<p>Complete and Early Vitrectomy for Endophthalmitis After Cataract Surgery: An Alternative Treatment Paradigm</p>

Abstract

In this study, we report the treatment outcomes of complete and early vitrectomy for endophthalmitis (CEVE) after cataract surgery as the predominate initial treatment, accompanied by systemic antibiotics and retreatment of persistent or recurrent purulence (CEVE+). Patients and Methods: Clinical features and microbiological factors were retrospectively reviewed in 62 eyes of 62 patients who were treated for acute postcataract endophthalmitis (APCE) occurring within three weeks of cataract surgery at Retina Specialists of Alabama, between 2007 and 2017. Results: Visual acuity on presentation included light perception (LP) in 18 eyes (29%) and hand motion (HM) in 23 eyes (37%). Initial treatment was maximum possible vitrectomy in 48 eyes (77%) and tap-and-inject in 14 eyes (23%), with 38 eyes (61%) receiving two or more treatments. Cultures for the first intervention were positive in 49 eyes (79%) and virulent in 18 eyes (29%). At a median follow-up time of five months, final visual acuity was ≥20/40 in 49 eyes (79%), between 20/50 and 5/200 in seven eyes (11%), and <5/200 in six eyes (10%). Virulence was the strongest predictor of poor visual outcome. Retinal detachment occurred in four eyes (6%), likely from necrotic retinal defects in each case. Conclusion: Complete and early vitrectomy is a safe and effective initial treatment for APCE. When accompanied by systemic antibiotics and retreatment (CEVE+) of recurrent media opacification, it improves recovery of 20/40 or better visual acuity by approximately 50% compared to a predominantly tap-and-inject treatment paradigm. We recommend CEVE for fundus-obscuring APCE (~75% of all cases) whenever the view is inadequate to rule out macular distress.

Complete and Early Vitrectomy for Endophthalmitis [Letter]

“…I read with great interest the article on Complete and Early Vitrectomy by Dib et al 1 The article heralds a paradigm shift from the recommendations of the landmark EVS trial. 2 The principles and theory discussed in the article seem to be guided by sound scientific principles.…”

Complete and early vitrectomy for endophthalmitis

“…We recently co-authored a report on the 10-year (2007-2017) results achieved at our center (Retina Specialists of Alabama) in the treatment of Acute Post-Cataract Endophthalmitis (APCE). 1 Small gauge, transconjunctival vitrectomy, unavailable at the time of the Endophthalmitis Vitrectomy Study (EVS), was employed as the primary treatment option for fundus-obscuring endophthalmitis, to restore adequate control of developing maculopathy/retinopathy. Of all eyes, 77.4% (48 of 62) were initially treated with Complete and Early Vitrectomy (CEVE).…”

“…If substantial maculopathy was not seen during initial vitrectomy, not a single eye failed to regain 20/40 or better visual acuity when corneal clarity allowed initial complete vitrectomy. 1 The EVS was published in 1995. To reduce the risk of iatrogenic retinal detachment (RD), it utilized only a "core" vitrectomy whose primary goal was not removing purulent vitreous, but rather obtaining a specimen and placing antibiotics.…”

“…Extensive images of these entities are provided in our report. 1 Urgent and inseparable goals of treatment are to identify and neutralize the bacterial threat, assess existent damage, and halt further tissue injury. To best accomplish these goals, we: (1) quickly restore and maintain a sterile, nontoxic vitreous cavity; (2) clear purulence from the retinal surface; (3) provide retinal/uveal tissue with systemic antibiotic protection against bacteria at the vitreoretinal interface; and (4) use intense steroid therapy for inflammation control.…”

“…In fact, half of the eyes initially treated with TAP in our series subsequently required vitrectomy, and 1 of 6 ultimately cultured positive for virulent bacteria, the strongest predictor of severe vision loss. 1 Henceforth, we believe that a truly informed consent must include the option of complete and early vitrectomy for acute endophthalmitis after cataract extraction. This is especially true if the fundus is obscured, precluding adequate assessment of endophthalmitis maculopathy/ retinopathy.…”