The
Endophthalmitis Vitrectomy Study
(70%) Mostplication ofofendophthalmitis intraocular surgery.1 The incidence of but it is occur as a com-
cases
endophthalmitis varies,
generally reported to
after 0.1% to 0.4% of cataract operations,2-5 and the vast majority of cases (88%) occur within 6 weeks of surgery.6 Despite measures believed to decrease the incidence of infection, such as microsurgical wound closure, perioperative antibiotic injections, and preservation of an intact posterior capsule, postoperative endophthalmitis continues to occur, and current management still leaves many eyes with only poor vision. In the not too distant past, conventional treatment of bacterial endophthalmitis consisted of intravenous, subconjunctival, and topical antibiotics. Visual results with this approach were poor, with visual acuity of only hand motions or worse in 67% to 96% of cases.5,7-9 Studies showing poor intravitreal antibiotic penetration by these routes led to trials using direct injection of antibiotics into the vitreous. It was not until the early 1980s that there was broad consensus that direct intravitreal injection of antibiotics was important in treating post¬ operative bacterial endophthalmitis.10 occur
INTRAVENOUS ANTIBIOTICS
Although systemic antibiotics have been part of the standard care of bacterial endophthalmitis, poor ocu¬ lar penetration and limited efficacy have been docu¬ mented.1" While other recently introduced drugs have been shown to have greater penetration into human eyes after intravenous administration, they still do not reach high enough levels in the vitreous to be effective against some of the common bacteria responsible for
postoperative endophthalmitis.11 Well-documented side effects of some systemic antibiotics include nephrotoxicity, ototoxicity, pseudomembranous colitis, aplastic anemia, hypersensitivity reactions, diarrhea, superinfections, bleeding disorders, and hepatotoxicity.12,13 Other concerns about intravenous (as distinct from in¬ travitreal) antibiotics include the cost not only of the
drugs, but also of the hospitalization required for their administration. The role of systemic antibiotics in the management of endophthalmitis remains uncertain. VITRECTOMY
Vitrectomy was introduced in the 1970s, and many began to employ it in conjunction with intra-
surgeons
vitreal antibiotics in
treating endophthalmitis. Vitrec¬
tomy offers several theoretical advantages, including
removal of the infecting organisms and the toxins they produce, better distribution of antibiotics, removal of vitreous membranes that could lead to traction detach¬ ment of the retina,14 clearing of vitreous opacities,15 and provision of adequate material for culture. Vitrectomy followed by intraocular antibiotics has been shown in certain animal studies1617 to offer advan¬ tages over intraocular antibiotics alone. Data from hu¬ man studies, however, have been less conclusive. In four studies in which vitrectomy along with intraocular antibiotic therapy were compared with intraocular antibiotic therapy alone, 20/400 visual acuity or better was achieved in 59%, 64%, 26%, and 50% of eyes that underwent vitrectomy, compared with 57%, 83%, 80%, and 95% of eyes that did not undergo vitrectomy, re¬ spectively.11'5·1819 In these human studies, the eyes se¬ lected for vitrectomy were those with the worst clinical presentations. This selection bias makes it impossible to determine whether vitrectomy combined with in¬ traocular antibiotics is better or worse than intraocular antibiotics alone. Similarly, while the incidence of po¬ tential side effects such as retinal detachment is re¬ ported to be higher15,20 in infected eyes undergoing vi¬ trectomy, it is possible that these results are due to differences in disease severity between treatment groups as opposed to differences in the effect of treat¬ ment. Therefore, the exact role of vitrectomy in the initial management of endophthalmitis remains controversial. ENDOPHTHALMITIS VITRECTOMY STUDY CLINICAL TRIAL
A prospective, randomized, multicenter, clinical trial has been designed to shed further light on the roles of pars plana vitrectomy and intravenous antibiotics in acute postoperative endophthalmitis. The Endophthal¬ mitis Vitrectomy Study recently began recruiting pa¬ tients.21 Clinical centers in 25 cities throughout the United States will cooperate in enrolling 420 patients over a 42-month period. Patients are eligible to participate in this trial if they have clinical signs and symptoms of bacterial endoph¬ thalmitis within 6 weeks after cataract surgery or sec¬ ondary lens implantation. Visual acuity must be light perception or better, and the patient must read fewer
