ENDOPHTHALMITIS IN VITRECTOMY
DR. JOÃO NASCIMENTO
DR. JOÃO NASCIMENTO
Endophthalmitis
• Rare condition
• May be categorized by:
– Clinical course (Acute versus Chronic)
– Etiology (Infectious versus Non-infectious)
– Route of the causative agent enters the globe (Exogenous versus Endogenous)
– By the organism(s) involved (bacteria, fungi, parasites and rarely, viruses1
IN VITRECTOMY
DR. JOÃO NASCIMENTO
Endophthalmitis in vitrectomy
• Very Rare condition
• Post 20G vitrectomy incidence range from 0.018% to 0.02%.
(Post Cataract surgery incidence from to 0.030% to 0.11%)
• But …
– Concerns that increasing use of sutureless vitrectomy would lead to an
increased incidence of exogenous endophthalmitis
DR. JOÃO NASCIMENTO
Is suturuless vitrectomy a risk
factor for endophthalmitis?
• The first reported case of endophthalmitis following 25-G surgery was published in 2005 (1)
• A large serie from the Wills Eye Institute showed an endophthalmitis 12-fold increased risk
for 25 g vitrectomy.(0.23% (7/3,103 eyes) for 25 g vitrectomy and only 0.018% (1/5,498 eyes)
for 20 g vitrectomy, (2,3)
• In a 2010 meta-analysis (4)
–
–
the evidence was found to be tentative.
Most of the postoperative endophthalmitis cases that were reported involved both straight incision technique
and were left fluid-filled at the end of the case.
• The incidence of endophthalmitis following 23G vitrectomy in the UK has been estimated at
around 0.04%. (5)
• In a recent (2011) retrospective multicentric analysis from the Latino nations the five-year
post-pars plana vitrectomy, endophthalmitis incidence rates were 0.020, 0.028, and 0.021%
for 20-G, 23-G, and 25-G, (6)
–
Small-gauge transconjunctival PPV does not appear to increase the rates of post-PPV endophthalmitis.
DR. JOÃO NASCIMENTO
Is suturuless vitrectomy a risk
factor for endophthalmitis?
(1) Taylor SR, Aylward GW. Endophthalmitis following 25-gauge vitrectomy. Eye (Lond) 2005;19:1228–9.
(2) Kunimoto DY, Kaiser RS, Wills Eye Retina Service. Incidence of endophthalmitis after 20- and 25-gauge vitrectomy.
Ophthalmology 2007; 114(12): 2133–2137
(3) Scott IU, Flynn HW Jr, Dev S, et al. Endophthalmitis after 25-gauge and 20-gauge pars plana vitrectomy: incidence and
outcomes. Retina 2008;28:138–42
(4) Bahrani HM, Fazelat AA, Thomas M et al. Endophthalmitis in the Era of Small Gauge Transconjunctival Sutureless VitrectomyMetaAnalysis and Review of Literature. Sem Ophthalmol 2010;25(5-6):275-282
(5) Patel KC, Rahman R. Incidence of post-operative endophthalmitis following 23-gauge transconjunctival sutureless vitrectomy in the
United Kingdom: a survey. Eye 2011 [epub ahead of print]
(6) Wu L, Berrocal MH, Arévalo JF, Carpentier C, Rodriguez FJ, Alezzandrini A, et al. Endophthalmitis after pars plana
vitrectomy: Results of the Pan American Collaborative Retina Study Group. Retina. 2011;31:673–8
No definitive answer
Question remains
•
•
•
25G>23G>20G
Diabetic
Use of triamcinolone acetonide
Potential Predisposing Factors for Endophthalmitis Following Small-gauge Pars Plana Vitrectomy
• Any bacterial innoculum into the vitreous cavity
Particulary in patients with relative immune compromise
(eg, patients with diabetes mellitus and the elderly)
• Leaking sclerotomies causing early postoperative hypotony
• Vitreous wick in sclerotomies
• Increasing use of intravitreal adjuvants such as triamcinolone acetonide
•Reduced wash effect
•Preservation of peripheral vitreo
• Non-use of subconjunctival antibiotics
WOUND ARCHITECTURE
DR. JOÃO NASCIMENTO
WOUND ARCHITECTURE
MICROINCISION VITRECTOMY SURGERY
• Pearls
• Iodopovidona
• Wound creation
• Wound closure
• Clinical situations
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
GOOD WOUND ARCHITECTURE
IN 4 STEPS
MICRO-INCISION VITRECTOMY
STEP 1
– Conjuntiva misalignment
Post.-Ant.
