However, we discovered that the saline solution containing gentamicin that had been prepared for this patient was not used during the vitreous lavage. Five hours later the patient underwent lensectomy and vitrectomy for removal of an opaque lens and vitreous opacities. At the end of the operation, we injected 20 μg of kanamycin and 50 μg of oxacillin intravitreally. Dense haze persisted in the vitreous cavity, and the cornea was edematous; we were unable to see fundus detail. Postoperatively, systemic oxacillin and kanamy cin were continued every six hours. Because of increased intraocular pressure (35 to 40 mm Hg), parenteral acetazolamide, 250 mg, was given every six hours. The dense vitreous haze did not clear and two days later the eye had no light perception. Four days after lensectomy and vitrectomy the eye was eviscerated. The postevisceration course was un eventful, and the patient was discharged four days later. Cultures of the vitreous and aqueous humors aspirated at lensectomy and vitrectomy grew Grampositive, coagulase-negative micrococci sensitive to gentamicin, kanamycin, and oxacillin, and resistant to only penicillin and tetracycline. Vitreous cultures at the time of evisceration grew the same organism. Five smears of aqueous and vitreous humors done at both of these procedures showed many polymorphonuclear leukocytes on Giemsa-stained slides but no microorganisms. Gram and potassium hydroxide stains were also negative. The source of the infec tion could not be traced. Eyelid and conjunctival cultures of the right eye were negative for micrococci. DISCUSSION
Endophthalmitis is difficult to diag nose after vitrectomy because of moderate to significant amounts of vitreous haze secondary to surgically induced uveitis or residual intravitreal blood. Cells and flare (1 to 2+) in the anterior chamber and vitreous cavity are not unusual findings the first day after vitrectomy; pain might be a more noteworthy sign of endophthal mitis. Because of our lack of experience with this complication after vitrectomy and in the absence of other signs or symp toms, including the absence of a hypo pyon, our patient's pain was interpreted as postoperative discomfort. The initial di agnosis was delayed until 48 hours after operation, too late for effective therapy.
NOTES, CASES, INSTRUMENTS
VOL. 81, NO. 4
On the basis of our experience, patients must be observed closely at first sign of severe pain after vitrectomy and appro priate treatment must be initiated as soon as a diagnosis of endophthalmitis is sus pected. If gentamicin had been present in the infusion fluid used for the vitreous lavage, 4 this case of endophthalmitis might have been prevented. This unfortunate occurrence reinforces the value of antibi otics in the infusion solution, particularly in traumatic or possibly contaminated in juries. SUMMARY
A 29-year-old white man with growthonset diabetes developed fulminant en dophthalmitis after vitreous lavage. The only significant symptom was severe pain 36 hours after surgery. The endophthal mitis rapidly became more severe. De spite systemic antibiotics, therapeutic vit rectomy and lensectomy, followed by the intraocular injection of antibiotics 48 hours postoperatively, the eye was lost. REFERENCES 1. Machemer, R.: A new concept for vitreous surgery. 2. Surgical technique and complications. Am. J. Ophthalmol. 74:1022, 1972. 2. Machemer, R., and Norton, E. W. D.: A new concept for vitreous surgery. 3. Indications and results. Am. J. Ophthalmol. 74:1034, 1972. 3. Michels, R. G., and Ryan, S. J.: Results and complications of 100 consecutive cases of pars plana vitrectomy. Am. J. Ophthalmol. 80:24, 1975. 4. Peyman, G. A., Paque, J. T., Meiseis, H. I., and Bennett, T. O.: Postoperative endophthalmitis. A comparison of methods for treatment and prophy laxis with gentamicin. Ophthalmic Surg. 6:45,1975.
F O C U S I N G L I G H T D I M M E R FOR T H E ZEISS F U N D U S CAMERA JEAN-MARIE PAREL, I N G . E T S - G . , AND R O N A L D L A S H L E Y , B.S. Miami,
Florida
When taking a fluorescein angiographie sequence, frequent refocusing in white
521
Figure (Parel and Lashley). The subminiature light dimmer in use.
