Incidence of endophthalmitis after 20-gauge vs 23-gauge vs 25-gauge pars plana vitrectomy

Increased incidence of endophthalmitis after vitrectomy relative to face mask wearing during COVID-19 pandemic

BACKGROUND/AIMS

To determine the incidence and causative pathogens of endophthalmitis after vitrectomy during strict face mask wearing in the COVID-19 period.

METHODS

This was a retrospective multicentre study including 31 ophthalmological institutions of the Japanese Retina and Vitreous Society or Japan-Clinical Retina Study group. Patients who had undergone vitrectomy during 2019, the pre-COVID-19 period, and from July 2020 to June 2021, the COVID-mask period, were studied. The results of cataract surgery were used as a control. The total number of vitrectomies and the total number of postoperative endophthalmitis were determined. Then, the differences in the incidence of postoperative endophthalmitis between the pre-COVID-19 period and the COVID-mask period, and the type of pathogens causing the endophthalmitis were studied.

RESULTS

The incidence of postvitrectomy endophthalmitis was significantly lower in the pre-COVID-19 period with 16 568 surgeries and 18 endophthalmitis cases (0.11%) than in the COVID-mask period of 14 929 surgeries and 31 endophthalmitis cases (0.21%; p=0.031, OR=1.913, 95% CI 1.078 to 3.394). In the pre-COVID-19 period, 4 of the 18 eyes were culture positive, and all were of the Staphylococcus family. In the COVID-mask period, 9 of the 31 eyes were culture positive, and 4 cases were related to oral commensals including Streptococcus spp, which are reportedly very rare in endophthalmitis after vitrectomy.

CONCLUSIONS

It is necessary for physicians to be aware of the higher incidence of postvitrectomy endophthalmitis during the COVID-mask period, and to treat their patients appropriately.

Long-Term Visual Acuity and Optical Coherence Tomography Changes After Vitrectomy for Idiopathic Epiretinal Membranes

Objective

To evaluate the long-term visual acuity and retinal thickness changes after pars plana vitrectomy (PPV) for idiopathic epiretinal membranes (ERM).

Methods

We performed a retrospective analysis of 72 patients who underwent PPV for idiopathic ERM in a tertiary hospital over 5 consecutive years. The main outcome measurement was change in visual acuity and macular thickness as recorded with optical coherence tomography (OCT).

Results

Medical records of 239 patients with a diagnosis of ERM who underwent PPV with or without internal limiting membrane (ILM) peeling were reviewed; of these, 72 patients with idiopathic ERM were included in the final analysis. All patients completed at least one year of follow-up, and 23 patients (30%) had 5 or more years of follow-up. The mean preoperative best corrected visual acuity (BCVA) was 20/65, and mean preoperative central macular thickness (CMT) on OCT was 434 microns (µm). Mean postoperative BCVA and CMT at one year were 20/40 and 303 µm, respectively (p<0.0001). A total of 42 patients (58%) improved by 2 or more lines; BCVA and CMT continued to improve postoperatively for up to 5 years of the follow-up period. There was no significant difference in BCVA or CMT between phakic and pseudophakic patients, and ILM peeling was performed in 67% of patients. Improved BCVA at 1 year was associated with younger age (p<0.0001) and ILM peeling (p=0.020).

Conclusion

PPV is an effective treatment for idiopathic ERM, and ILM peel may be of benefit. BCVA continues to improve up to 2 years and beyond after surgery regardless of the duration of symptoms.

Incidence rate and clinical characteristics of acute endophthalmitis following 23-gauge pars plana vitrectomy

PURPOSE

In this study, we evaluated the incidence and clinical characteristics of post-vitrectomy acute endophthalmitis in a tertiary eye center.

METHODS

Data were obtained by reviewing the patients' medical records who underwent primary pars plana vitrectomy (PPvitx) from September 2011 to March 2017. We excluded patients who had any ocular surgery in the past 6 months, immunocompromised patients, and patients with a pre-operative diagnosis of endophthalmitis. The primary outcome was the incidence of acute post-pars plana vitrectomy endophthalmitis.

RESULTS

Out of 6474 cases who underwent PPvitx, 12 cases of endophthalmitis (incidence rate of 0.18%) were identified. We found two positive cultures for staphylococcus epidermidis and one positive culture for staphylococcus aureus. Underlying causes of primary vitrectomy in patients who got endophthalmitis were diabetic retinopathy (8 cases), rhegmatogenous retinal detachment (2 cases), and the epiretinal membrane (1 case), and non-clearing vitreous hemorrhage secondary to central retinal vein occlusion (1 case).

CONCLUSION

In the present study, the rate of post-vitrectomy acute endophthalmitis was higher than in other reported studies.

Early vitrectomy for exogenous endophthalmitis following surgery

BACKGROUND

Endophthalmitis is a sight-threatening emergency that requires prompt diagnosis and treatment. The condition is characterised by purulent inflammation of the intraocular fluids caused by an infective agent. In exogenous endophthalmitis, the infective agent is foreign and typically introduced into the eye through intraocular surgery or open globe trauma.

OBJECTIVES

To assess the potential role of combined pars plana vitrectomy and intravitreal antibiotics in the acute management of exogenous endophthalmitis, versus the standard of care, defined as vitreous tap and intravitreal antibiotics.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 5); Ovid MEDLINE; Ovid Embase; the International Standard Randomised Controlled Trial Number registry; ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. There were no restrictions to language or year of publication. The date of the search was 5 May 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared pars plana vitrectomy and intravitreal injection of antibiotics versus intravitreal injection of antibiotics alone, for the immediate management of exogenous endophthalmitis.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. Two review authors independently screened search results and extracted data. We considered the following outcomes: visual acuity improvement and change in visual acuity at three and six months; additional surgical procedures, including vitrectomy and cataract surgery, at any time during follow-up; quality of life and adverse effects. We assessed the certainty of the evidence using the GRADE approach.  MAIN RESULTS: We identified a single RCT that met our inclusion criteria. The included RCT enrolled a total of 420 participants with clinical evidence of endophthalmitis, within six weeks of cataract surgery or secondary intraocular lens implantation. Participants were randomly assigned according to a 2 x 2 factorial design to either treatment with vitrectomy (VIT) or vitreous tap biopsy (TAP) and to treatment with or without systemic antibiotics. Twenty-four participants did not have a final follow-up: 12 died, five withdrew consent to be followed up, and seven were not willing to return for the visit.  The study did not report visual acuity according to the review's predefined outcomes. At three months, 41% of all participants achieved 20/40 or better visual acuity and 69% had 20/100 or better acuity. The study authors reported that there was no statistically significant difference in visual acuity between treatment groups (very low-certainty evidence). There was low-certainty evidence of a similar requirement for additional surgical procedures (risk ratio RR 0.90, 95% confidence interval 0.66 to 1.21). Adverse effects included: VIT group: dislocated intraocular lens (n = 2), macular infarction (n = 1). TAP group: expulsive haemorrhage (n = 1). Quality of life and mean change in visual acuity were not reported.  AUTHORS' CONCLUSIONS: We identified a single RCT (published 27 years ago) for the role of early vitrectomy in exogenous endophthalmitis, which suggests that there may be no difference between groups (VIT vs TAP) for visual acuity at three or nine months' follow-up.   We are of the opinion that there is a clear need for more randomised studies comparing the role of primary vitrectomy in exogenous endophthalmitis. Moreover, since the original RCT study, there have been incremental changes in the surgical techniques with which vitrectomy is performed. Such advances are likely to influence the outcome of early vitrectomy in exogenous endophthalmitis.

