|Year : 2022 | Volume
| Issue : 2 | Page : 59-65
Outcomes of early vitrectomy for endophthalmitis after cataract surgery in delta population, Egypt, 2015–2020
Ahmed A Tabl, Mohamed G Masoud, Gehad H Abdelhalim, Marwa A Tabl
Department of Ophthalmology, Faculty of Medicine, Benha University, Benha, Egypt
|Date of Submission||26-Feb-2022|
|Date of Acceptance||31-Mar-2022|
|Date of Web Publication||08-Jul-2022|
MD Ahmed A Tabl
Department of Ophthalmology, Asad Street, Faculty of medicine, Benha University, Benha 13511
Source of Support: None, Conflict of Interest: None
Purpose To evaluate the outcomes of early pars-plana vitrectomy (PPV) in the management of acute onset endophthalmitis after cataract surgery.
Study design Retrospective observational study.
Patients and methods We collected data from 11 patients who were diagnosed as acute infectious endophthalmitis within 6 weeks after cataract surgery, from January 2015 to December 2020 and had undergone early 23-G PPV and were followed up for 3 months. We analyzed factors that may affect prognosis and final visual outcomes.
Results The mean age was 58±5 years, there was male predominance (72.7%). The mean axial length was 24.76±1.58 mm. The baseline best-corrected visual acuity was 2.3 logMAR and was improved to 1.2 logMAR at the third month (P<0.001). Mixed air/fluid intraocular tamponade was used in 63.6% of patients. About half of the cases had positive cultures (54.5%), and the most frequent organism was Staphylococcus aureus (66.7%). Retinal detachment was reported in 36.4% of patients. The preoperative factors correlated with final best-corrected visual acuity were posterior vitreous detachment and intraocular tamponade.
Conclusions Early PPV for acute-onset endophthalmitis after cataract surgery aided in improving final visual outcome and preserving structural and functional integrity of the globe, thus preventing late complications that could affect patients’ quality of life. Factors that influence the final visual outcome were intraocular tamponade and posterior vitreous detachment.
Keywords: cataract surgery, endophthalmitis, pars-plana vitrectomy
|How to cite this article:|
Tabl AA, Masoud MG, Abdelhalim GH, Tabl MA. Outcomes of early vitrectomy for endophthalmitis after cataract surgery in delta population, Egypt, 2015–2020. J Egypt Ophthalmol Soc 2022;115:59-65
|How to cite this URL:|
Tabl AA, Masoud MG, Abdelhalim GH, Tabl MA. Outcomes of early vitrectomy for endophthalmitis after cataract surgery in delta population, Egypt, 2015–2020. J Egypt Ophthalmol Soc [serial online] 2022 [cited 2022 Sep 28];115:59-65. Available from: http://www.jeos.eg.net/text.asp?2022/115/2/59/350247
| Introduction|| |
Postoperative infectious endophthalmitis is a devastating condition that causes diffuse intraocular inflammation and may lead to blindness. Acute postoperative endophthalmitis (APE) is usually presented within 6 weeks of intraocular procedure and diagnosis is confirmed by clinical examination and by the aid of B-scan ultrasonography ,. The incidence of APE ranges from 0.03 to 0.2% in previous publications ,,,. It is commonly caused by coagulase-negative Staphylococcus and Streptococcus species ,. Treatment options for APE are intravitreal antibiotics and/or pars-plana vitrectomy (PPV). The Endophthalmitis Vitrectomy Study (EVS) concluded that immediate 20-G (PPV) did not produce different visual outcomes if the presenting vision is better than perception of light, where intravitreal antibiotics may have a favorable role in such cases ,.
Small-gauge PPV improved the surgical outcome of postoperative endophthalmitis significantly in the last two decades, using wide-field viewing systems and the direction toward using silicone oil as an intraocular tamponade that was not used in the EVS study encourage toward seeing new clinical trials investigating the outcome of small-gauge PPV in the early management of APE ,. While using preoperative antibiotics has decreased the rate of APE, it has increased the ratio of drug resistance, which may lead to significant problems in the future ,.
Intravitreal vancomycin and ceftazidime are still widely used in the management of APE before PPV with a low incidence of drug resistance and excellent coverage for Gram positive and Gram negative species, respectively ,. Intracameral moxifloxacin is used as an intracameral injection at the end of the cataract surgery to reduce the incidence of APE up to threefold according to recent publications with a potent effect against both Gram positive and Gram negative species ,,,.