Downloaded From: http://archopht.jamanetwork.com/ by a Monash University Library User on 06/15/2015
than 36 letters on the Endophthalmitis Vitrectomy Study visual acuity chart (approximately 20/50 or worse). The cornea and anterior chamber of the in¬ volved eye must be clear enough to allow visualization of some part of the iris, and the cornea must be clear enough to allow the possibility of pars plana vitrec¬ tomy. A hypopyon must be present in the involved eye, or clouding of the anterior chamber or vitreous media must be severe enough to obscure visualization of sec¬ ond-order retinal arterioles. All patients in the Endophthalmitis Vitrectomy Study will undergo immediate cultures of the anterior chamber and vitreous and will receive intravitreal (amikacin sulfate [0.4 mg] and vancomycin hydrochloride [1.0 mgj) and subconjunctival (vancomycin [25 mgj and ceftazidime [100 mg]) antibiotics, topical antibiotics (vancomycin and amikacin), and topical cycloplegics. Topical, periocular, and systemic corticosteroide will also be administered. Additional management at presentation will depend on the group to which the patient is randomly assigned. One group will undergo immediate pars plana vitrec¬ tomy with intravenous antibiotics (ceftazidime and ami¬ kacin), and another will undergo pars plana vitrectomy without intravenous antibiotics. A third group will un¬ dergo an initial tap of the vitreous (vitrectomy is de¬ ferred) with intravenous antibiotics, and the fourth will undergo an initial tap of the vitreous without intrave¬ nous antibiotics. Taps of the vitreous will involve re¬ moval of no more than 0.2 mL of vitreous fluid for culture. Between 36 and 60 hours after the initial proce¬ dure, patients will be assessed to determine if addition¬ al treatment is required based on study-defined crite¬ ria21 for eyes responding poorly to treatment. Eyes originally randomized to undergo taps will undergo vitrectomy and reinjection of intravitreal antibiotics. Eyes that initially underwent vitrectomy will have re¬ peat cultures of the vitreous performed, and intra¬ vitreal antibiotics will be reinjected. The treatment strategy of the study is summarized in the Figure. The primary outcome determinants in this clinical trial will be visual acuity and clarity of ocular media. The latter will be measured clinically and photographi¬ cally. Initial end points will be assessed at 3 months, after which procedures to clear residual opacification of the media may be performed if required. Final end point assessment, representing the results after every¬ thing has been done to maximize visual result, will be assessed at 9 months. Secondary end points include the need for multiple surgical procedures, the presence of systemic complications such as renal disease, and the cost of treatment (hospitalization for intravenous
antibiotics).
SUMMARY
Endophthalmitis after cataract surgery can be a di¬ sastrous complication that may result in functional loss of an eye. All patients with this problem should receive direct initial
injection of intravitreal antibiotics. The roles of vitrectomy and of intravenous antibiotics in treating this condition are controversial. Through a
Initial Visit Randomization
_L Initial Pars Plana Vitrectomy Anterior Chamber and Vitreous Culture Intraocular Antibiotics
Vitrectomy Tap/Biopsy
Initial
Anterior Chamber and Vitreous Culture Intraocular Antibiotics
X Without
With Intravenous Antibiotics
Without Intravenous
With Intravenous Antibiotics
Intravenous
Antibiotics
Assessment 36-60 h After
Antibiotics
Surgery
j: Assess for Additional Treatment Criteria. If Present: Vitreous Tap/Biopsy
Assess for Additional Treatment Criteria. If Present: Pars Plana Vitrectomy
Reculture of the Vitreous Reinjection of Antibiotics
Reculture of the Vitreous
Reinjection of Antibiotics
I
X
3-mo (±3 wk) Follow Up Measure End Points Assess For Remediable Problems
Proceed With Appropriate Management
(eg,
Late
Vitrectomy and Capsulotomy)
(±6 wk) Follow Up Measure End Points
9-mo
Treatment strategy for the
Endophthalmitis Vitrectomy Study.
prospective, randomized, clinical trial, these issues can be assessed. We encourage ophthalmologists close to each clinical center to refer patients with postoperative endophthalmitis to these clinics. Questions concerning the Endophthalmitis Vitrectomy Study can be ad¬ dressed to the principal investigator at the nearest clinical trial center. Bernard H. Doft, MD Pittsburgh, Pa The Endophthalmitis Vitrectomy Study trials are supported by cooperative agreements EY08150, EY08151, EY08210, EY08587, EY08588, EY08589, EY08591, EY08595, EY08596, EY08597, EY08599, EY08603, EY08605, and EY08614 from the National Eye
Institute, Bethesda, Md. Reprint requests to 3501 Forbes Ave, Pittsburgh, PA 15213 (Dr
Doft).