light is necessary. Unless the camera is fully automated, 1 the photographer must first manually lower the observation beam intensity before removing the barrier fil ter. With the systems that are commercial ly available today, he must actually oper ate a switch installed on the remote power unit. Usually such a maneuver will result in a loss of visual contact with the pa tient's retina. Precise refocusing will then be time consuming and a precious por tion of the fluorescein sequence will be lost. We eliminated this problem by intro ducing a subminiature electronic dimmer (Figure) within the observation lamp socket that was modified to include a heat shield. A small potentiometer allows the photographer full, fingertip control of the observation beam intensity. As it replaces the standard observation lamp socket, such a device* can be readi ly plugged into the main body or power supply of any Zeiss fundus camera with out modification. From the Bascom Palmer Eye Institute, Depart ment of Ophthalmology, University of Miami School of Medicine, Miami, Florida. Reprint requests to Jean-Marie Parel, Ing. E T S G., P.O. Box 520875, Biscayne Annex, Miami, F L 33152. *This device is available from Clinitex, Inc., 183 Newbury St., Danvers, MA 01923.
AMERICAN JOURNAL OF OPHTHALMOLOGY E N D O P H T H A L M I T I S AFTER VITRECTOMY
D O N A L D R. M A Y , M.D., PEYMAN,
AND G H O L A M A. M.D.
Chicago, Illinois The incidence of endophthalmitis re ported after vitrectomy is extremely low. Machemer did not report a single case in his series 1,2 ; in a recent series of 100 cases Michels and Ryan 3 reported one case of endophthalmitis. Of 250 vitrectomies performed here, we have encountered only one case of endophthalmitis. CASE REPORT A 29-year-old white man with growth-onset diabe tes, controlled with 50 units of NPH insulin daily, first noted a subjective decrease in vision one year before hospital admission in April 1974. He was examined for diabetic retinopathy, and over the next month, received 360-degree argon laser peripheral ablation in both eyes. Within one month after treat ment, he experienced bilateral vitreous hemorrhages that recurred for the next ten months. On admission in April 1975, his best corrected visual acuity was R.E.: hand motions, and L.E.: counting fingers at 1 foot. Intraocular pressure by applanation tonometry was 14 mm Hg in each eye. Dense fresh and old blood in the vitreous humor of both eyes obscured the view of the fundus. Ultra sound examination showed no evidence of retinal detachment. In May he underwent an uncomplicat ed pars plana vitrectomy with partial lysis on the vitreous traction bands in the right eye. The day after vitrectomy, we noted a dense vitreous hemor rhage that did not clear. Ten weeks later, the patient had a vitreous lavage with the vitrophage. A moderate vitreous haze, pre sent at the end of the operation, persisted 24 hours after operation, and the anterior chamber had 1 to 2 + flare and several cells. The patient complained of moderate pain in the eye and reported episodes of intermittent chills and loss of appetite. Thirty-six hours after surgery, the appearance of the eye was unchanged, but the pain was more severe. The patient was afebrile. Forty-eight hours after the operation, the patient reported that he had had severe pain during the preceding night, and he had marked inflammation and edema of the conjunctiva From the Department of Ophthalmology, Univer sity of Illinois Eye and Ear Infirmary, Chicago, Illinois. This study was supported in part by Public Health Service grant 1107-03, and in part by the Lions of Illinois Foundation. Reprint requests to Donald R. May, M.D., Univer sity of Illinois Eye and Ear Infirmary, 1855 W. Taylor St., Chicago, IL 60612.