DR. JOÃO NASCIMENTO
MICRO-INCISION VITRECTOMY
STEP 2
- Indentation
the bevel facing inwards
DR. JOÃO NASCIMENTO
MICRO-INCISION VITRECTOMY
STEP 3
- Angle perforation
-15º -20º
DR. JOÃO NASCIMENTO
MICRO-INCISION VITRECTOMY
STEP 4
- Translation 90º
DR. JOÃO NASCIMENTO
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
ADVANTAGES OF THE PROCEDURE
•
Misalignment the holes, minimize the chance of some vitreous wick to
extend beyond the conjunctiva.
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
ADVANTAGES OF THE PROCEDURE
•
Indentation -The longer the chord length with the sclera, the better the
wound sealing.
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
ADVANTAGES OF THE PROCEDURE
•
Angled incisions are better than straight incisions, regardless of the gauge
used.
•
Most patients that developed endophthalmitis after micro-incision surgery,
had straight incisions.
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
23 GAUGE VERSUS 25 GAUGE
I want to emphasize that a straight incision, even with 25-gauge surgery,
probably is not a good idea.
Many surgeons feel that wound construction, in terms of straight versus angled,
is important only when you are doing 23-gauge surgery.
Perhaps this could explain the increased
initial incidence of endophthalmitis on the 25G
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
One of our main concerns with micro-incision surgery is endophthalmitis. It is a fact that endophthalmitis
rates are higher with micro-incision surgery than with 20-gauge surgery, but if you analyze the papers and
look at the patients who developed endophthalmitis, most of those patients had straight incisions. It is
important to note that endophthalmitis rates in micro-incision surgery with angled incisions are similar to
those with 20-gauge 2,3,5-7
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
As shown in Figure 2, the India ink was visible in the 25-gauge and 23-gauge
straight incisions, not only on the ocular surface, but also within the wound itself
and inside the eye, while the angled incisions were clean with no ink found in
the wound or eye.
Figure 2. In this experiment, the India ink is used to mimic bacteria, the ink is visible on and within the
straight incisions (left) but not in the angled incisions (right).
MICRO-INCISION VITRECTOMY
VIDEO 23 G
DR. JOÃO NASCIMENTO
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
WOUND CLOSURE TIPS
EXTRACTION OF SUPERIOR TROCARS
4 STEPS
TO AVOID VITREOUS WICK AND IMPROVE TIGHTNESS
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
STEP 1
Stop infusion
STEP 2
Close superior trocars (If no valve)
STEP3
Respect the angle and
STEP 4
Counter pression with a rigid instrument
(the superficial edge of incision)
Reestablish infusion (15-20 mmHg)
MICRO-INCISION VITRECTOMY
VIDEO 23 G
DR. JOÃO NASCIMENTO
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
EXTRACTION OF INFUSION TROCAR
3 STEPS
TO AVOID VITREOUS WICK AND IMPROVE TIGHTNESS
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
STEP 1
Reestablish infusion (15-20 mmHg)
STEP2
Respect the angle
STEP 3
counter pression
Do not inject toxic antibiotics subconj.
Suture if you judge necessary
Reestablish IOP
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
VIDEO 23 G
Extracao infusão
MICRO-INCISION VITRECTOMY
SHAPE OF INCISION AND BLADE DESIGN
DR. JOÃO NASCIMENTO
MICRO-INCISION VITRECTOMY
V Shaped
needle-like
DR. JOÃO NASCIMENTO
I Shaped
beveled blade
U shaped
ESA
EdgePlus Trocar Blade, Alcon, Fort Worth, TX
The wounds pictured here are 90-degree entries, which are typically not done, but the
images provide an idea of the resultant wound contours.