The Endophthalmitis Vitrectomy Study Group Clinical Centers and Principal Investigators University of Michigan, Kellogg Eye Center, Ann Arbor.—Andrew K. Vine, MD.
Emory Eye Center, Atlanta, Ga.—Michael Lambert, MD. The Johns Hopkins University, The Wilmer Eye Institute, Baltimore, Md.— Travis Meredith, MD. Massachusetts Eye & Ear Infirmary, Boston.—Carmen Puliafito, MD. Illinois Retina Associates, Chicago.—Kirk Packo, MD. Retina Associates of Cleveland (Ohio).—Thomas Rice, MD. Ohio State University, Columbus.—Robert Chambers, DO. Vitreo Retinal Surgery, Edina, Minn.—Herbert Cantrill, MD. University of Southern California, Los Angeles.—Richard Ober, MD. Medical College of Wisconsin Eye Institute, Milwaukee. —Dennis P. Han, MD.
University of Minnesota, Minneapolis.—Edwin H. Ryan, MD. Retina-Vitreous Consultants, Pittsburgh, Pa.—Bernard H. Doft, MD. Royal Oak, Mich.—Raymond Margherio, MD, University of South Florida, Tampa.—P. ReedPavan, MD. Tampa Bay (Fla) Vitreo-Retinal Associates.—Scott E. Pautler, MD.
Downloaded From: http://archopht.jamanetwork.com/ by a Monash University Library User on 06/15/2015
Family Medical Arts Center, Tampa, Fla.—Mark E. Hammer, MD. University of Maryland Eye Associates, Baltimore.—Vinod Lakhanpal. MD. The Retina Group of Washington, Chevy Chase, Md.—Richard A. Garfinkel,
MD. Retina-Vitreous Center, Edison, NJ.—David Yarian, MD. University of Florida, Gainesville.—Scott Friedman, MD. Hershey (Pa) Medical Center.—Thomas Gardner, MD. Cullen Eye Institute, Houston, Tex.—David W. Parke II, MD. Regents Medical Center, La Jolla, Calif. —Lon Poliner, MD. Kentucky Lions Eye Research Institute, Louisville.—Charles Ban·, MD Dean A. McGee Eye Institute, Oklahoma City, Okla.—Charles P. Wilkinson,
MD
Wills Eye Hospital, Philadelphia, Pa.—Gary C. Brown, MD. St Vincent Medical Center, Toledo, Ohio.—Philip T. Nelsen, MD. University of British Columbia, Vancouver, Canada.—Alan L. Maberley, MD. Georgetown University, Washington, DC—Leonard Parver, MD. Coordinating Center, University of Pittsburgh (Pa).—Principal Investigator: Sheryl Kelsey, PhD. Fundus Photograph Reading Center, University of Wisconsin, Madison. Principal Investigator. Matthew Davis, MD. Executive Committee.—Chairman and Study Director. Bernard H. Doft, MD; Committee Members: Matthew Davis, MD; Donald Everett, MA; Sheryl Kelsey, PhD; Travis Meredith, MD; Rick Mowery, PhD; Kirk Packo, MD; Thomas Rice, MD. Data and Safety Monitoring Committee.—Chairperson: Kathryn Davis, PhD; Committee Members: Stanley Azen, PhD; Preston Covey, PhD; Brooks McCuen, MD; Andrew Packer, MD; Jeffrey Robin, MD. Study Consultants.—Michael Barza, MD; Aaron Kassoff, MD; Margaret Leonard, RPh, MS; Louis Wilson, MD. National Eye Institute Program Office.—Donald Everett, MA, Richard Mowery, PhD. —
References 1. Forster RK. Management of infectious endophthalmitis. Ophthalmology. 1980;87:313-319. 2. Bohigian GM, Olk RJ. Factors associated with a poor visual result in endophthalmitis. Am J Ophthalmol. 1986;101:332-334. 3. Christy NE, Lall P. A randomized, controlled comparison of anterior and posterior periocular injection of antibiotics in the prevention of postoperative endophthalmitis. Ophthalmic Surg.