In this study, we aimed to evaluate the outcome of early PPV in the management of APE after cataract surgery and to analyze the factors related to the final visual outcome in such cases.
| Patients and methods|| |
In this single-center retrospective observational study, we collected data from 11 patients who were diagnosed as APE within 6 weeks after cataract surgery, at the Ophthalmology Department, Benha University Hospital, Egypt from January 2015 to December 2020, and had been managed by early 3-port 23-G PPV within 48 h of their confirmed diagnosis using clinical examination and B-scan ultrasonography (Sonomed EZ scan AB-500 plus, Sonomed Escalon, Marcus Avenue, NY 11042, USA). All patients have completed the follow-up for 3 months.
This study followed the principles outlined in the Declaration of Helsinki, and was approved by the Institutional Review Board of Faculty of Medicine, Benha University, Egypt. It was retrospectively registered on ClinicalTrials.gov (identifier, NCT05249413). The inclusion criteria were acute onset endophthalmitis within 6 weeks after primary cataract surgeries; the exclusion criteria were patients diagnosed as endogenous or chronic endophthalmitis, those with a previous history of rupture globe surgery or trauma, and those who did not complete the follow-up period.
Demographic and ophthalmological examination data were collected for all patients as follows: age, sex, and systemic diseases such as diabetes mellitus. Medical and surgical history with preoperative medications, best-corrected visual acuity (BCVA) measured with the Snellen chart and was converted to equivalent logMAR units for statistical analysis. Intraocular pressure was measured by Goldmann applanation tonometry in cooperative patients (Haag-streit holding u.s inc, Kings Mills Road Mason, OH 45040 USA) and by digital palpation in uncooperative ones. Ocular signs of the anterior and posterior segment, the presence of hypopyon, corneal clarity, and the reactions of posterior segments were graded from mild, moderate to severe vitritis according to the fundus view, in which the optic dis and retinal vessels could be seen or not.
Pars-plana vitrectomy operation technique
The 23-G PPV was done by the same surgeon for all cases (A.A.T.) in the operating room with maximum care taken for complete sterilization and under aseptic condition. Surgeries were done using megaTRON S4 (Geuder AG, Hertzstr, Heidelberg, Germany). Vitreous and aqueous samples were collected for culture and sensitivity. The main surgical steps were insertion and check of the infusion line 3.5 mm from the limbus/or insertion into the anterior chamber in cases where there was a doubt about its position due to poor view, aspiration of any fibrin from the anterior chamber and removal of any pupillary membranes trying to maximize view of the posterior segment, core and peripheral vitrectomy. Removal of intraocular lens (IOL) and opening of the posterior capsule was done using the cutter leaving the anterior capsule for supporting future secondary IOL implantation, in cases of partial posterior vitreous detachment (partial-PVD) trimming of the central vitreous leaving vitreous base to avoid creation of iatrogenic breaks, in cases with total PVD removal of all vitreous up to the base was done, in cases with no PVD, just core vitrectomy was done, and staining with triamcinolone acetonide suspension to clear all central vitreous. Intraocular tamponade was chosen according to each case scenario; if no breaks were noted the patient was left on partial air/fluid tamponade, in cases with retinal breaks the patient was left on silicone oil 2000 cs tamponade. All sclerotomies were sutured using vicryl 8-0 to ensure no leakage. Intravitreal ceftazidime 2.25 mg/0.1 ml and vancomycin 1 mg/0.1 ml were injected separately at the end of the surgery 3.5 mm posterior to the limbus, and intraocular pressure was checked digitally.
Data management and statistical analysis were done using SPSS, version 28 (IBM, Armonk, New York, USA). Quantitative data were assessed for normality using the Shapiro–Wilk test and direct data visualization methods. According to normality testing, numerical data were summarized as means and SDs or medians and ranges. Categorical data were summarized as numbers and percentages. BCVA was compared between different follow-up times using repeated-measures analysis of variance. All post-hoc analyses were Bonferroni adjusted. Percent change of BCVA at 1 and 3 months was compared according to systemic diseases and intraocular tamponade using the Mann–Whitney U test. Fisher’s exact test assessed associations between retinal detachment and other parameters. Correlation analyses were done using Spearman’s correlation. All statistical tests were two-sided. P values of less than 0.05 were considered significant.
| Results|| |
The mean age of the studied patients was 58±5 years. There was male predominance (72.7%). The mean axial length was 24.76±1.58 mm. About half of the patients (45.5%) had a systemic disease ([Table 1]).