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
PARTICULARITIES OF SOME CLINICAL SITUATIONS
THAT HAMPER THE CONSTRUCTION
AND SEALING OF WOUNDS
MICRO-INCISION VITRECTOMY
CLINICAL SITUATIONS
•
Myopic eyes
•
Eyes with previous vitrectomy
•
Hipotonic eyes (Phakic and Pseudophakic)
•
Diabetic retinopathy
•
Trisense
Role of Air/Gaz exchange and Sutures
DR. JOÃO NASCIMENTO
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
Differentiation between non-infectious and infectious
endophthalmitis
• lack of pain
• Lack of conjunctival injection
• Earlier presentation,
Trisense
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
HIGH MYOPIC EYE
High Myopic Eye + Previous vitrectomy + Shaving vitreous base
Fluid air exchange -> sutures
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
IN SELECT CLINICAL SITUATIONS
Consider Injection of antibiotics
Pseudo-phakic
Phakic
Diabetic,Elderly, Bedridden, Institutionalized
MICRO-INCISION VITRECTOMY
CLINICAL SITUATIONS
- Diabetic Retinopathy
DR. JOÃO NASCIMENTO
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
CLINICAL SITUATIONS
Fluid air exchange
Suture
DR. JOÃO NASCIMENTO
Endophthalmitis in vitrectomy
• Very Rare condition
• Post 20G vitrectomy incidence range from 0.018% to 0.02%.
(Post Cataract surgery incidence from to 0.030% to 0.11%)
• But …
– Concerns that increasing use of sutureless vitrectomy would lead to an
increased incidence of exogenous endophthalmitis
WOUND ARCHITECTURE
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
CONCLUSION
Wound construction is critical in micro-incision surgery, and after reviewing the
literature,
Angled incisions are better than straight incisions, regardless of the gauge we
use. In fact, if we move to 27-gauge surgery in the future, I still will be creating
angled incisions.
Remember, too, that wound closure is just as critical as wound construction
Some of the new advancements, especially the EDGEPLUS® trocar blade, will
make our ability to do micro-incision surgery better in the future.
If doubt  sutures
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
end
MICRO-INCISION VITRECTOMY
DR. JOÃO NASCIMENTO
REFERENCES
1. Acar N, Kapran Z, Unver YB, Altan T, Ozdogan S. Early postoperative hypotony after 25-gauge
sutureless vitrectomy with straight incisions. Retina. 2008;28:545-552.
2. Kunimoto DY, Kaiser RS. Incidence of endophthalmitis after 20- and 25-gauge vitrectomy.
Ophthalmology. 2007;114:2133-2137.
3. Scott IU, Flynn HW Jr, Dev S, Shaikh S, Mittra RA, Arevalo JF, et al. Endophthalmitis after 25-gauge
and 20-gauge pars plana vitrectomy: incidence and outcomes. Retina. 2008;28:138-142.
4. Taban M, Ventura AA, Sharma S, Kaiser PK. Dynamic evaluation of sutureless vitrectomy wounds: an
optical coherence tomography and histopathology study. Ophthalmology. 2008;115:2221-2228.
5. Mason JO 3rd, Yunker JJ, Vail RS, White MF Jr, Feist RM, Thomley ML, et al. Incidence of
endophthalmitis following 20-gauge and 25-gauge vitrectomy. Retina. 2008;28:1352-1354.
6. Chen JK, Khurana RN, Nguyen QD, Do DV. The incidence of endophthalmitis following
transconjunctival sutureless 25- vs 20-gauge vitrectomy. Eye. 2009;23:780-784.
7. Eifrig CW, Scott IU, Flynn HW Jr, Smiddy WE, Newton J. Endophthalmitis after pars plana vitrectomy:
Incidence, causative organisms, and visual acuity outcomes. Am J Ophthalmol. 2004;138:799-802.
8. McDonnell PJ, Taban M, Sarayba M, et al. Dynamic morphology of clear corneal cataract incisions.
Ophthalmology. 2003;110:2342-2348. (
9.Taylor SR, Aylward GW. Endophthalmitis following 25-gauge vitrectomy. Eye (Lond) 2005;19:1228–9
10. Kunimoto DY, Kaiser RS, Wills Eye Retina Service. Incidence of endophthalmitis after 20- and 25gauge vitrectomy. Ophthalmology 2007; 114(12): 2133–2137
11 . Bahrani HM, Fazelat AA, Thomas M et al. Endophthalmitis in the Era of Small Gauge
(
Transconjunctival
Sutureless Vitrectomy-MetaAnalysis and Review of Literature. Sem Ophthalmol
2010;25(5-6):275-282
12.( Patel KC, Rahman R. Incidence of post-operative endophthalmitis following 23-gauge
transconjunctival sutureless vitrectomy in the United Kingdom: a survey. Eye 2011 [epub ahead of print]
( Wu L, Berrocal MH, Arévalo JF, Carpentier C, Rodriguez FJ, Alezzandrini A, et al. Endophthalmitis
13)
after pars plana vitrectomy: Results of the Pan American Collaborative Retina Study Group. Retina.
2011;31:673–8
DR. JOÃO NASCIMENTO
39