1986;17:715-718. 4. Weber DJ, Hoffman KL,
Thoft RA, Baker AS. Endophthalmitis following intraocular lens implantation: report of 30 cases and review of the literature. Rev Infect Dis. 1986;8:12-20.
5. Cameron ME, Forster TDC. Endophthalmitis occurring during hospitalization following cataract surgery. Ophthalmic Surg.
1978;9:52-57. 6. Olson JC, Flynn HW, Forster RK, Culbertson WW. Results in
the treatment of
postoperative endophthalmitis. Ophthalmology.
1983;90:692-699. 7. Rowsey JJ, Newson DL, Sexton DJ, Harms WK. Endophthalmitis: current approaches. Ophthalmology. 1982;89:1055-1066. 8. Puliafito CA, Baker AS, Haaf J, Foster CS. Infectious endophthalmitis. Ophthalmology. 1982;89:921-929. 9. Verbraeken H, van Laethem J. Treatment of endophthalmitis with and without pars
1985;191:1-3.
plana
vitrectomy.
Ophthalmologica.
10. Baum J, Peyman GA, Barza M. Intravitreal administration of antibiotic in the treatment of endophthalmitis, III: consensus. Surv
Ophthalmol. 1982;26:204-206.
11. Axelrod JL, Newton JC, Sarakhun C, et al. Ceftriaxone. Arch Ophthalmol. 1985;103:71-72. 12. Thompson RL. Cephalosporin, carbapenem, monobactam antibiotics. Mayo Clin Proc. 1987;62:821-834. 13. Edson RS, Terrell CL. The aminoglycosides: streptomycin, kanamycin, gentamicin, tobramycin, amikacin, netilmicin, and sisomicin. Mayo Clin Proc. 1987;62:916-920. 14. Hadden OB. Vitrectomy in the management of endophthalmitis. Aust JOphthalmol. 1981;9:27-32. 15. Olson JC, Flynn HW, Forster RK, Culbertson WW. Results in the treatment of postoperative endophthalmitis. Ophthalmology.
1983;90:692-699. 16. Peyman GA, Vastine DW, Raichand M. Symposium: postoperative endophthalmitis: experimental aspects and their clinical application. Ophthalmology. 1978;85:374-385. 17. Cottingham AJ, Forster RK. Vitrectomy in endophthalmitis. Arch Ophthalmol. 1976;94:2078-2081. 18. Diamond JG. Intraocular management of endophthalmitis: a systemic approach. Arch Ophthalmol. 1981;99:96-99. 19. Driebe WT, Mandelbaum S, Forster RK, Schwartz LK, Culbertson WW.
Pseudophakic endophthalmitis. Ophthalmology.
1986;93:442-448. 20. Nelsen PT, Marcus DA, Bovino JA. Retinal detachment following endophthalmitis. Ophthalmology. 1986;92:1112-1117. 21. Endophthalmitis Vitrectomy Study: Manual of Operations. Pittsburgh, Pa: University of Pittsburgh, Data Coordinating Center; March 1990.
The Altar of High Technology and the Excimer Laser society is often accused of worshipping the Our altar of high technology. Ophthalmology often of the mirrors this fascination. We all at
applaud
success
scientific advances, but are often careless in determining whether new technology is an improvement over the status quo or merely adding more excitement (and often more expense) to the nature of how something is done. See also p 491.