The Role of Silicone Oil in the Surgical Management of Endophthalmitis: A Systematic Review

(1) Background: We aimed to systematically review the current literature to evaluate if in patients with postoperative endophthalmitis treated with pars plana vitrectomy, silicone oil tamponade could provide a useful contribution to the control and eradication of infection and if it could influence anatomical recovery and functional outcome. (2) Randomized controlled trials, cross-sectional studies, case series, and case reports published in the English language in peer-reviewed journals were included. No restriction was placed based on the study location. We used medical subject headings (MeSH) and text words. We searched MEDLINE (OVID and PubMed), Google Scholar, ISI Web of Science (Thom-on-Reuters), and the Cochrane Library (Wiley) from January 1995 to the present. To ensure literature saturation, we scanned the reference lists of included studies or relevant reviews identified through the search. Risk of Bias was assessed using the Newcastle-Ottawa scale for longitudinal studies and Cochrane risk-of-bias tool for randomized trials. (3) Results: abstracts of 75 articles were selected for full-text reading; after full-text reading, 44 articles were taken into consideration in the systematic review. 5 out of 7 in vitro experimental studies demonstrated antimicrobial activity against different species of bacteria and fungi. The use of SO as endotamponade associated with PPV led to better visual acuity and a lower rate of retinal detachment and the need for additional surgery. (4) Conclusions: Silicone oil reduces the risk of postoperative retinal detachment, especially in case of undetected retinal breaks, produces compartmentalization of the eye, may lead to early visual recovery, allows laser photocoagulation, prevents severe postoperative hypotony and has antimicrobic activity due to an inhibitory effect for several species of pathogens. Concerns regarding possible toxic effects on the retina and optic disc, compartmentalization and impaired washout of pathogen toxins have been reported. It may also influence intravitreal antibiotic distribution and clearance.

Endophthalmitis Post Pars Plana Vitrectomy Surgery: Incidence, Organisms' Profile, and Management Outcome in a Tertiary Eye Hospital in Saudi Arabia

PURPOSE

To determine the incidence of endophthalmitis after pars plana vitrectomy (PPV), organisms' profile, and management outcomes at a tertiary eye hospital in a Middle East country.

METHODS

In this single-arm cohort study conducted in 2020, medical records of patients who underwent PPV not accompanied by any other intraocular surgery were reviewed; those with a diagnosis of acute endophthalmitis in the immediate postoperative period (within 6 weeks) during the past 6 years were analyzed.

RESULTS

A total of 8153 records of PPV surgeries were reviewed. Five cases had endophthalmitis post-PPV with an incidence of 0.061%. Three (0.037%) had positive cultures, all of them for Staphylococcus epidermidis. The interval between PPV and diagnosis of endophthalmitis ranged from 3 to 25 days (mean, 15.8 days). Final vision after treatment ranged from 20/400 to no light perception, and one eye was eviscerated.

CONCLUSION

The incidence of endophthalmitis post PPV is low. Despite prompt diagnosis and standard management, visual prognosis seems to be poor. The infective agents for endophthalmitis were commensals from the ocular surface.

[Postoperative endophthalmitis-a review of literature]

Postoperative endophthalmitis is one of the most feared complications for ophthalmologists, and the number of infections after intraocular procedures have been increasing. Nonetheless, a prompt intervention can result in the recovery of vision. In the past, endophthalmitis after cataract surgery was accountable for the majority of cases but is becoming less frequent due to the progress of surgical techniques and demographic developments with a steadily increasing number of intravitreal injections. In this article, the different forms of postoperative endophthalmitis are assessed in terms of pathophysiology and their specific characteristics depending on their etiology.

Comparison of Visual and Anatomic Outcomes Following RRD Surgery Using 23-Gauge Versus 25-Gauge Vitrectomy: PRO Study Report No. 12

BACKGROUND AND OBJECTIVE

Most surgeons now utilize small-gauge (23- or 25-gauge) pars plana vitrectomy (PPV) with or without scleral buckling for repair of rhegmatogenous retinal detachments (RRD), in addition to primary scleral buckle (SB), but comparative data between the two gauges are limited.

PATIENTS AND METHODS

This study is an analysis of primary RRD repairs comparing 23- versus 25-gauge vitrectomy for PPV or combination PPV/SB from January 1, 2015, through December 31, 2015, across multiple institutions. The primary outcome was single-surgery success and secondary outcomes included postoperative complications.

RESULTS

There were 1,932 eyes that met inclusion criteria. There was no statistically significant difference in single-surgery success (82.9% vs. 83.8%; P = 0.6329). There were similar rates of postoperative hypotony, endophthalmitis, vitreous hemorrhage, and choroidal detachment. The findings were similar when analyzing only eyes that underwent primary PPV without SB.

CONCLUSION

Both 23- and 25-gauge vitrectomy systems have similar anatomic and visual outcomes in the primary repair of RRD. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:70-76.].

Endophthalmitis after pars plana vitrectomy with reused single-use devices: a 13-year retrospective study

BACKGROUND

To describe the incidence, clinical characteristics, and treatment outcomes of endophthalmitis after pars plana vitrectomy (PPV) with recycled single-use devices. The recommended sterilization process as well as safety measures are discussed.

METHODS

Medical charts of patients who developed endophthalmitis after PPV were retrospectively reviewed and reported in a descriptive manner. Cases undergoing PPV for preexisting endophthalmitis or open globe injury were excluded. Data collection included patient demographics, operative details, ocular findings, microbiological profiles, treatment modalities, and visual outcomes.

RESULTS

Over the past thirteen years, a total of 12,989 pars plana vitrectomy operations were included. In total, 13 eyes of 13 cases (0.10%) experienced endophthalmitis after vitrectomy. These occurred in 3 cases (0.11%) using 20-gauge vitrectomy compared to 8 cases (0.09%) using 23-gauge vitrectomy and 2 cases (0.18%) using 25-gauge vitrectomy. There were no statistically significant differences between the 20-gauge and microincisional vitrectomy surgery (MIVS) group (P = 0.64), and the 23- and 25-gauge approach (P = 0.34). Causative pathogens were positive by culture in 5 cases (45%): 3 g-positive cases, 1 g-negative case, and 1 fungus case.

CONCLUSIONS

The rate of endophthalmitis in patients who underwent 23-gauge PPV was comparable to those who underwent 25-gauge PPV. With our standardized protocol for instrument sterilization, endophthalmitis rates in those undergoing PPV using recycled single-use instruments were within the range of previously published results in which vitrectomy tools were disposed of after one use.

Safety of intracameral cefuroxime in pars plana vitrectomy

BACKGROUND/OBJECTIVES

Postoperative endophthalmitis is a rare, but serious complication of pars plana vitrectomy (PPV). Subconjunctival cefuroxime injection has been the traditional choice for post vitrectomy endophthalmitis prophylaxis. Its effectiveness and safety in this context are however poorly understood and cases of retinal toxicity have been reported. The traditional standard subconjunctival antibiotic prophylaxis has been superceded in cataract surgery by intracameral antibiotic prophylaxis.

