To determine the efficacy of immediate pars plana vitrectomy as the primary treatment for acute endophthalmitis in patients with a visual acuity (VA) of hand motion (HM) or better.
A total of 149 patients who were referred to a single center for acute endophthalmitis after cataract surgery over the 13-year study period were retrospectively analyzed. Only patients presenting with a VA of at least HM were included. Patients were initially treated with either primary vitrectomy or intravitreal antibiotic injection alone, and their visual outcomes and reintervention rates after initial treatment were compared.
There was no significant difference in the proportion of good (final VA ≥20 / 40) and poor (VA ≤ counting finger) visual outcomes between the groups. However, subgroup analysis of patients with a VA of HM (92 eyes) showed that the incidence of reintervention (14 of 72 eyes [19.4%] vs. 9 of 20 eyes [45.0%]) and poor visual outcomes (10 of 72 eyes [13.9%] vs. 8 of 20 eyes [40.0%]) were lower after prompt vitrectomy than after intravitreal antibiotic injection alone (
For patients with endophthalmitis presenting with a VA of HM, performing a prompt vitrectomy reduced the incidence of reintervention and poor visual outcomes than the administration of intravitreal antibiotics alone. Our results suggest that primary vitrectomy for patients with endophthalmitis presenting with a VA of HM could be more beneficial than intravitreal antibiotic injection alone.
Although infectious endophthalmitis is a rare complication of ocular surgery, it is a severe infection that can affect vision, and requires prompt and effective treatment. Cataract surgery is one of the most commonly performed surgical procedures globally [
Since the mid-1990s, one of the most important studies on the treatment of endophthalmitis has been the Endophthalmitis Vitrectomy Study (EVS). The EVS was a multicenter, randomized, prospective clinical trial that involved 420 consecutive cases of endophthalmitis and was used to establish guidelines for the management of infectious endophthalmitis. The study concluded that vitrectomy had no benefit when visual acuity (VA) was better than light perception (LP) [
Vitrectomy has been increasingly performed in patients with endophthalmitis presenting with VAs better than LP, although this practice disregards the EVS guidelines [
Currently, there is no consensus on the effectiveness of immediate vitrectomy as an initial treatment for endophthalmitis after cataract surgery. It is therefore appropriate to validate the conclusions of the EVS, especially those regarding patients with an initial VA better than LP. The purpose of this study was to determine the efficacy of immediate pars plana vitrectomy as the primary treatment for acute endophthalmitis in patients with a VA better than LP (HM or better).
The study was approved by the Institutional Review Board of Kim’s Eye Hospital, Konyang University College of Medicine (No. 2020-02-002), and it conformed to the tenets of the Declaration of Helsinki. The requirement for informed consent was waived by the Institutional Review Board of Kim’s Eye Hospital.
We retrospectively reviewed computerized medical records and collected the data of patients who were referred from other local hospitals due to acute endophthalmitis after cataract surgery. All patients were referred from facilities across South Korea and treated at Kim’s Eye Hospital, a referral center in South Korea, between January 2007 and December 2019.
Postoperative endophthalmitis was diagnosed by vitreoretinal specialists when decreased VA was combined with the following typical clinical features: marked intraocular inflammation, conjunctival injection, and hypopyon. Toxic anterior segment syndrome was ruled out using ultrasound after confirming significant vitritis at baseline. Only the patients presenting with a VA of HM or better were included in the analysis (those with VAs of LP or worse were excluded). We included all the referred patients with endophthalmitis; however, those with more than 7 days of referral delay were excluded. In addition, patients with endophthalmitis after vitrectomy, bleb complications from glaucoma surgery, penetrating trauma, or intravitreal injection were excluded.
Patients were initially treated with either primary vitrectomy or intravitreal antibiotic injection alone. Those who underwent an initial treatment of intravitreal antibiotics received an intravitreal injection of vancomycin hydrochloride (1.0 mg in 0.1 mL) and ceftazidime (2.25 mg in 0.1 mL). At the discretion of the surgeon, some patients also received an intravitreal injection of dexamethasone sodium phosphate. All injections were performed on the day of diagnosis, without delay, in a sterile surgical room.
When a patient’s fundus could not be assessed due to media opacities, immediate vitrectomy was performed as an initial treatment, regardless of the presenting VA. Specific indications for immediate vitrectomy are as follows: (1) severe vitreous opacity (vitritis) confirmed on ultrasound or no red reflex and/or (2) severely edematous cornea. For such patients, pars plana vitrectomies were performed using a standard 23G or 25G transconjunctival vitrectomy system. Vitrectomy was performed to remove as much vitreous as possible, including the induction of posterior vitreous detachment, except in cases of necrotic retina or severe vitreous haziness, where inducing posterior vitreous detachment is difficult. Intravitreal antibiotics were injected at the end of the vitrectomy.