One significant and exciting area in ophthalmology revolves around a very expensive piece of high technology. The excimer laser shows tremendous promise in
its ability to mold and shape the cornea. In this issue of the ARCHIVES, Sher et al1 present clinical results of one aspect of how this technology can be used. Before discussing their report, however, I would like to lay a few ground rules that seem logical in measuring the success of new procedures: High technology simply for the sake of high technology is no improvement, and not a reason to supplant old
procedures. New procedures should show clinically significant advantages over our present practices before they are generally accepted as part of the norm. Prospectively randomized clinical trials should be the standard for verifying results of new technology
Downloaded From: http://archopht.jamanetwork.com/ by a Monash University Library User on 06/15/2015
Endophthalmitis Vitrectomy Study
(70%) Mostplication ofofendophthalmitis intraocular surgery.1 The incidence of but it is occur as a com-
cases
endophthalmitis varies,
generally reported to
after 0.1% to 0.4% of cataract operations,2-5 and the vast majority of cases (88%) occur within 6 weeks of surgery.6 Despite measures believed to decrease the incidence of infection, such as microsurgical wound closure, perioperative antibiotic injections, and preservation of an intact posterior capsule, postoperative endophthalmitis continues to occur, and current management still leaves many eyes with only poor vision. In the not too distant past, conventional treatment of bacterial endophthalmitis consisted of intravenous, subconjunctival, and topical antibiotics. Visual results with this approach were poor, with visual acuity of only hand motions or worse in 67% to 96% of cases.5,7-9 Studies showing poor intravitreal antibiotic penetration by these routes led to trials using direct injection of antibiotics into the vitreous. It was not until the early 1980s that there was broad consensus that direct intravitreal injection of antibiotics was important in treating post¬ operative bacterial endophthalmitis.10 occur
INTRAVENOUS ANTIBIOTICS
Although systemic antibiotics have been part of the standard care of bacterial endophthalmitis, poor ocu¬ lar penetration and limited efficacy have been docu¬ mented.1" While other recently introduced drugs have been shown to have greater penetration into human eyes after intravenous administration, they still do not reach high enough levels in the vitreous to be effective against some of the common bacteria responsible for
postoperative endophthalmitis.11 Well-documented side effects of some systemic antibiotics include nephrotoxicity, ototoxicity, pseudomembranous colitis, aplastic anemia, hypersensitivity reactions, diarrhea, superinfections, bleeding disorders, and hepatotoxicity.12,13 Other concerns about intravenous (as distinct from in¬ travitreal) antibiotics include the cost not only of the
drugs, but also of the hospitalization required for their administration. The role of systemic antibiotics in the management of endophthalmitis remains uncertain. VITRECTOMY
Vitrectomy was introduced in the 1970s, and many began to employ it in conjunction with intra-
surgeons
vitreal antibiotics in
treating endophthalmitis. Vitrec¬
tomy offers several theoretical advantages, including
removal of the infecting organisms and the toxins they produce, better distribution of antibiotics, removal of vitreous membranes that could lead to traction detach¬ ment of the retina,14 clearing of vitreous opacities,15 and provision of adequate material for culture. Vitrectomy followed by intraocular antibiotics has been shown in certain animal studies1617 to offer advan¬ tages over intraocular antibiotics alone. Data from hu¬ man studies, however, have been less conclusive. In four studies in which vitrectomy along with intraocular antibiotic therapy were compared with intraocular antibiotic therapy alone, 20/400 visual acuity or better was achieved in 59%, 64%, 26%, and 50% of eyes that underwent vitrectomy, compared with 57%, 83%, 80%, and 95% of eyes that did not undergo vitrectomy, re¬ spectively.11'5·1819 In these human studies, the eyes se¬ lected for vitrectomy were those with the worst clinical presentations. This selection bias makes it impossible to determine whether vitrectomy combined with in¬ traocular antibiotics is better or worse than intraocular antibiotics alone. Similarly, while the incidence of po¬ tential side effects such as retinal detachment is re¬ ported to be higher15,20 in infected eyes undergoing vi¬ trectomy, it is possible that these results are due to differences in disease severity between treatment groups as opposed to differences in the effect of treat¬ ment. Therefore, the exact role of vitrectomy in the initial management of endophthalmitis remains controversial. ENDOPHTHALMITIS VITRECTOMY STUDY CLINICAL TRIAL