SUBJECTS/METHODS

The primary aim of this three centre non-randomised retrospective database cohort study of 7,532 PPV procedures was to identify the rate of endophthalmitis in cohorts of patients treated with intracameral or subconjunctival cefuroxime. A secondary aim was to estimate the achieved intraocular antibiotic concentrations of cefuroxime in eyes with intracameral versus subconjunctival administration using mathematical modelling.

RESULTS

The overall incidence of postoperative endophthalmitis was 0.07% (5/7532). There were no cases of endophthalmitis in eyes receiving intracameral cefuroxime alone or in combination with subconjunctival cefuroxime (0/5586). Patients receiving subconjunctival cefuroxime alone had a higher incidence of endophthalmitis (0.22%, 4/1835), and there was one case of endophthalmitis in eyes not receiving any perioperative antibiotics (0.9%, 1/111). No cases of cefuroxime toxicity were identified. With subconjunctival cefuroxime, in the presence of a sclerotomy leak, we estimated the vitreous drug concentration to be higher than that for intracameral cefuroxime and potentially toxic.

CONCLUSIONS

Intracameral cefuroxime appears to be a safe and efficient choice for prophylaxis against endophthalmitis after PPV. Small eyes with intraocular tamponade seem to be at particular risk of drug toxicity if cefuroxime is administered via the subconjunctival route.

INCIDENCE OF ENDOPHTHALMITIS AFTER VITRECTOMY: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this study was to review the literature reporting rates of postoperative endophthalmitis after pars plana vitrectomy and investigate whether modern microincision vitrectomy surgery (MIVS) increases the postoperative endophthalmitis rate, compared with traditional 20-gauge (20 G) vitrectomy.

METHODS

A comprehensive literature search was performed to identify studies describing the incidence of post-pars plana vitrectomy endophthalmitis. A meta-analysis of comparative studies reporting the endophthalmitis rates after MIVS versus 20 G vitrectomy was also conducted.

RESULTS

A total of 31 studies reported 199 endophthalmitis cases in 363,544 participants (0.05%). The incidence of endophthalmitis after 20 G vitrectomy was 0.04% (88/229,435), compared with 0.03% (8/27,326) after 23 G and 0.11% (33/29,676) after 25 G. The meta-analysis demonstrated that the incidence of endophthalmitis was higher after MIVS (23 G/25 G) compared with 20 G vitrectomy (odds ratio = 3.39, 95% confidence interval, 1.39-8.23). In a subgroup analysis, we also found an increased risk of endophthalmitis after 25 G compared with 20 G vitrectomy (odds ratio = 4.09, 95% confidence interval, 2.33-7.18), but not for 23 G versus 20 G (odds ratio = 1.14, 95% confidence interval, 0.47-2.78).

CONCLUSION

The incidence of post-pars plana vitrectomy endophthalmitis was low, with no significant differences between 23 G MIVS and 20 G vitrectomy, but 25 G MIVS may result in a higher postoperative endophthalmitis rate.

Incidence of acute postoperative endophthalmitis following macular surgery in France between 2006 and 2016

PURPOSE

To report the incidence of acute postoperative endophthalmitis (POE) after macular surgery in France between 2006 and 2016 and to identify associated factors.

METHODS

This retrospective database study included all hospital discharge records involving a surgical procedure for an epiretinal membrane or a macular hole in France from January 2006 to October 2016. Acute POE was identified by two codes in the tenth edition of the International Classification of Diseases within 42 days of a macular surgical procedure in the French national administrative database.

RESULTS

In France, 152 034 macular surgical procedures for epiretinal membranes or macular holes were recorded from 1 January 2006 to 31 October 2016. Suspected acute POE was reported in 381 cases. The incidence of POE was 0.25% overall, 0.30% for epiretinal membrane surgery and 0.14% for macular hole surgery. In multivariable Poisson regression analysis, epiretinal membrane surgery was associated with POE [incidence rate ratio (IRR), 2.24; 95% CI, 1.62-3.11; p < 0.001]. For epiretinal membrane surgery, the 2010-2011 period was significantly associated with a higher risk of POE (IRR, 1.66; 95% CI, 1.13-2.42; p = 0.03).

CONCLUSION

The incidence of POE after macular surgery was 0.25% overall in France between 2006 and 2016 and twice higher for epiretinal membrane surgery than for macular hole surgery. For epiretinal surgery only, the incidence of POE was higher in 2010-2011 (period of the switch to transconjunctival vitrectomy) than in the rest of the study period.

Comparative Study of Microbiological Profile and Management Outcomes of Acute Endophthalmitis after Microincision Vitrectomy Surgery versus Intravitreal Injections

Purpose: The aim of this study was to evaluate and compare incidence and outcomes of management of acute endophthalmitis after microincision vitrectomy surgery (MIVS) and intravitreal injections (IVIs).Methods: Medical records were retrospectively reviewed from January 2012 to December 2017, and the incidence, clinical and microbiological profiles of acute endophthalmitis were documented.Results: Of 26,332 MIVS and 24,143 IVI performed, incidence of acute endophthalmitis in MIVS group was 0.027% (1 in 3761 cases) against 0.054% (1 in 1857 cases) in IVI. Gram-positive organisms were causative in post IVI group as against gram-negative organisms in MIVS group.Conclusion: Incidence of endophthalmitis after IVI is almost twice that after MIVS. A trend toward poorer outcomes in MIVS eyes was observed. Both MIVS and IVI being pars plana procedures warrant similar kind of aseptic precautions.

Risk Factors for Endophthalmitis after Pars Plana Vitrectomies in a Tertiary Eye Institute in India

PURPOSE

To identify the risk factors associated with endophthalmitis after pars plana vitrectomy (PPV).

DESIGN

Retrospective case-control study.

PARTICIPANTS

All eyes that presented with endophthalmitis after PPV within 6 weeks in a tertiary eye care center were evaluated. There were 36 cases with endophthalmitis and 93 controls without endophthalmitis.

METHODS

Other patients undergoing operation by the same surgeon on the same date and in the same operating room were included as controls. Univariate and multivariate regression analyses were performed to evaluate the risk factors.

MAIN OUTCOME MEASURES

Incidence and risk factors for endophthalmitis after PPV.

RESULTS

In this study, 36 cases and 93 controls met the inclusion criteria. For endophthalmitis, 3 independent risk factors were identified: systemic immunosuppression (odds ratio [OR], 10.673; 95% confidence interval [CI], 1.114-102.292; P = 0.04), balanced salt solution (BSS) or Ringer's lactate (RL) as vitreous substitute (OR, 5.288; 95% CI, 1.769-15.813; P = 0.003), and surgery performed in the second half of the day (OR, 0.016; 95% CI, 1.266-10.398; P = 0.016). Operating on phakic patients compared with pseudophakic or aphakic patients (OR, 0.962; 95% CI, 5.049-57.644; P < 0.001) and the use of endotamponade (OR, 5.288; 95% CI, 1.769-15.813; P = 0.003) were associated with a reduced risk for endophthalmitis. In culture-positive endophthalmitis, the presence of diabetes (OR, 4.61; 95% CI, 1.15-18.39; P = 0.03), vitreous substitute (BSS or RL) (OR, 6.08, 95% CI, 1.47-25.10, P = 0.012), and pseudophakia (OR, 5.68; 95% CI, 1.37-23.47; P = 0.016) were significant risk factors.