At baseline, the anterior chamber fluids and vitreous specimens were collected and an antibiotic sensitivity test was performed for each patient. During each vitrectomy, an initial undiluted vitreous specimen was obtained before the fluid infusion was initiated and after all the sclerotomies had been performed. Cultures from the samples were incubated on blood agar, chocolate agar, thioglycolate broth, and fresh Sabouraud dextrose agar.
Twenty-four to 48 hours after the initial procedure, patients were reevaluated for endophthalmitis. Improvement was defined as increased VA, clearer media in the vitreous or anterior chamber, and pain relief. However, if there was no significant improvement at the time of reevaluation, reinterventions, including additional pars plana vitrectomies with intravitreal antibiotic injections, were performed until the vitreous and anterior chambers were sufficiently clear.
The final VA was defined as the best-corrected VA after the resolution of intraocular inflammation. The proportion of patients with good visual outcomes (final VA ≥20 / 40) and poor visual outcomes (final VA ≤ counting finger [CF]) were compared between the prompt vitrectomy and intravitreal antibiotic injection groups. Further, the rate of reintervention was compared between the subjects. A subgroup analysis was also performed for the patients who presented with a VA of HM, CF, and better than 5 / 200. Continuous variables were analyzed using a
A total of 196 eyes of 196 patients were diagnosed with acute endophthalmitis after cataract surgery and treated during the 13-year study period. Forty-seven eyes were excluded because of an initial VA of LP or worse (37 eyes) or a referral delay of more than 7 days (10 eyes). Thus, 149 eyes of 149 patients (70 female and 79 male patients) were eligible for inclusion. The mean age of the patients was 67.5 years (range, 41–84 years) at the time of diagnosis. The mean length of follow-up was 12.4 months (range, 3 months to 8 years; median, 6 months).
The mean time from cataract surgery to the onset of endophthalmitis symptoms was 4.82 days (range, 1–20 days). Endophthalmitis manifested within 3 days in 71 eyes (47.7%), within 4 to 7 days in 51 eyes (34.2%), and after more than 7 days postoperatively in 27 eyes (18.1%). The mean duration from the development of symptoms to referral was 3.14 days (range, 0–7 days). For 102 patients, a referral was made within 3 days, and for 47 patients, it was made within 4–7 days.
The presenting VA was HM in 92 eyes (61.7%), CF in 20 eyes (13.4%), and better than CF (more than 5 / 200) in 37 eyes (24.8%). The baseline characteristics of the patients are summarized in
Most of the patients were referred without any intervention after the diagnosis of postoperative endophthalmitis. However, 29 of 149 patients (13.4%) had undergone immediate treatment at their local hospital before referral: 28 patients received intravitreal antibiotic injections and one patient had undergone a partial vitrectomy.
Of the 149 bacterial cultures, 85 (57.0%) were positive and 64 (43.0%) were negative for bacterial growth. Among the positive cultures, 62 (72.9%) were gram-positive bacteria, 20 (23.5%) were gram-negative bacteria, and three (3.5%) had fungal growth. The most commonly isolated gram-positive bacterium was
Of the 149 cases investigated, primary vitrectomy with intravitreal antibiotic injections was performed in 92 patients (61.7%), and 57 patients (38.3%) received intravitreal antibiotic injection alone. The percentage of patients in the primary vitrectomy group who presented with VAs of HM, CF, and 5 / 200 or better were 78.3% (72 of 92 cases), 45.0% (9 of 20 cases), and 29.7% (11 of 37 cases), respectively.