A prospective, randomized, multicenter, clinical trial has been designed to shed further light on the roles of pars plana vitrectomy and intravenous antibiotics in acute postoperative endophthalmitis. The Endophthal¬ mitis Vitrectomy Study recently began recruiting pa¬ tients.21 Clinical centers in 25 cities throughout the United States will cooperate in enrolling 420 patients over a 42-month period. Patients are eligible to participate in this trial if they have clinical signs and symptoms of bacterial endoph¬ thalmitis within 6 weeks after cataract surgery or sec¬ ondary lens implantation. Visual acuity must be light perception or better, and the patient must read fewer
Downloaded From: http://archopht.jamanetwork.com/ by a Monash University Library User on 06/15/2015
than 36 letters on the Endophthalmitis Vitrectomy Study visual acuity chart (approximately 20/50 or worse). The cornea and anterior chamber of the in¬ volved eye must be clear enough to allow visualization of some part of the iris, and the cornea must be clear enough to allow the possibility of pars plana vitrec¬ tomy. A hypopyon must be present in the involved eye, or clouding of the anterior chamber or vitreous media must be severe enough to obscure visualization of sec¬ ond-order retinal arterioles. All patients in the Endophthalmitis Vitrectomy Study will undergo immediate cultures of the anterior chamber and vitreous and will receive intravitreal (amikacin sulfate [0.4 mg] and vancomycin hydrochloride [1.0 mgj) and subconjunctival (vancomycin [25 mgj and ceftazidime [100 mg]) antibiotics, topical antibiotics (vancomycin and amikacin), and topical cycloplegics. Topical, periocular, and systemic corticosteroide will also be administered. Additional management at presentation will depend on the group to which the patient is randomly assigned. One group will undergo immediate pars plana vitrec¬ tomy with intravenous antibiotics (ceftazidime and ami¬ kacin), and another will undergo pars plana vitrectomy without intravenous antibiotics. A third group will un¬ dergo an initial tap of the vitreous (vitrectomy is de¬ ferred) with intravenous antibiotics, and the fourth will undergo an initial tap of the vitreous without intrave¬ nous antibiotics. Taps of the vitreous will involve re¬ moval of no more than 0.2 mL of vitreous fluid for culture. Between 36 and 60 hours after the initial proce¬ dure, patients will be assessed to determine if addition¬ al treatment is required based on study-defined crite¬ ria21 for eyes responding poorly to treatment. Eyes originally randomized to undergo taps will undergo vitrectomy and reinjection of intravitreal antibiotics. Eyes that initially underwent vitrectomy will have re¬ peat cultures of the vitreous performed, and intra¬ vitreal antibiotics will be reinjected. The treatment strategy of the study is summarized in the Figure. The primary outcome determinants in this clinical trial will be visual acuity and clarity of ocular media. The latter will be measured clinically and photographi¬ cally. Initial end points will be assessed at 3 months, after which procedures to clear residual opacification of the media may be performed if required. Final end point assessment, representing the results after every¬ thing has been done to maximize visual result, will be assessed at 9 months. Secondary end points include the need for multiple surgical procedures, the presence of systemic complications such as renal disease, and the cost of treatment (hospitalization for intravenous
antibiotics).
SUMMARY
Endophthalmitis after cataract surgery can be a di¬ sastrous complication that may result in functional loss of an eye. All patients with this problem should receive direct initial
injection of intravitreal antibiotics. The roles of vitrectomy and of intravenous antibiotics in treating this condition are controversial. Through a
Initial Visit Randomization
_L Initial Pars Plana Vitrectomy Anterior Chamber and Vitreous Culture Intraocular Antibiotics
Vitrectomy Tap/Biopsy
Initial
Anterior Chamber and Vitreous Culture Intraocular Antibiotics
X Without
With Intravenous Antibiotics
Without Intravenous
With Intravenous Antibiotics
Intravenous
Antibiotics
Assessment 36-60 h After
Antibiotics
Surgery
j: Assess for Additional Treatment Criteria. If Present: Vitreous Tap/Biopsy
Assess for Additional Treatment Criteria. If Present: Pars Plana Vitrectomy
Reculture of the Vitreous Reinjection of Antibiotics
Reculture of the Vitreous
Reinjection of Antibiotics
I
X
3-mo (±3 wk) Follow Up Measure End Points Assess For Remediable Problems
Proceed With Appropriate Management
(eg,
Late
Vitrectomy and Capsulotomy)
(±6 wk) Follow Up Measure End Points
9-mo
Treatment strategy for the
Endophthalmitis Vitrectomy Study.
prospective, randomized, clinical trial, these issues can be assessed. We encourage ophthalmologists close to each clinical center to refer patients with postoperative endophthalmitis to these clinics. Questions concerning the Endophthalmitis Vitrectomy Study can be ad¬ dressed to the principal investigator at the nearest clinical trial center. Bernard H. Doft, MD Pittsburgh, Pa The Endophthalmitis Vitrectomy Study trials are supported by cooperative agreements EY08150, EY08151, EY08210, EY08587, EY08588, EY08589, EY08591, EY08595, EY08596, EY08597, EY08599, EY08603, EY08605, and EY08614 from the National Eye
Institute, Bethesda, Md. Reprint requests to 3501 Forbes Ave, Pittsburgh, PA 15213 (Dr
Doft).