CONCLUSIONS

Patients who are immunocompromised, pseudophakic, or aphakic are at a higher risk of endophthalmitis after PPV. Endotamponade significantly mitigates the risk of infection after vitrectomy surgery.

Incidence of endophthalmitis after 23-gauge pars plana vitrectomy

Background

Endophthalmitis is a rare but severe complication following PPV. The incidence of endophthalmitis varies between 20-gauge, 23-gauge, and 25-gauge incisions. The incidence and clinical features of endophthalmitis after 23-gauge PPV in an eye hospital in China was reported in this study.

Methods

Data of the eyes that underwent 23-gauge PPV from January 2011 to December 2014 at the Eye Hospital of Wenzhou Medical University was retrospectively collected. All the information was obtained from the electronic medical system. The exclusion criteria included: (1) preoperative diagnosis of endophthalmitis; (2) history of vitrectomy; (3) intraocular surgery within 6 months; (4) history of ocular penetrating trauma; (5) sutures for any of the 3 sclerotomy incisions; (6) patients with cancer, acquired immune deficiency syndrome, or taking drugs that may influence the immune system. The diagnosis of endophthalmitis was based on clinical characteristics and/or culture results from an operative sample.

Results

Three thousand nine hundred seventy nine eyes that underwent 23-gauge PPV surgery were included in this study. Among these eyes, 3 eyes developed endophthalmitis after surgery, giving an incidence of 0.075% (3/3979). The period in which endophthalmitis developed ranged from 1 to 5 days post-operation. The visual acuity decreased to hand motions or light perception postoperatively. The culture of aqueous and vitreous of the 2 eyes revealed Staphylococcus epidermidis and enterococcus faecalis respectively, however was negative for the third eye. All 3 eyes had a favorable response to the treatment of vitreous tap and intravitreal antibiotics injection. Two eyes gained visual acuity of 0.05 and 0.5, respectively at the final visit.

Conclusions

Endophthalmitis is a rare but sight-threatening complication after 23-gauge pars plana vitrectomy. The peak duration of onset was within 5 days post-operation, with gram positive cocci being the common pathogenic organism.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-0678-5) contains supplementary material, which is available to authorized users.

Incidence, microbiology, and outcomes of endophthalmitis after 111,876 pars plana vitrectomies at a single, tertiary eye care hospital

Purpose

To describe the incidence, risk factors, clinical presentation, causative organisms, and outcomes in patients with endophthalmitis following pars plana vitrectomy (20G and minimally invasive vitrectomy surgery (MIVS).

Methods

Of 111,876 vitrectomies (70,585 20-G 41,291 MIVS) performed, 45 cases developed acute-onset, postoperative endophthalmitis.

Results

The rate of culture positive and culture negative endophthalmitis was 0.021% (2.1/10,000 surgeries) and 0.019% (1.9/10,000 surgeries) overall, 0.031% (3.1/10,000 surgeries) and 0.025% (2.5/10,000 surgeries) in 20G, and 0.005% (0.5/10,000 surgeries) and 0.007% (0.7/10,000 surgeries) in the MIVS group respectively. Potential predisposing factors were as follows: diabetes, 46.7%; vitrectomy for vascular retinopathies, 44.4%; and vitrectomy combined with anterior segment surgeries, 35.5%. The culture proven rates were 53.3% overall, 55.0% for 20G and 40.0% for MIVS. The most common organism was Pseudomonas aeruginosa for 20G. Klebsiella and Staphylococcus aureus were isolated in the two culture positive cases in MIVS group. The follow-up period for the patients with endophthalmitis was 586.14 ± 825.15 days. Seven were lost to follow up beyond one week. Of the remaining 38, 13 (34.2%) cases had a favorable visual outcome (i.e., best-corrected visual acuity [BCVA] > 5/200) and 24 (63.2%) had unfavorable visual outcome (BCVA < 5/200). Group with culture test results negative had significantly better outcomes (P < 0.05) as compared to those with positive.

Conclusions

MIVS does not increase the risk of endophthalmitis. Outcomes are poor despite appropriate treatment, particularly in cases with culture results positive.

Postoperative Endophthalmitis: A Review of Risk Factors, Prophylaxis, Incidence, Microbiology, Treatment, and Outcomes

Postoperative endophthalmitis is one of the most feared complications of intraocular surgery. The most common types of intraocular surgeries performed worldwide are cataract extraction, glaucoma drainage implants/trabeculectomy, and pars plana vitrectomy. This review will focus on the clinical features, risk factors, prophylaxis, and treatment of endophthalmitis in these three main intraocular surgeries.

25-Gauge Vitrectomy in Open Eye Injury with Retained Foreign Body

Purpose. Ocular trauma with retained foreign body is an important cause of visual impairment in working-age population. Clinical status impacts on the timing and planning of surgery. In the last year small gauge vitrectomy has become safer and more efficient, extending the range of pathologies successfully treated. Aims. To evaluate the safety and outcomes in patients with open eye injury with retained foreign body that underwent early 25-gauge vitrectomy. Methods. In this retrospective, noncomparative, interventional case series, we performed 25-gauge vitrectomy on 10 patients affected by open globe injuries with retained foreign body, over 3 years. We analyzed age, wound site, foreign body characteristics, ocular lesions correlated, relative afferent pupillary defect, visual acuity, and intraocular pressure. Follow-up evaluations were performed at 1, 3, and 6 months. According to the clinical status we performed other procedures to manage ocular correlated lesions. Results. The median age of patients was 37 years. The foreign body median size was 3.5 mm (size range, 1 to 10 mm). 25-gauge vitrectomy was performed within 12 hours of trauma. Foreign body removal occurred via a clear corneal or scleral tunnel incision or linear pars plana scleral access. Visual acuity improved in all patients. Endophthalmitis was never reported. Only two cases reported postoperative ocular hypertension resolved within the follow-up. Retinal detachment recurred in one case only. Conclusions. 25-gauge vitrectomy could be considered as early approach to manage open globe injuries with a retained posterior segment foreign body in selected cases with good outcomes and low complication rate.

Epiretinal membrane surgery evaluated by subjective outcome

PURPOSE

To examine pre- and postoperative visual interference, subjective symptoms and visual acuity in patients undergoing epiretinal membrane (ERM) surgery.

METHODS

A retrospective observational case series comparing 239 eyes in 231 consecutive patients with idiopathic ERM in a selected catchment area from 2002 to 2009. Demography, visual acuity (VA), lens status and subjective symptoms were analysed before and after the operation. Patients, healthy enough to participate at least 2 years post surgery, answered a questionnaire about their subjective functional impairment before and after the ERM peeling. Visual disturbance was assessed on a visual analogue scale (VAS) ranging from 1 to 100 mm.

RESULTS

The preoperative VA for the eyes in the study was median 0.40 logMAR (logarithm of the minimum angle of resolution) (range -0.1 to 1.22) resulted in VA of 0.22 logMAR (range -0.1 to 1.1), which is a statistical significant difference (p -). Of 180 patients contacted, answers were received from 103 (57%). Subjective visual disturbance assessed on the VAS showed a median of 70 mm (range 0-100) before surgery compared to a subjective disturbance median 27 mm (range 0-98) postoperatively. The change preoperatively to postoperatively was mean -34 mm (SD 31), median -37 (range -96 to 37), p -. Patients with much disturbance at baseline measured by VAS experienced more subjective benefit of the operation measured by the distance between the mark on the VAS preoperatively and postoperatively, p -, Spearman correlation coefficient.

