1. Vitrectomy is an important treatment for endophthalmitis as it removes infected vitreous material to reduce the bacterial load and toxins in the eye. 2. The Endophthalmitis Vitrectomy Study showed that for acute post-operative endophthalmitis presenting with light perception vision or worse, immediate vitrectomy provided significant benefits over antibiotics alone. For better vision, vitreous tap with intravitreal antibiotics was equally effective. 3. Traumatic and chronic endophthalmitis often require vitrectomy due to severity of infection and inflammation, and difficulty sterilizing the vitreous cavity with antibiotics alone. Vitrectomy allows removal of infected material

1. Vitrectomy in
endophthalmitis

2. Disease entity
• Post operative (62%)
• Bleb associated (25%)
• Post trauma (10%)
• Endogenous (<4)
• Post intravitreal injection (<1%)

3. Acute endophthalmitis
• < 6 weeks
• Infective, TASS, lens indused, reactivation of uveitis
• flora colonizing the lids and lash
• Staph (35%)(epidermidis or aureus), strepto spp.(35%), p. acnes (5%)

4. Chronic post operative endophthalmitis
• >6 weeks
• P. acne (41.2%), Staph. Epidermidis, corynebacterium spp., fungi

5. Therapy
• In the past, topically, subconjunctivally, by IV, and by IM injection
• 1980s - intravitreal antibiotics were accepted and recommended
• PPV - significant amount of material obtained for culture
Removal of infected vitreous - reduces bacterial load and toxins.
Media opacities are cleared
more rapid restoration of visual function

6. Antimicrobial Therapy
• role of subconjunctival and systemic antibiotics is more controversial
• Intravitreal – emperic
MIC - only 36–48 hours
• 1. Vancomycin 1 mg/0.1 mL
• 2. Cefazolin 2.25 mg/0.1 mL
• 3. Amikacin 0.2–0.4 mg/0.1 mL
• 4. Ceftazidime 2 mg/0.1 mL
• In select cases with severe vitreous inflammation consider:
• • Dexamethasone 4 mg/0.1 mL
• In traumatic endophthalmitis with vegetable matter consider:
• • Amphotericin B 5 μL/0.1 mL

7. Endophthalmitis vitrectomy study 1995
• Purpose –
• role of IV antibiotics and
• necessity of immediate PPV(within 6 hours of presentation) in post op.
endophthalmitis within 6 weeks

8. • Four treatment groups
• two groups underwent a three-port PPV, with or without IV
antibiotics
• two groups underwent a vitreous tap again with or without IV
antibiotics.
• All patients in the four treatment groups received systemic steroids

9. EVS drug regimen
• vancomycin 1 mg/0.1 cc and
• amikacin 400 mcg/0.1 cc.
• no intravitreal steroids
• Topical drops included vancomycin, amikacin, cycloplegics, and
corticosteroids

10. • Systemic medications were used for 5–10 days
• They were prednisone (PO) 60 mg,
• amikacin (IV) 50 mg/kg every 12 hours, and
• ceftazidime (IV) 2 g every 8 hours(Oral ciprofloxacin if the patient was
allergic to penicillin)

11. Key points of EVS results
• average onset of signs and symptoms of endophthalmitis was 6 days
after surgery
• 25% were without pain and
• 14% had no hypopyon
• Cultures were positive in only 69% of the cases
• 94% were Gram positive, with the majority being Staphylococcus
coagulase negative (70%), Staphylococcus aureus (10%), and
Streptococcus species (11.5%).
• Only 6% were Gram-negative organisms

12. Conclusions of EVS
• streptococci, Staph. aureus and Gram-negative organisms were more
virulent and more difficult to sterilize in the vitreous cavity
• intravenous antibiotics used at the time showed no additional benefit
• Immediate vitrectomy (up to 6 hours) is of significant benefit to those
who present with LP vision
• when the vision is hand-motion or better, a vitreous tap and
intravitreal antibiotics were as efficacious and recommended
• patients with diabetes mellitus had a better outcome with an initial
strategy of vitrectomy regardless of presenting vision

13. Traumatic Endophthalmitis
• Others effects of the injury
• wider, more virulent spectrum of bacteria
• Bacillus species
• Vitrectomy has been recommended because of
severity of the injuries,
severity of infection, and
more adverse outcome reported in these cases
• retained lens cortex, vitreous hemorrhage, and retinal breaks, as well
as allowing removal of infected vitreous, bacteria, and toxins

14. Chronic post-operative endophthalmitis
• indolent, initially responding to topical corticosteroid
• P. acnes – produces a granulomatous inflammation
characteristically a white plaque on the lens capsule
Cultures should be kept for at least 2 weeks
• fungal (particularly Candida parapsilosis),and
• nonvirulent forms of Staph. Epidermidis
• Surgery
• Recommended antimicrobial - vancomycin for P. acnes and amphotericin
for fungi;
imidazoles, - ketoconazole, fluconazole, or voriconazole may be of
benefit

15. Bleb-Associated Endophthalmitis
• occurs long after the initial surgery and is preceded by irritation and
redness of the eye
• classic initial finding is “white on red”
• Streptococcus is the infecting organism in as many as 60% of these
• initial vitrectomy
• In some (phakic) initial infection may be confined to the anterior
segment (“blebitis”), so systemic and intensive topical antibiotics may
work

16. Endogenous Endophthalmitis
• systemic illness or IV drug use
• Repeated blood cultures and a multidisciplinary approach are often
helpful
• Systemic therapy may be sufficient if the vitreous is not heavily
involved
• If fungal disease is strongly suspected, therapeutic vitrectomy is the
treatment of choice

17. Surgical Techniques
• placement of the infusion cannula
• AC wash
• inflammatory membrane
• in pseudophakic, the lens need not be removed initialyy - attempting
to do so may increase the risk of bleeding
• Removal of membrane over crystalline lens should begin over the iris,
close to the pupillary border, so the lens can be spared
• poor dilation and poor visualization, the lens in phakic eyes removed

18. • In severe cases the cornea and anterior chamber may be totally opaque.
• a temporary keratoprosthesis / open-sky vitrectomy can be used, followed
by a penetrating keratoplastic.
• Pockets of more heavily infiltrated vitreous are sometimes located near the
vitreous base; in the aphakic eye, peripheral depression may be used to
bring these into view
• posterior vitreous detachment
• cutting of vitreous near inflamed/necrotic retina can cause breaks
• If good visibility cannot be obtained, it is better to discontinue the
procedure
• In the end, watertight closure and intravitreal antimicrobials

19. Postoperative Management
• Analgesics
• Topical antibiotics and steroids, cycloplegic
• Systemic steroid
• If the inflammation appears to worsen - repeat tap and injection of
antibiotics
• In the EVS, 35% of all eyes needed some secondary procedure

20. Thank you