Best-corrected visual acuity at baseline, 1, and 3 months
BCVA showed an overall significant difference between different follow-up times (P<0.001). Post-hoc analysis revealed significantly higher BCVA at baseline (2.3 logMAR) than at 1 and 3 months (1.2 logMAR) ([Table 2] and [Figure 1]).
|Table 2 Best-corrected visual acuity at baseline, 1, 3 months in the studied patients|
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|Figure 1 BCVA at baseline, 1, and 3 months in the studied patients. BCVA, best-corrected visual acuity.|
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Mixed air/fluid intraocular tamponade was used in about two-thirds of the patients (63.6%). About half of the patients had positive cultures (54.5%), and the most frequent organism was Staphylococcus aureus (66.7%). Retinal detachment was reported in about one-third of the patients (36.4%), and most of them (75%) had retinal detachment after 1month. About half of the patients had total PVD (54.5%), and one-third (36.4%) had no PVD. Only one patient had partial PVD. One-quarter (27.3%) of the patients had moderate vitritis, while three-quarters (72.7%) had severe vitritis ([Table 3]).
Correlation between the percent change of best-corrected visual acuity and other parameters
The percent change of BCVA at 1 month showed a significant positive correlation with preoperative PVD grade (r=0.896 and P<0.001). Also, percent change of BCVA at 3 months showed a significant positive correlation with preoperative PVD grade (r=0.625 and P<0.001) ([Table 4] and [Figure 2]).
|Table 4 Correlation between best-corrected visual acuity percent change and other parameters|
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|Figure 2 Correlation between BCVA percent change and PVD degree at 1 and 3 months. BCVA, best-corrected visual acuity; PVD, posterior vitreous detachment.|
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Best-corrected visual acuity percent change according to systemic diseases and intraocular tamponade
At 1 and 3 months, percent change of BCVA showed no significant differences regarding systemic diseases (P=0.429 and 0.537, respectively) and intraocular tamponade used (P=0.927 and 0.164, respectively) ([Table 5]).
|Table 5 Best-corrected visual acuity percent change according to systemic diseases and intraocular tamponade|
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Retinal detachment association with intraocular tamponade used and preoperative posterior vitreous detachment grade
Partial or no preoperative PVD was significantly higher in four (100%) cases, who had retinal detachment than those with no retinal detachment (14.3%) (P=0.015). No significant association was reported between retinal detachment and the intraocular tamponade used (P=1.0) ([Table 6]).
|Table 6 Retinal detachment association with intraocular tamponade and preoperative posterior vitreous detachment grade|
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[Figure 3] shows an example of a case diagnosed as APE 3 days after primary cataract surgery. [Figure 3]a shows the preoperative view with cloudy cornea and inflammatory membranes; the baseline BCVA was 1.9 (logMAR). [Figure 3]b shows intraoperative view after PPV with removal of IOL and air/fluid tamponade. [Figure 3]c shows improvement of corneal edema on the first follow-up, and [Figure 3]d–e shows preoperative and postoperative B-scan ultrasound with severe vitritis and total PVD. LogMAR BCVA was improved to 1.0 at 1 and 3 months.
|Figure 3 Example of a case with APE: (a) preoperative view, (b) immediately after PPV and removal of the IOL, (c) first follow-up view, (d) preoperative B-scan US with total PVD, and (e) postoperative B-scan US. APE, acute postoperative endophthalmitis; IOL, intraocular lens; PPV, pars-plana vitrectomy; PVD, posterior vitreous detachment; US, ultrasound.|
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| Discussion|| |
In this retrospective observational study, we analyzed the data of 11 patients, who were diagnosed as APE after primary cataract surgery and were managed by a 23-G PPV within 48 h from their diagnosis. The mean timing of the presentation of APE was 5±2 days.
There is no consensus regarding the timing of vitrectomy in cases with APE after cataract surgery. The EVS concluded that vitrectomy should be preserved for cases with only light perception . The advances in posterior segment machines and small-gauge cannulas decrease the incidence of intraoperative complications and encourage for early intervention in cases with APE ,.