CONCLUSION

Patients with considerable preoperative disturbance benefit more from an operation than those with less disturbance.

Endophthalmitis following 27-Gauge Pars Plana Vitrectomy for Vitreous Floaters

PURPOSE

To report a case of Staphylococcus epidermidis endophthalmitis following 27-gauge pars plana vitrectomy for symptomatic vitreous floaters.

METHODS

The clinical course and imaging findings, including fundus optomap, and spectral domain optical coherence tomography of a 24-year-old male patient were documented.

RESULTS

The patient, with a preoperative best-corrected visual acuity (BCVA) of 1.0, developed endophthalmitis following 27-gauge pars plana vitrectomy for symptomatic vitreous floaters. After a series of treatments, including emergent vitreous tap and silicone oil injection, antibiotic treatment, and silicone oil removal, the patient regained a BCVA of 0.6.

CONCLUSION

Although rare, the potential risk of endophthalmitis should be explicitly discussed with patients considering surgical intervention for vitreous floaters.

Endophthalmitis after small-gauge vitrectomy: a retrospective case series from Sweden

PURPOSE

To investigate the anatomical and functional outcomes of acute-onset endophthalmitis after small-gauge vitrectomy.

METHODS

Retrospective case series of patients who underwent 23- or 25-gauge vitrectomy at four centres in Sweden between 2008 and 2012. Postvitrectomy endophthalmitis was identified through the search of the journal records of each institution, and the diagnosis was based on clinical criteria regardless of culture results.

RESULTS

Twenty-four patients (24 eyes) were included. The incidence of endophthalmitis following small-gauge vitrectomy was 0.14%. Indications for small-gauge vitrectomy enclosed epiretinal membrane (n = 13), retinal detachment (n = 5) and others (n = 6). Surgical technique included 23- and 25-gauge vitrectomy (23:1). Four eyes had sutured sclerotomies, and two had postoperative hypotony <7 mmHg. Days to endophthalmitis presentation varied between 1 and 21 (mean 6 ± 6). Treatment methods included the following: tap and antibiotic injection (n = 7), tap, antibiotic injection with subsequent vitrectomy (n = 2) and prompt vitrectomy with antibiotics (n = 15). Sixteen eyes (66.7%) were culture positive, whereas the other eight cases were culture negative. Anatomical results included evisceration (n = 1), phthisis (n = 1), and globe intact (n = 22). Presenting best corrected visual acuity (BCVA) were hand motion (n = 14), light perception (n = 7), counting fingers (n = 2), and no data (n = 1). Functionally 19 eyes (79%) had Snellen VA ≥0.1; 11 eyes (46%) had VA ≥0.5 Mean logMar BCVA preoperatively and at the last follow-up were 2.07 ± 0.6 and 0.79 ± 0.99, respectively.

CONCLUSIONS

In spite of good anatomical and functional results, this study showed higher rate of endophthalmitis than the latest reports suggesting that small-gauge vitrectomy has reached the safety level of standard 20-gauge vitrectomy when infectious endophthalmitis is concerned.

Endophthalmitis After Pars Plana Vitrectomy: Clinical Features, Risk Factors, and Management Outcomes

PURPOSE

To report the clinical presentations, risk factors, and outcomes of endophthalmitis after pars plana vitrectomy at 4 tertiary eye care centers of an institute in South India.

DESIGN

A retrospective case series.

METHODS

The records of 38,591 patients undergoing vitrectomy were reviewed using the coding assigned by the medical records department. Consecutive cases diagnosed as endophthalmitis after pars plana vitrectomy (PPV) between 1990 and 2014 for various indications were analyzed.

RESULTS

The clinical incidence of postvitrectomy endophthalmitis was 0.052%, and culture-positive incidence of postvitrectomy endophthalmitis was 0.031%. Twelve cases (60%) were culture positive. Mean presenting vision was 2.16 ± 1.51 logMAR (Snellen equivalent 20/2890). Seventeen eyes had received sutureless vitreous surgery (15 cases 23G, 2 cases 25G) and 3 eyes had received 20G suture-assisted vitreous surgery (P < 0.0001). The odds of developing endophthalmitis in sutureless versus sutured vitrectomy were 25.14 [95% confidence interval (CI), 7.37-85.84] (P < 0.0001) and those of developing endophthalmitis in sutureless surgery versus sutured with final tamponade of Ringer lactate (RL) were 19.53 (95% CI, 5.37-71.03) (P < 0.0001). In sutureless surgeries, the odds of developing endophthalmitis in RL tamponaded eyes versus non-RL ones was 4.39 (95% CI, 1.67-11.56) (P = 0.002). Mean interval between vitreous surgery and endophthalmitis was 4 ± 6.89 days; median, 1.5 days. Mean postoperative vision was 1.7 ± 1.36 logMAR (Snellen equivalent 20/1002) (P = 0.31).

CONCLUSIONS

Endophthalmitis after vitrectomy is an acute presentation. Sutureless surgery, especially with aqueous tamponade, has a higher risk. The visual outcome is relatively poor.

Current Perspectives of Prophylaxis and Management of Acute Infective Endophthalmitis

Endophthalmitis is an intraocular inflammatory condition which may or may not be caused by infective agents. Noninfectious (sterile) endophthalmitis may be attributable to various causes including postoperative retained soft lens matter or toxicity following introduction of other agents into the eye. Infectious endophthalmitis is further subdivided into endogenous and exogenous. In endogenous endophthalmitis there is hematogenous spread of organisms from a distant source of infection whereas in exogenous endophthalmitis direct microbial inoculation may occur usually following ocular surgery or penetrating eye injury with or without intraocular foreign bodies. Acute infective endophthalmitis is usually exogenous induced by inoculation of pathogens following ocular surgery, open-globe injury and intravitreal injections. More infrequently the infective source is internal and septicemia spreads to the eye resulting in endogenous endophthalmitis. Several risk factors have been implicated including immunosuppression, ocular surface abnormalities, poor surgical wound construction, complicated cataract surgery with vitreous loss and certain types of intraocular lens. Comprehensive guidelines and recommendations on prophylaxis and monitoring of surgical cases have been proposed to minimize the risk of acute endophthalmitis. Early diagnosis and prompt management of infective endophthalmitis employing appropriately selected intravitreal antibiotics are essential to optimize visual outcome.

Optimal management of idiopathic macular holes

This review evaluates the current surgical options for the management of idiopathic macular holes (IMHs), including vitrectomy, ocriplasmin (OCP), and expansile gas use, and discusses key background information to inform the choice of treatment. An evidence-based approach to selecting the best treatment option for the individual patient based on IMH characteristics and patient-specific factors is suggested. For holes without vitreomacular attachment (VMA), vitrectomy is the only option with three key surgical variables: whether to peel the inner limiting membrane (ILM), the type of tamponade agent to be used, and the requirement for postoperative face-down posturing. There is a general consensus that ILM peeling improves primary anatomical hole closure rate; however, in small holes (<250 µm), it is uncertain whether peeling is always required. It has been increasingly recognized that long-acting gas and face-down positioning are not always necessary in patients with small- and medium-sized holes, but large (>400 µm) and chronic holes (>1-year history) are usually treated with long-acting gas and posturing. Several studies on posturing and gas choice were carried out in combination with ILM peeling, which may also influence the gas and posturing requirement. Combined phacovitrectomy appears to offer more rapid visual recovery without affecting the long-term outcomes of vitrectomy for IMH. OCP is licensed for use in patients with small- or medium-sized holes and VMA. A greater success rate in using OCP has been reported in smaller holes, but further predictive factors for its success are needed to refine its use. It is important to counsel patients realistically regarding the rates of success with intravitreal OCP and its potential complications. Expansile gas can be considered as a further option in small holes with VMA; however, larger studies are required to provide guidance on its use.

