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Endoscopy assisted vitrectomy ( eav) for severe endophthalmitis with initial visual acuity limited to light perception .

Claude Boscher

Paris, France

Objective : to collect informations provided by , and results of endoscopy assisted vitrectomy for severe endophthalmitis .

Purpose : Endophthalmitis Vitrectomy Study has demonstrated that vitrectomy is beneficial in eyes with LP-only initial visual acuity. Endoscopy allows : 1) viewing on 360° , through non transparent media, without scleral indentation (potentially problematic after recent anterior surgery) 2) high magnification and tangential approach to the anterior " zonular " vitreous base , involved in anterior PVR and cyclitic membranes .The purpose of the study is 1) to collect additional informations about in vivo anatomical vitreoretinal condition in severe endophthalmitis with LP-only initial visual acuity 2) to find out if specific capacities of eav , in terms of viewing and anterior base cleansing, improve the results.

Methods : retrospective non randomized non comparative consecutive interventional case series ; 18 pseudophakic eyes with endophthalmitis were operated from September 1995 to February 2001 . 12 eyes were operated under endoscopy and had LP-only vision . Endophthalmitis was consecutive to anterior segment surgery in all but 1 case (vitrectomy , ICG , macular peeling) .Timing for vitrectomy varyied from 20 hours to 6 weeks ( mean 13 days ) after onset of symptoms . Eav was performed as a primary procedure in 5 eyes , 1 to 20 days (mean 7 days) after intravitreal AB injections alone in 7 eyes . A fiber optics endoscopic system including a laser channel , and a peristaltic pump vitrectomy machine were used ; Gram staining , vitreous cytology analysis and cultures were performed in all cases ; concomitant intravitreal AB injections were performed in 4 cases ; there was no steroid intravitreal injection . Patients charts , operative reports and video recording have been reviewed ; follow up data were provided by the referring ophthalmologists .

Results : 1) cultures were positive for streptococcus in 3 (25%)eyes , staphylococcus aureus in 3 (25%) eyes , staphylococcus coagulase negative in 2 (17%) eyes . 2) anatomical conditions were : a) thick cyclitic membrane covering ciliary processes and pars plana in 8 (67%) eyes , preventing endoscopic entry site control in 7 (58 %), with ciliary detachment in 8 eyes , total retinal detachment (RD) in 1 eye (8.5%) (no attempt was made to fix it ) and anterior retinal displacement in 2 eyes ; cyclitic membranes consistence was different from other types (trauma , PVR ) : much more elastic and difficult to aspirate and cut . b) vitreous : intravitreal pus was concentrated anteriorly only in 6/12 ( 50%) eyes , PVD was present in 3 eyes , posterior vitreous schisis in 2 eyes ; vitreous was still attached in 5 eyes , with inter hyaloido retinal pus pockets , in contact with the retinal surface in 2 eyes , without pus posteriorly in 3 eyes , with macular pucker and tractional detachment in 1 eye . c) vascular involvement : aspect of subtotal arterioveinous occlusion in 2 eyes , of CRVO in 5 (42 % ) eyes , very severe, with macular infarction aspect in 2 cases ; retinal ischemia alone with disseminated pre retinal hemorrages in 5 (42%) eyes .d) Pus was found inside the posterior capsular bag in 10/12 (83%) eyes . 2) perioperative complications : entry site retinal perforation in 2 (17%)eyes ; iatrogenic retinal tears in 3 ( 25%) eyes , by traction at distance in 1 case, during attempt to achieve total vitreous base cleansing in 1 case, during macular pucker peeling in 1 eye . 3) associated perioperative techniques were : PFCL injection in 2 eyes ; cryopexy in 4 eyes , endolaser in 2 eyes ; gas internal tamponade in 2 eyes , silicone oil in 2 eyes ; scleral buckling in 1 eye ; anterior segment cleansing in 5 eyes . No IOL explantation was performed . 4) follow up : 1 eye with ischemia , not treated preventively (early in the series ), developed rubeosis and neovascular glaucoma (NVG) 1 month after vitrectomy and was treated successfully with endoscopic cyclophotocoagulation . 1 eye developed recurrent inflammation with cystoid macular edema , and was successfully treated with repeated procedure and ILM peeling . 1 eye developed reopening of an ancient break previously laser treated , subsequent tractionnal / rhegmatogenous retinal detachment , cyclitic membrane and hypotony , and reoperation was successful on redetachment but ocular pressure remains at 5. Retina redetached in the 2 eyes with gas tamponade , silicone oil is still present in 2 eyes . 2 (17 %) eyes are atrophic , 1 patient might have developed unproven sympathetic ophthalmia 1 year after surgery . 4/12 ( 33%)eyes achieved visual acuity ³20/200 , 2/12 eyes (17%) achieved visual acuity of 20/30 .

Conclusions : severe damage observed , especially for the most known devastating infectious agents ( half of the cases in this series ) , have to be spread among anterior surgeons , who still may be unwilling to refer early ; eav specific viewing ability allowed to display in severe endophthalmitis 1) extremely early elastic and strong cyclitic membrane formation , early ciliary detachment and anterior displacements with potential entry site complications 2) early anterior retinal ischemia in a significant number of eyes ; it can lead to secondary NVG and jeopardize initial good results 3) possible adverse objectives for vitrectomy : anterior vitreous base cleansing to be as achieved as endoscopic visualization allows it ,but extensive dissection to be potentially iatrogenic because of the severity of the tractions on a frequently friable ischemic retina . Results show that despite visualization provided : 1) eav sometimes did not overcome entry site difficulties 2) eav did not succeed better than conventional vitrectomy in treating retinal detachment associated to severe endophthalmitis 3) contrary to other indications , obstinate achieved anterior base cleansing can be harmful in severe endophthalmitis . Eav in endophthalmitis requires training both in specific problems of endoscopy and endophthalmitis ( video control , orientation , discrimination between vitreous membranes and ischemic avascular retina).