In a retrospective study conducted by Oshitari et al. , data of 29 eyes with APE after cataract surgery were analyzed and concluded that visual acuity was improved to 0.5 logMAR or better in 50% of eyes when early vitrectomy was performed. Our results are consistent with them as six of our patients gained a final BCVA of 1.0 logMAR. Better results were also reported in other publications ,,. On the other hand, a recent study by Soliman et al.  concluded that similar outcomes were obtained after treatment of APE with intravitreal antibiotics alone in 55 eyes and early vitrectomy within 1 week of presentation in 149 eyes; however, their inclusion criteria were considering any intraocular operation.
In a study conducted by Peng and colleagues, they concluded that the baseline BCVA was one of the prognostic factors correlated with the final visual outcome during 3 months of follow-up. In contrast to the current study, there was a significant correlation between baseline and 1 month BCVA ([Table 4]). Previous studies have reported significant correlations between the severities of APE and the virulence of the causative organism ,,,. Vitreous tapping was the most sensitive way in obtaining positive culture results. Gram positive cocci were the most common organisms that were obtained in about 64% out of 82 eyes with APE in a study by Peng et al. . Gram negative bacteria were obtained in about 30% of cases in the same study, in which pseudomonas cases showed the worst final visual outcome. In contrast to our study, six cases had a positive culture, in 66.7% of them, S. aureus was the causative organism and pseudomonas was found in only one (16.7%) case.
The most significant signs at the time of presentation in this study were hypopyon (91%), fibrin deposition and posterior synechiae (63.6%) and vitritis on B-scan ultrasonography in all cases; these results are similar to other publications ,,.
Regarding PVD in this study, total PVD was found in 54.5%) no PVD in 36.4%, and partial PVD in 9.1%. Cases with total and partial PVD showed a better final visual outcome when compared with cases with no PVD. Also, retinal detachment had occurred in all cases with preoperative absent PVD. Similar results had been reported suggesting that vitreous has an important role for the spread and proliferation of microorganisms in APE ,.
In this study, silicone oil tamponade was used in 36.3% of cases, which had a suspicious retinal break or incomplete vitreous removal due to poor intraoperative view, while seven (63.6%) cases were left on a mixture of fluid/air tamponade. During the 3 months of follow-up, retinal detachment had occurred in four (36.3%) cases in which three of them were left on fluid/air tamponade; missed break and proliferative vitreoretinopathy (PVR) were the main causes. Similar results were obtained in a randomized prospective study conducted by Nagpal et al. , in which 64 eyes that underwent PPV with silicone oil showed better anatomical and functional outcomes when compared with 65 eyes that underwent PPV alone. Also less incidence of retinal detachment was found among silicone-filled eyes (6.2%) when compared with fluid-filled eyes (25.5%). Silicone oil tamponade was reported to have a bactericidal effect  and a better final visual outcome in previous reports ,.
On the basis of the previous results, prognostic factors that may lead to poor visual outcome were virulent organisms such as Pseudomonas aeruginosa, delayed intervention, absence of PVD, and leaving the eye on fluid/air mixture. Similar results were reported in previous studies ,,,,,. Chronic intraocular inflammation seems to be responsible for the irreversible retinal cell damage and delayed adverse effects that may occur after PPV for APE such as PVR, retinal detachment, and macular pucker. In this study, retinal detachment due to PVR occurred in 36.3% of cases and macular pucker in 45.4%, which is in accordance with other recent reports ,.
This study was conducted in a single tertiary university hospital, the incidence of APE after primary cataract surgeries in the period from January 2015 to December 2020 was 0.1%, and this is in accordance with previously reported range of 0.02–0.2% ,.
Preventive measures widely used to decrease the incidence of APE after cataract surgeries are using povidone-iodine, preoperative and postoperative antibiotics, intracameral antibiotics, single-use instrumentations, and cataract machines’ cassettes. However, these measures still vary between each center and around the world ,. Intracameral moxifloxacin 0.5% was used at the end of cataract surgery in five (45.4%) cases enrolled in this study.
The limitations in this study are the short-period of follow-up, small sample size, and only studied APE after primary cataract surgeries. Thus, further studies are recommended with a longer follow-up period and a larger sample size to strengthen the outcomes of this study. Authors recommend early PPV in confirmed cases with APE after cataract surgeries and encourage the use of silicone oil endotamponade, especially in cases with no PVD to preserve the functional and anatomical integrity and evade the need for evisceration in such cases.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]