There was no statistical difference in the proportion of patients with good visual outcomes (final VA ≥20 / 40) after treatment in the primary vitrectomy group (50 of 92 eyes, 54.3%) and intravitreal antibiotic injection alone group (35 of 57 eyes, 61.4%;
In a subgroup analysis of patients with a baseline VA of HM, the proportion of patients with good visual outcomes in the primary vitrectomy group (36 of 72 eyes, 50.0%) and intravitreal antibiotic injection group (12 of 20 eyes, 60.0%) did not differ significantly (
There was no statistically significant difference in the proportion of patients with poor visual outcomes (final VA ≤ CF) between the primary vitrectomy group (11 of 92 eyes, 12.0%) and intravitreal antibiotic injection only group (10 of 57 eyes, 17.5%;
Thirty-six of 149 eyes (24.2%) of total participants required reintervention for infection control. Reintervention after initial treatment was significantly more frequent in the intravitreal antibiotic injection group than that in the primary vitrectomy group (
These results were consistent in the subgroup analysis of patients presenting with a VA of HM, with reintervention being significantly more frequent in the intravitreal antibiotic injection group (9 of 20 eyes, 45.0%) than in the primary vitrectomy group (14 of 72 eyes, 19.4%;
Pars plana vitrectomy may have several advantages for the management of endophthalmitis because it allows for a large specimen to be used for diagnostic evaluation, permits the removal of an infectious agent, and enables a reduction in the inflammatory debris or mediators in the vitreous cavity [
The EVS results recommended primary vitrectomy only for patients presenting with a VA of LP or worse because there was no evidence that it improved visual outcomes for those with initial VAs better than LP (HM or better) [
Improved surgical techniques and technology may motivate physicians to perform immediate vitrectomy for endophthalmitis rather than strictly follow the EVS guidelines. The small-gauge, wide-angle viewing vitrectomy system, which has been used since the 2000s, is associated with decreased surgical duration, less tissue manipulation, reduced inflammation and postoperative complications, and more rapid visual recovery [
Bacterial virulence is an important prognostic factor in the management of endophthalmitis [
In the current study, the patients who were treated with prompt vitrectomy showed significantly less need for reintervention, which allowed for a faster recovery from the infection. Twelve of 23 patients (52.2%) with a baseline VA of HM who received intravitreal antibiotic injections as the initial treatment (as recommended by EVS) eventually required a vitrectomy for infection control. Thus, waiting 24 to 48 hours before performing a vitrectomy after antibiotic injections was not necessary for nearly half of the patients with endophthalmitis who had a VA of HM in this study. A recent report also showed that the need for early reintervention was 54.9% after intravitreal antibiotic injections versus 6.2% after prompt vitrectomy [
Concerning visual outcomes, prompt vitrectomy had no impact on the visual outcomes of patients with VAs of CF or better in this study. A recent investigation regarding acute postoperative endophthalmitis reported similar visual outcomes in the 1st week of presentation between the group treated with intravitreal antibiotics alone and that treated with immediate vitrectomy [
To the best of our knowledge, this study included the largest number of patients with endophthalmitis after cataract surgery with initial VAs of HM or better from a single referral center. Moreover, the treatment of endophthalmitis was conducted using a single protocol as much as possible. These are the strengths of this study since endophthalmitis has a very low incidence and is therefore difficult to study.
However, this study also has several limitations, including its retrospective study design. First, delays in treatment before the referral or interventions before the referral may have affected the visual outcomes. The visual outcomes could have been different had the patients been treated at our institution earlier. Second, our study only included cases of endophthalmitis following phacoemulsification. We did not include cases associated with trauma, bleb-related complications following trabeculectomy, vitrectomy, or intravitreal injections to maintain homogeneity of the study population. Given that the prognosis of endophthalmitis varies according to condition [
In conclusion, prompt vitrectomy for patients with endophthalmitis and a VA of HM reduced the incidence of both reintervention and poor visual outcomes. Our results suggest that immediate vitrectomy for patients with endophthalmitis presenting with a VA of HM could be more beneficial than intravitreal antibiotic injection alone. Well-organized prospective randomized studies, which apply the currently improved clinical practice protocols, are encouraged.
None.
Baseline characteristics of patients referred due to endophthalmitis after cataract surgery presenting visual acuity of hand motion or better (n = 149)
Characteristic | Value |
---|---|
Age (yr) | 67.5 (41–84) |
Follow-up period (mon) | 12.4 (3–100) |
Sex | |
Male | 79 (53.0) |
Female | 70 (47.0) |
Involved eye | |
Right | 72 (48.3) |
Left | 77 (51.7) |
Presenting visual acuity | |
Hand motion | 92 (61.7) |
CF | 20 (13.4) |
Better than CF (more than 5 / 200) |
37 (24.8) |
Time from surgery to presentation (day) | |
1–3 | 71 (47.7) |
4–7 | 51 (34.2) |
>7 | 27 (18.1) |
Presence of hypopyon at presentation | 79 (53.0) |
Ruptured posterior capsule at presentation | 5 (3.4) |
Intraocular pressure at baseline (mmHg | 14.4 (6–38) |
Values are presented as mean (range) or number (%).