Advantages of diabetic tractional retinal detachment repair

Purpose

To evaluate the outcomes and complications of patients with diabetic tractional retinal detachment (TRD) treated with pars plana vitrectomy (PPV).

Patients and methods

We retrospectively studied a case series of 24 eyes of 21 patients at a single tertiary, university-affiliated medical center. A review was carried out on patients who underwent PPV for the management of TRD due to proliferative diabetic retinopathy from October 2011 to November 2013. Preoperative and final visual outcomes, intraoperative and postoperative complications, and medical background were evaluated.

Results

A 23 G instrumentation was used in 23 eyes (95.8%), and a 25 G instrumentation in one (4.2%). Mean postoperative follow-up time was 13.3 months (4–30 months). Visual acuity significantly improved from logarithm of the minimum angle of resolution (LogMAR) 1.48 to LogMAR 1.05 (P<0.05). Visual acuity improved by ≥3 lines in 75% of patients. Intraoperative complications included iatrogenic retinal breaks in seven eyes (22.9%) and vitreal hemorrhage in nine eyes (37.5%). In two eyes, one sclerotomy was enlarged to 20 G (8.3%). Postoperative complications included reoperation in five eyes (20.8%) due to persistent subretinal fluid (n=3), vitreous hemorrhage (n=1), and dislocated intraocular lens (n=1). Thirteen patients (54.2%) had postoperative vitreous hemorrhage that cleared spontaneously, five patients (20.8%) required antiglaucoma medications for increased intraocular pressure, seven patients (29.2%) developed an epiretinal membrane, and two patients (8.3%) developed a macular hole.

Conclusion

Patients with diabetic TRD can benefit from PPV surgery. Intraoperative and postoperative complications can be attributed to the complexity of this disease.

Comparison of the effects of 23-gauge and 25-gauge microincision vitrectomy blade designs on incision architecture

Purpose

To compare the effects of different 23- and 25-gauge microincision vitrectomy trocar cannula entry systems on incision architecture.

Methods

We tested one ridged microvitreoretinal (MVR), one non-ridged MVR, one pointed beveled, and one round-tipped beveled blade (n=10 per blade design per incision type). Each blade’s straight and oblique incision architecture was assessed in a silicone disc simulating the sclera. Wound leakage under pressure and endoscopic observations were conducted on sclerotomy sites of isolated porcine eyes (n=4 per blade design) after simulated vitrectomy.

Results

Differences in blade design created distinct incision architecture. Incisions were linear with the ridged MVR blade, flattened “M-shaped” with the non-ridged MVR blade, asymmetrical chevron-shaped with the pointed beveled blade, and curved with the round-tipped beveled blade. With the exception of oblique entry incision thickness, both MVR blade designs created thinner incisions than the beveled blades at entry and exit sites. Only the ridged MVR blade created incisions with no leakage. Vitreous incarceration was observed with all trocar cannula systems.

Conclusion

Wound closure in porcine eyes was similar with all blades despite differences in incision architecture. Wound leakage occurred at low to moderate infusion pressures with most blades; no wound leakage was observed with ridged MVR blades.

Endophthalmitis following pars plana vitrectomy: a literature review of incidence, causative organisms, and treatment outcomes

Endophthalmitis following pars plana vitrectomy is a very uncommon cause of endophthalmitis. Cases reported over the last decade show a decrease in incidence over time. To optimize visual outcome, early diagnosis and treatment are essential. In this review we report a summary of the incidence of endophthalmitis following vitrectomy, various risk factors for their occurrence, the microbiological profile and the visual outcomes post treatment.

25-gauge transconjunctival diagnostic vitrectomy in suspected cases of intraocular lymphoma: a case series and review of the literature

AIM

To report the cytology results of 25-gauge transconjunctival (25G-TSV) diagnostic vitrectomy in cases suspicious for intraocular lymphoma (IOL), and compare the results to those reported in the literature.

METHODS

Clinical and cytopathological records of 18 vitreous biopsy specimens obtained via 25G-TSV diagnostic vitrectomy in 12 patients suspicious for IOL were reviewed retrospectively. A review of the literature in regards to the diagnostic yields of vitreous specimens obtained via 25-gauge and 20-gauge diagnostic vitrectomy in suspected cases of IOL was performed.

RESULTS

Eighteen eyes from 12 patients with clinical suspicion of IOL underwent diagnostic 25G-TSV. The cytopathological investigations demonstrated IOL in 15 eyes (83.3%). Vitreous analysis was non-diagnostic in 3 eyes (16.7%).

CONCLUSION

Twenty-five-gauge diagnostic vitrectomy yields adequate sample for cytological evaluation of the vitreous in cases suspicious for IOL. The diagnostic results of the 25G-TSV in the current study are superior to those reported for 20-gauge vitrectomy but equivalent to those reported for 25G-TSV in the published literature.

Evaluation of the vitreous microbial contamination rate in office-based three-port microincision vitrectomy surgery using Retrector technology

Background

To perform a microbiological contamination analysis of the vitreous during office-based micro-incision vitrectomy surgery (MIVS) assessing whether the bacteria detected correlated with patient's ocular conjunctival flora.

Methods

This is a prospective, interventional, nonrandomized case series of patients undergoing office-based MIVS, anti-VEGF, and dexamethasone intravitreal injections (triple therapy) for the treatment of wet age-related macular degeneration (AMD) and diabetic macular edema (DME).

All patients were operated at a small procedure room in an ambulatory clinic of the Department of Ophthalmology, University of Montreal, Quebec, Canada. Conjunctival samples were done before placing the sclerotomies. The MIVS was done with a 23-gauge retractable vitrector, a 27-gauge infusion line, and a 29-gauge chandelier. Undiluted and diluted vitreous were collected for aerobic, anaerobic and fungal cultures. Outcomes measured were bacterial species identification within samples collected from the conjunctiva and the vitreous.

Results

Thirty-seven patients (37 eyes) were recruited and completed over 17 months of follow-up. Twenty-eight had wet AMD and nine had DME. There were 13 men and 24 women, with a mean age of 78 years. Eighteen patients (46%) had culture positive conjunctival flora. Twenty-six bacterial colonies were tabulated in total from the conjunctival swabs. All bacteria detected were gram-positive bacteria (100%), most commonly: Staphylococcus epidermitis in 11 (42%) and Corynebacterium sp. in 6 (23%). Only 1/18 patients had more than 3 species isolated, 6/18 patients had 2 species and 11/18 patients had 1 species identified on the conjunctival swab. Only 1 of the 37 undiluted midvitreous samples was culture positive, equating to a contamination rate of 2.7%. None of the diluted vitreous samples were culture positive. All cultures were negative for fungus. No serious postoperative complications occurred, including bacterial endophthalmitis, choroidal detachment, and retinal detachment.