APRIL, 1976
and eyelids. The anterior chamber showed a 2-mm hypopyon with 3+ cells; the vitreous cavity was hazy. Because we thought the infecting organism might be gentamicin-resistant, we administered parenteral kanamycin, 150 mg, and oxacillin, 500 mg. However, we discovered that the saline solution containing gentamicin that had been prepared for this patient was not used during the vitreous lavage. Five hours later the patient underwent lensectomy and vitrectomy for removal of an opaque lens and vitreous opacities. At the end of the operation, we injected 20 μg of kanamycin and 50 μg of oxacillin intravitreally. Dense haze persisted in the vitreous cavity, and the cornea was edematous; we were unable to see fundus detail. Postoperatively, systemic oxacillin and kanamy cin were continued every six hours. Because of increased intraocular pressure (35 to 40 mm Hg), parenteral acetazolamide, 250 mg, was given every six hours. The dense vitreous haze did not clear and two days later the eye had no light perception. Four days after lensectomy and vitrectomy the eye was eviscerated. The postevisceration course was un eventful, and the patient was discharged four days later. Cultures of the vitreous and aqueous humors aspirated at lensectomy and vitrectomy grew Grampositive, coagulase-negative micrococci sensitive to gentamicin, kanamycin, and oxacillin, and resistant to only penicillin and tetracycline. Vitreous cultures at the time of evisceration grew the same organism. Five smears of aqueous and vitreous humors done at both of these procedures showed many polymorphonuclear leukocytes on Giemsa-stained slides but no microorganisms. Gram and potassium hydroxide stains were also negative. The source of the infec tion could not be traced. Eyelid and conjunctival cultures of the right eye were negative for micrococci. DISCUSSION
Endophthalmitis is difficult to diag nose after vitrectomy because of moderate to significant amounts of vitreous haze secondary to surgically induced uveitis or residual intravitreal blood. Cells and flare (1 to 2+) in the anterior chamber and vitreous cavity are not unusual findings the first day after vitrectomy; pain might be a more noteworthy sign of endophthal mitis. Because of our lack of experience with this complication after vitrectomy and in the absence of other signs or symp toms, including the absence of a hypo pyon, our patient's pain was interpreted as postoperative discomfort. The initial di agnosis was delayed until 48 hours after operation, too late for effective therapy.
NOTES, CASES, INSTRUMENTS
VOL. 81, NO. 4
On the basis of our experience, patients must be observed closely at first sign of severe pain after vitrectomy and appro priate treatment must be initiated as soon as a diagnosis of endophthalmitis is sus pected. If gentamicin had been present in the infusion fluid used for the vitreous lavage, 4 this case of endophthalmitis might have been prevented. This unfortunate occurrence reinforces the value of antibi otics in the infusion solution, particularly in traumatic or possibly contaminated in juries. SUMMARY
A 29-year-old white man with growthonset diabetes developed fulminant en dophthalmitis after vitreous lavage. The only significant symptom was severe pain 36 hours after surgery. The endophthal mitis rapidly became more severe. De spite systemic antibiotics, therapeutic vit rectomy and lensectomy, followed by the intraocular injection of antibiotics 48 hours postoperatively, the eye was lost. REFERENCES 1. Machemer, R.: A new concept for vitreous surgery. 2. Surgical technique and complications. Am. J. Ophthalmol. 74:1022, 1972. 2. Machemer, R., and Norton, E. W. D.: A new concept for vitreous surgery. 3. Indications and results. Am. J. Ophthalmol. 74:1034, 1972. 3. Michels, R. G., and Ryan, S. J.: Results and complications of 100 consecutive cases of pars plana vitrectomy. Am. J. Ophthalmol. 80:24, 1975. 4. Peyman, G. A., Paque, J. T., Meiseis, H. I., and Bennett, T. O.: Postoperative endophthalmitis. A comparison of methods for treatment and prophy laxis with gentamicin. Ophthalmic Surg. 6:45,1975.
F O C U S I N G L I G H T D I M M E R FOR T H E ZEISS F U N D U S CAMERA JEAN-MARIE PAREL, I N G . E T S - G . , AND R O N A L D L A S H L E Y , B.S. Miami,
Florida
When taking a fluorescein angiographie sequence, frequent refocusing in white
521
Figure (Parel and Lashley). The subminiature light dimmer in use.
light is necessary. Unless the camera is fully automated, 1 the photographer must first manually lower the observation beam intensity before removing the barrier fil ter. With the systems that are commercial ly available today, he must actually oper ate a switch installed on the remote power unit. Usually such a maneuver will result in a loss of visual contact with the pa tient's retina. Precise refocusing will then be time consuming and a precious por tion of the fluorescein sequence will be lost. We eliminated this problem by intro ducing a subminiature electronic dimmer (Figure) within the observation lamp socket that was modified to include a heat shield. A small potentiometer allows the photographer full, fingertip control of the observation beam intensity. As it replaces the standard observation lamp socket, such a device* can be readi ly plugged into the main body or power supply of any Zeiss fundus camera with out modification. From the Bascom Palmer Eye Institute, Depart ment of Ophthalmology, University of Miami School of Medicine, Miami, Florida. Reprint requests to Jean-Marie Parel, Ing. E T S G., P.O. Box 520875, Biscayne Annex, Miami, F L 33152. *This device is available from Clinitex, Inc., 183 Newbury St., Danvers, MA 01923.