CF = counting finger.
Range, 5 / 200 to 20 / 30.
Results of bacterial cultures from patients referred due to endophthalmitis after cataract surgery (n = 85)
Pathogen | No. (%) |
---|---|
Gram-positive bacteria | 62 (72.9) |
|
35 (41.2) |
Methicillin-resistant |
1 (1.2) |
|
4 (4.7) |
|
3 (3.5) |
|
2 (2.4) |
|
3 (3.5) |
|
2 (2.4) |
|
2 (2.4) |
|
10 (11.8) |
Gram-negative bacteria | 20 (23.5) |
|
13 (15.3) |
|
2 (2.4) |
|
1 (1.2) |
|
1 (1.2) |
|
3 (3.5) |
3 (3.5) | |
2 (2.4) | |
1 (1.2) |
Proportions of good visual outcomes (more than 20 / 40 final VA) after endophthalmitis treatment in the primary vitrectomy and intravitreal antibiotic injection groups
Initial treatment | Total | Final VA ≥20 / 40 | |
---|---|---|---|
Total cases presenting VA of HM or better | 149 | 85 (57.0) | 0.523 |
Primary vitrectomy | 92 | 50 (54.3) | |
Intravitreal antibiotics only | 57 | 35 (61.4) | |
Cases presenting VA of 5 / 200 or better | 37 | 26 (70.3) | 0.421 |
Primary vitrectomy | 11 | 9 (81.8) | |
Intravitreal antibiotics only | 26 | 17 (65.4) | |
Cases presenting VA of CF | 20 | 11 (55.0) | 0.618 |
Primary vitrectomy | 9 | 5 (55.6) | |
Intravitreal antibiotics only | 11 | 6 (54.5) | |
Cases presenting VA of HM | 92 | 48 (52.2) | 0.457 |
Primary vitrectomy | 72 | 36 (50.0) | |
Intravitreal antibiotics only | 20 | 12 (60.0) |
Values are number of patients.
VA = visual acuity; HM = hand motion; CF = counting finger.
Chi-square test.
Proportions of poor visual outcomes (less than CF final VA) after endophthalmitis treatment in the primary vitrectomy and intravitreal antibiotic injection groups
Initial treatment | Total | Final VA ≤ CF | |
---|---|---|---|
Total cases presenting VA of HM or better | 149 | 21 (14.1) | 0.418 |
Primary vitrectomy | 92 | 11 (12.0) | |
Intravitreal antibiotics only | 57 | 10 (17.5) | |
Cases presenting VA of 5 / 200 or better | 37 | 2 (5.4) | 0.591 |
Primary vitrectomy | 11 | 1 (9.1) | |
Intravitreal antibiotics only | 26 | 1 (3.8) | |
Cases presenting VA of CF | 20 | 1 (5.0) | 0.741 |
Primary vitrectomy | 9 | 0 (0) | |
Intravitreal antibiotics only | 11 | 1 (9.1) | |
Cases presenting VA of HM | 92 | 18 (19.6) | 0.022 |
Primary vitrectomy | 72 | 10 (13.9) | |
Intravitreal antibiotics only | 20 | 8 (40.0) |
Values are number of patients.
VA = visual acuity; CF = counting finger; HM = hand motion.
Chi-square test;
Fisher exact test.
Patients with endophthalmitis who required reintervention after initial treatment in the primary vitrectomy and intravitreal antibiotic injection groups
Initial treatment | Total | No. of patients | |
---|---|---|---|
Total cases presenting VA of HM or better | 149 | 36 (24.2) | 0.039 |
Primary vitrectomy | 92 | 17 (18.5) | |
Intravitreal antibiotics only | 57 | 19 (33.3) | |
Cases presenting VA of 5 / 200 or better | 37 | 9 (24.3) | 0.331 |
Primary vitrectomy | 11 | 2 (18.2) | |
Intravitreal antibiotics only | 26 | 7 (26.9) | |
Cases presenting VA of CF | 20 | 4 (20.0) | 0.531 |
Primary vitrectomy | 9 | 1 (11.1) | |
Intravitreal antibiotics only | 11 | 3 (27.3) | |
Cases presenting VA of HM | 92 | 23 (25.0) | 0.019 |
Primary vitrectomy | 72 | 14 (19.4) | |
Intravitreal antibiotics only | 20 | 9 (45.0) |
VA = visual acuity; HM = hand motion; CF = counting finger.
Chi-square test;
Fisher exact test.