The Endophthalmitis Vitrectomy Study Group Clinical Centers and Principal Investigators University of Michigan, Kellogg Eye Center, Ann Arbor.—Andrew K. Vine, MD.
Emory Eye Center, Atlanta, Ga.—Michael Lambert, MD. The Johns Hopkins University, The Wilmer Eye Institute, Baltimore, Md.— Travis Meredith, MD. Massachusetts Eye & Ear Infirmary, Boston.—Carmen Puliafito, MD. Illinois Retina Associates, Chicago.—Kirk Packo, MD. Retina Associates of Cleveland (Ohio).—Thomas Rice, MD. Ohio State University, Columbus.—Robert Chambers, DO. Vitreo Retinal Surgery, Edina, Minn.—Herbert Cantrill, MD. University of Southern California, Los Angeles.—Richard Ober, MD. Medical College of Wisconsin Eye Institute, Milwaukee. —Dennis P. Han, MD.
University of Minnesota, Minneapolis.—Edwin H. Ryan, MD. Retina-Vitreous Consultants, Pittsburgh, Pa.—Bernard H. Doft, MD. Royal Oak, Mich.—Raymond Margherio, MD, University of South Florida, Tampa.—P. ReedPavan, MD. Tampa Bay (Fla) Vitreo-Retinal Associates.—Scott E. Pautler, MD.
Downloaded From: http://archopht.jamanetwork.com/ by a Monash University Library User on 06/15/2015
Family Medical Arts Center, Tampa, Fla.—Mark E. Hammer, MD. University of Maryland Eye Associates, Baltimore.—Vinod Lakhanpal. MD. The Retina Group of Washington, Chevy Chase, Md.—Richard A. Garfinkel,
MD. Retina-Vitreous Center, Edison, NJ.—David Yarian, MD. University of Florida, Gainesville.—Scott Friedman, MD. Hershey (Pa) Medical Center.—Thomas Gardner, MD. Cullen Eye Institute, Houston, Tex.—David W. Parke II, MD. Regents Medical Center, La Jolla, Calif. —Lon Poliner, MD. Kentucky Lions Eye Research Institute, Louisville.—Charles Ban·, MD Dean A. McGee Eye Institute, Oklahoma City, Okla.—Charles P. Wilkinson,
MD
Wills Eye Hospital, Philadelphia, Pa.—Gary C. Brown, MD. St Vincent Medical Center, Toledo, Ohio.—Philip T. Nelsen, MD. University of British Columbia, Vancouver, Canada.—Alan L. Maberley, MD. Georgetown University, Washington, DC—Leonard Parver, MD. Coordinating Center, University of Pittsburgh (Pa).—Principal Investigator: Sheryl Kelsey, PhD. Fundus Photograph Reading Center, University of Wisconsin, Madison. Principal Investigator. Matthew Davis, MD. Executive Committee.—Chairman and Study Director. Bernard H. Doft, MD; Committee Members: Matthew Davis, MD; Donald Everett, MA; Sheryl Kelsey, PhD; Travis Meredith, MD; Rick Mowery, PhD; Kirk Packo, MD; Thomas Rice, MD. Data and Safety Monitoring Committee.—Chairperson: Kathryn Davis, PhD; Committee Members: Stanley Azen, PhD; Preston Covey, PhD; Brooks McCuen, MD; Andrew Packer, MD; Jeffrey Robin, MD. Study Consultants.—Michael Barza, MD; Aaron Kassoff, MD; Margaret Leonard, RPh, MS; Louis Wilson, MD. National Eye Institute Program Office.—Donald Everett, MA, Richard Mowery, PhD. —
References 1. Forster RK. Management of infectious endophthalmitis. Ophthalmology. 1980;87:313-319. 2. Bohigian GM, Olk RJ. Factors associated with a poor visual result in endophthalmitis. Am J Ophthalmol. 1986;101:332-334. 3. Christy NE, Lall P. A randomized, controlled comparison of anterior and posterior periocular injection of antibiotics in the prevention of postoperative endophthalmitis. Ophthalmic Surg.