Conclusion

This preliminary study of office-based MIVS gives us insights on the ocular surface microbial profile and vitreous contamination rate of performing such procedures outside the OR-controlled environment. Our initial results seem to indicate that there is little risk of bacterial translocation and contamination from the conjunctiva into the vitreous. Therefore, if endophthalmitis occurs post-operatively, the source may likely arise after the procedure. Larger studies are needed to confirm our data.

Pediatric infectious endophthalmitis: a review

Infectious endophthalmitis is a rare but severe complication of septecemia, intraocular surgeries, or penetrating eye trauma. The etiology, prognosis, and management of pediatric endophthalmitis resulting from exogenous and endogenous infections are reviewed. Open-globe trauma and glaucoma surgery are the most frequent causes of endophthalmitis in children, whereas endogenous infection is the least common cause. Streptococcus and Staphylococcus species are common bacterial agents in both posttraumatic and postoperative pediatric endophthalmitis, whereas Candida albicans is a commonly reported organism in endogenous endophthalmitis. Additionally, Streptococcus pneumoniae and Haemophilus influenzae appear more likely as pathogens in children than in adults. The clinical manifestations and outcome usually correlate with the virulence of the infecting organism. The visual prognosis of endophthalmitis is generally poor.

Intra- and Postoperative Risks and Complications of Small-Gauge (23-G) versus Conventional (20-G) Vitrectomy for Macular Surgery

Purpose

To compare the complication spectrum and rate of 23-G and 20-G vitrectomy for macular surgery.

Methods

This was a retrospective comparative analysis of 20-G and 23-G vitrectomy (introduced in 2007) for macular surgery due to macular pucker or macular hole performed between 2006 and 2010 in 61 and 59 eyes, respectively, by 2 experienced surgeons and 2 trainees. We assessed the adjusted hazard ratio for vitrectomy 23-G vs 20-G with a Cox proportional hazard model. We counted retinal detachment, vitreous hemorrhage, endophthalmitis (as early postoperative complications), or cataract progression (as late postoperative complication) as endpoint. We adjusted for indication, surgeon, retinopexy method, and the endotamponade.

Results

Follow-up averaged 712 days. Median time to first event was 385 days in the 23-G group and 342 days in the 20-G group. Cox proportional hazard analysis showed no significant difference between vitrectomy 23-G vs 20-G with regard to postoperative complications (hazard ratio 0.79, 95% confidence interval 0.41-1.52). The other covariates did not exert a statistically significant effect on the risk of adverse events. Looking at individual complications, retinal detachment was exclusively found after 20-G.

Conclusions

In this homogenous large cohort, we did not find a statistically significant difference in rates of complications between 23-G and 20-G vitrectomy techniques for macular surgery. Trainees performed equally well as experienced surgeons.

Idiopathic vitreomacular traction and macular hole: a comprehensive review of pathophysiology, diagnosis, and treatment

Posterior vitreous detachment (PVD) is a common phenomenon in the aging eye. However, this may be complicated by persistent symptomatic vitreomacular adhesions that exert tractional forces on the macula (vitreomacular traction; VMT). VMT itself may be associated with epiretinal membrane formation and the development of idiopathic macular holes (IMH). Such pathologies may cause visual disturbances, including metamorphopsia, photopsia, blurred vision, and decreased visual acuity, which impact an individual's quality of life. Technologies such as optical coherence tomography allow an increasingly more accurate visualisation of the macular anatomy, including quantification of macular hole characteristics, and this facilitates treatment decision-making. Pars plana vitrectomy remains the primary treatment option for many patients with VMT or IMH; for the latter, peeling of the inner limiting membrane (ILM) of the retina has shown improved outcomes when compared with no ILM peeling. The development of narrow-gauge transconjunctival vitrectomy systems has improved the rate of visual recovery following surgery. Ocriplasmin, by degrading laminin and fibronectin at the vitreoretinal interface, may allow induction of PVD in a non-invasive manner. Indeed, clinical studies have supported its use as an alternative to surgery in certain patient populations. However, further research is still needed with respect to greater understanding of the pathophysiology underlying the development of VMT and IMH.

Surgical outcomes of 23-gauge vitrectomy for the management of lens fragments dropped into the vitreous cavity during cataract surgery

PURPOSE

To assess the clinical features and surgical outcomes of 23-Gauge (G) vitrectomy for lens fragments dropped into the vitreous during cataract surgery.

METHODS

A retrospective, non-comparative, interventional case series at a single medical center. The medical records of 45 eyes from 45 consecutive patients who were referred to our hospital for surgical retrieval of phacoemulsification dropped lens fragments and who underwent 23-G vitrectomy were retrospectively reviewed. Data pertaining to patient demographics, pre- and post-operative Snellen visual acuity, and postoperative complications were recorded. Factors associated with dropped lens fragments were also examined.

RESULTS

Mean patient age was 68.18 ± 11.47 years. The preoperative and postoperative mean logarithm of minimum angle of resolution (logMAR) visual acuity was 1.91 ± 0.59 (Snellen equivalent 0.06 ± 0.15) and 0.42 ± 0.51 (Snellen equivalent 0.54 ± 0.31), respectively. Forty-two eyes (93.3%) had dislocated lens fragments <50% of the total lens size. Two eyes (4.4%) had a large and hard lens nucleus, which necessitated the use of a 20-G fragmatome to efficiently and completely remove the lens material. At the final examination, 30 eyes (66.6%) had a visual acuity better than 20/40. Post-vitrectomy complications included elevated IOP for at least 3 months (n = 5 eyes, 11.1%), intraocular lens dislocation (n = 2 eyes, 4.4%), and cystoid macular edema (n = 1 eye, 2.2%). No cases of postoperative endophthalmitis or retinal detachment were observed.

CONCLUSIONS

A 23-G vitrectomy is safe and efficient for the surgical management of dropped lens fragments following cataract surgery.

A prospective and nationwide study investigating endophthalmitis following pars plana vitrectomy: incidence and risk factors

BACKGROUND/AIMS

This is the first nationwide prospective study to investigate the incidence and risk factors of endophthalmitis following pars plana vitrectomy (PPV).

METHODS

This was a prospective, nationwide case-control study. Cases of presumed infectious endophthalmitis within 6 weeks of PPV were reported via the established British Ophthalmological Surveillance Unit. The surveillance period was 2 years. Controls (patients who had PPV but no endophthalmitis) were recruited from nine randomly selected UK centres.

RESULTS

37 reports were received and 28 cases met the diagnostic criteria for presumed infectious endophthalmitis following PPV. The incidence of endophthalmitis following PPV was 28 cases per 48 433 PPVs (1 in 1730 with a 95% CI of 1 in 1263 to 1 in 2747). 272 controls were randomly recruited from nine UK centres. Smaller gauge port sizes were not found to be a risk. Immunosuppression (OR 19.0, p=0.001) and preoperative topical steroids (OR 131.4, p<0.001) increased the endophthalmitis risk. Operating for retinal detachment was associated with a reduced risk of endophthalmitis (OR 0.10, p=0.005).

CONCLUSIONS

Endophthalmitis following PPV is rare. Operating with smaller gauge port sizes does not increase the risk of endophthalmitis.

Hypopyon and pseudoendophthalmitis 1 month after vitrectomy for retinal detachment with subretinal hemorrhage

The presence of postoperative hypopyon warrants consideration of the diagnosis of infectious endophthalmitis, but other etiologies may mimic a hypopyon. The differential diagnosis of a postoperative hypopyon must include causes of pseudoendophthalmitis to avoid unnecessary and invasive interventions. The context and clinical presentation are the most important factors allowing such a distinction. A patient with a hypopyon and elevated intraocular pressure presented 1 month after pars plana vitrectomy for a hemorrhagic retinal detachment. Slit lamp examination disclosed khaki-colored cells layered in the anterior chamber, and a diagnosis of pseudoendophthalmitis was made. The hypopyon resolved without intervention.

Safety of 20-gauge transconjunctival sutureless vitrectomy

PURPOSE

To study the safety of 20-gauge transconjunctival sutureless vitrectomy.

METHODS

Clinical data of patients who underwent 20-gauge transconjunctival sutureless vitrectomy for the first time, for various disorders, were reviewed retrospectively. The main outcome measures were the number of sclerotomies requiring suturing as well as the intra- and postoperative complications.

RESULTS

A total of 179 operations were performed. Indications for vitrectomy included 68 idiopathic epiretinal membranes, 26 macular holes, 23 phakic and 16 pseudophakic retinal detachments, and 46 various other, less common etiologies. Of these 179 operations, 166 (93%) were sutureless. Of the 537 sclerotomies created, 25 (5%) received a single transconjunctival-scleral suture. Intraoperative complications included premature dislodging of the cannulas in 2 sclerotomies and an iatrogenic horseshoe tear at 1 sclerotomy site. Postoperative complications comprised transient hypotony in 14 cases, subconjunctival gas in 2 cases, and choroidal effusion in 1 case. No serious complications (such as endophthalmitis) were observed.

CONCLUSION

20-gauge transconjunctival sutureless vitrectomy can be considered safe, as the intra- and postoperative complications observed are neither numerous nor significant. Sclerotomies appear to be safe and relatively easy to perform, without compromising the advantages of sutureless surgery.

Twenty-five-gauge vitrectomy versus 23-gauge vitrectomy in the management of macular diseases: a comparative analysis through a Health Technology Assessment model

Small-gauge vitreoretinal techniques have been shown to be safe and effective in the management of a wide spectrum of vitreoretinal diseases. However, the costs of the new technologies may represent a critical issue for national health systems. The aim of the study is to plan a Health Technology Assessment (HTA) by performing a comparative analysis between the 23- and 25-gauge techniques in the management of macular diseases (epiretinal membranes, macular holes, vitreo-macular traction syndrome). In this prospective study, 45-80-year-old patients undergoing vitrectomy surgery for macular disease were enrolled at the Torino Eye Hospital. In the HTA model we assessed the safety, clinical effectiveness, and cost and financial evaluation of 23-gauge compared with 25-gauge vitrectomies. Fifty patients entered the study; 14 patients underwent 23-gauge vitrectomy and 36 underwent 25-gauge vitrectomy. There was no statistically significant difference in post-operative visual acuity at 1 year between the two groups. No cases of retinal detachment or endophtalmitis were registered at 1-year follow-up. The 23-gauge technique was slightly more expensive than the 25-gauge: the total surgical costs were EUR1217.70 versus EUR1164.84 (p = 0.351). We provide a financial comparison between new vitreoretinal procedures recently introduced in the market and reimbursed by the Italian National Health System and we also stimulate a critical debate about the expensive technocratic model of medicine.

Management of posteriorly dislocated crystalline lens with perfluorocarbon liquid and fibrin glue-assisted scleral-fixated intraocular lens implantation

We describe a technique that uses a 23-gauge transconjunctival sutureless vitrectomy with perfluorocarbon liquid (PFCL) and phacoemulsification to manage a dropped nucleus. The PFCL is injected into the vitreous space until the dislocated lens reaches the iris plane and is then removed using phacoemulsification in the anterior chamber. After intraocular lens (IOL) implantation, a 23-gauge forceps is passed through the sclerotomy to grasp the IOL haptic, which is pulled onto the ocular surface. Tunnels are made at the edge of the flap with a 26-gauge needle into which the 2 haptics are tucked for additional stability. The scleral flaps and conjunctiva are then glued using biological glue. Perfluorocarbon liquid reduces lens repulsion and blocks the transmission of the ultrasound stream to the retina. The fibrin glue-assisted sutureless IOL implantation technique could reduce complications and suture-related problems.

Intraocular Microsurgical Forceps (20, 23, and 25 gauge) Membrane Peeling Forces Assessment

Background. To assess the peeling forces exerted by different calibers of microsurgical forceps on an experimental model of epiretinal membrane. Methods. A model of epiretinal membrane was constructed using thin cellulose paper and heptanes-isopropyl alcohol 1% mixture. The model was mounted on a force censoring device. Subsequently, flaps were created with three different microsurgical forceps of different calibers. We recorded the number of attempts, the duration of the event, and the pushing and the pulling forces during the peeling. The results were compared by a one-way ANOVA and a Fisher unprotected least significant difference test with an alpha value of 0.05 for statistically significance. Results. There was a statistical significant difference on the pulling and pushing forces between the 25 gauge (13.79 mN; -13.27 mN) and the 23 (6.63 mN; -5.76 mN) and 20 (5.02 mN; -5.30 mN) gauge, being greater in the first (P < 0.001). There were no differences in the duration of all events, meaning that all the forces were measured within the same period of time. Conclusions. The 25 gauge microsurgical forceps exerted the greatest mechanical stress over our simulated epiretinal membrane model and required more attempts to create a surgical suitable flap. The clinical implication of this finding is still to be determined.

A systematic review of endophthalmitis after microincisional versus 20-gauge vitrectomy

BACKGROUND

Endophthalmitis is a rare but severe complication of vitrectomy.

CLINICAL RELEVANCE

Post-surgical endophthalmitis is suspected to be more frequent after microincisional (23- and 25-gauge) compared with standard (20-gauge) vitrectomy.

METHODS

We conducted a systematic review of studies that compared microincisional and standard vitrectomy by searching MEDLINE and EMBASE up to November 2012. We used the Bayesian meta-analysis method to compute the odds ratio (OR) of endophthalmitis. We conducted subgroup analyses to compare the effect of different incision types and use of perioperative antibiotics.

RESULTS

We identified 3 small randomized and 18 nonrandomized studies that reported 68 cases of endophthalmitis in 148 643 participants. The overall OR of endophthalmitis for microincisional versus standard vitrectomy was 2.3 (95% credible interval [CrI], 0.8-5.8). We found an increased risk of endophthalmitis using a microincisional straight approach compared with standard vitrectomy (OR, 15.1; 95% CrI, 2.01-179), but not for a beveled approach (OR, 0.82; 95% CrI, 0.23-2.28). The OR of studies that reported on mixed microincision was between these 2 values (OR, 4.4; 95% CrI, 1.32-14.3). We estimated that the overall rate of endophthalmitis with 20-gauge vitrectomy was 3 cases in 10 000 procedures, and the probability that a beveled microincision increases the rate of endophthalmitis to more than 6 or 9 events was small (no more than 5% or 1%, respectively).

CONCLUSIONS

We did not find an increased risk of endophthalmitis for microincisional vitrectomy compared with standard vitrectomy. The beveled approach seems to be safer than a straight approach, supporting the current recommendation of its adoption in microincisional vitrectomy. However, these findings must be interpreted cautiously because of the small number of endophthalmitis events reported from included studies.