1986;17:715-718. 4. Weber DJ, Hoffman KL,
Thoft RA, Baker AS. Endophthalmitis following intraocular lens implantation: report of 30 cases and review of the literature. Rev Infect Dis. 1986;8:12-20.
5. Cameron ME, Forster TDC. Endophthalmitis occurring during hospitalization following cataract surgery. Ophthalmic Surg.
1978;9:52-57. 6. Olson JC, Flynn HW, Forster RK, Culbertson WW. Results in
the treatment of
postoperative endophthalmitis. Ophthalmology.
1983;90:692-699. 7. Rowsey JJ, Newson DL, Sexton DJ, Harms WK. Endophthalmitis: current approaches. Ophthalmology. 1982;89:1055-1066. 8. Puliafito CA, Baker AS, Haaf J, Foster CS. Infectious endophthalmitis. Ophthalmology. 1982;89:921-929. 9. Verbraeken H, van Laethem J. Treatment of endophthalmitis with and without pars
1985;191:1-3.
plana
vitrectomy.
Ophthalmologica.
10. Baum J, Peyman GA, Barza M. Intravitreal administration of antibiotic in the treatment of endophthalmitis, III: consensus. Surv
Ophthalmol. 1982;26:204-206.
11. Axelrod JL, Newton JC, Sarakhun C, et al. Ceftriaxone. Arch Ophthalmol. 1985;103:71-72. 12. Thompson RL. Cephalosporin, carbapenem, monobactam antibiotics. Mayo Clin Proc. 1987;62:821-834. 13. Edson RS, Terrell CL. The aminoglycosides: streptomycin, kanamycin, gentamicin, tobramycin, amikacin, netilmicin, and sisomicin. Mayo Clin Proc. 1987;62:916-920. 14. Hadden OB. Vitrectomy in the management of endophthalmitis. Aust JOphthalmol. 1981;9:27-32. 15. Olson JC, Flynn HW, Forster RK, Culbertson WW. Results in the treatment of postoperative endophthalmitis. Ophthalmology.
1983;90:692-699. 16. Peyman GA, Vastine DW, Raichand M. Symposium: postoperative endophthalmitis: experimental aspects and their clinical application. Ophthalmology. 1978;85:374-385. 17. Cottingham AJ, Forster RK. Vitrectomy in endophthalmitis. Arch Ophthalmol. 1976;94:2078-2081. 18. Diamond JG. Intraocular management of endophthalmitis: a systemic approach. Arch Ophthalmol. 1981;99:96-99. 19. Driebe WT, Mandelbaum S, Forster RK, Schwartz LK, Culbertson WW.
Pseudophakic endophthalmitis. Ophthalmology.
1986;93:442-448. 20. Nelsen PT, Marcus DA, Bovino JA. Retinal detachment following endophthalmitis. Ophthalmology. 1986;92:1112-1117. 21. Endophthalmitis Vitrectomy Study: Manual of Operations. Pittsburgh, Pa: University of Pittsburgh, Data Coordinating Center; March 1990.
The Altar of High Technology and the Excimer Laser society is often accused of worshipping the Our altar of high technology. Ophthalmology often of the mirrors this fascination. We all at
applaud
success
scientific advances, but are often careless in determining whether new technology is an improvement over the status quo or merely adding more excitement (and often more expense) to the nature of how something is done. See also p 491.
One significant and exciting area in ophthalmology revolves around a very expensive piece of high technology. The excimer laser shows tremendous promise in
its ability to mold and shape the cornea. In this issue of the ARCHIVES, Sher et al1 present clinical results of one aspect of how this technology can be used. Before discussing their report, however, I would like to lay a few ground rules that seem logical in measuring the success of new procedures: High technology simply for the sake of high technology is no improvement, and not a reason to supplant old
procedures. New procedures should show clinically significant advantages over our present practices before they are generally accepted as part of the norm. Prospectively randomized clinical trials should be the standard for verifying results of new technology
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