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Recently, we analyzed patients devel patients analyzed we Recently, AFTER INJECTIONS ENDOPHTHALMITIS AFTER INJECTIONS intravitrealafter endophthalmitis oping toinhibitors VEGF with injection immediateof outcomes the compare intravitrealof (TAI) injection and tap PPV. surgical initial versus antibiotics injectionsintravitreal 258,357 Reviewing weperiod, 10-year a over performed who(0.016%) patients 40 identified Thereendophthalmitis. acute developed differencesignificant statistically no was betweenmonths 6 at outcomes visual in OurPPV. and TAI with treatment initial EVS,the mirror to designed was study fashion. retrospective a in albeit 8 ERIC K. CHIN, MD ERIC K. CHIN, MD and D, h Correspondingly, Correspondingly, 7 Despite the low incidence of endophthalmitis after intravitreal injections, injections, incidence of endophthalmitis after intravitreal low Despite the for the surgical management of pearls present their The authors Infectious endophthalmitis is a devastating vision-threatening condition condition vision-threatening Infectious endophthalmitis is a devastating the high volume of these injections makes this an increasing cause of cause of an increasing injections makes this volume of these the high infectious exogenous endophthalmitis. endophthalmitis. most often caused by an exogenous organism. most often caused by an exogenous    AT A GLANCE s s s The Endophthalmitis Vitrectomy Vitrectomy Endophthalmitis The demonstrated that immediate immediate that demonstrated after (PPV) vitrectomy plana pars to lead not does endophthalmitis difference significant statistically a with patients in outcomes visual in vision perception light than better presentation. at for PPV decades, ensuing the over surgery post– of treatment use in decreased has endophthalmitis cases. of 10% only to 26% from management of endophthalmitis, of management for pearls imparting of hope the with surgeons. vitreoretinal 1995, in published (EVS), Study - A three- or five-trocar setup may be appropriate, depending on the severity severity on the be appropriate, depending setup may A three- or five-trocar infection. of the BY DAVID R.P. ALMEIDA, MD, MBA, P In light In 2-6 758) seen 758) the most the = Specifically, 1 1 2018

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days after the procedure. the after days With respect to endophthalmitisto respect With We previously reviewed 10 years of years 10 reviewed previously We that involves inflammation of theof inflammation involves that formcommon most The . entire results endophthalmitis infectious of nfectious endophthalmitis is a dev a is endophthalmitis nfectious conditionvision-threatening astating volume of injections performed makesperformed injections of volume infectiousof cause increasing an this endophthalmitis. exogenous intravitreal of use increased the of article this years, recent in injections surgical the to approach our reviews Staphylococcus epidermidis Staphylococcus species. common overallthe injections, intravitreal after 0.016%(between low is rate incidence highthe however, 0.056%); and at a tertiary referral center and found and center referral tertiary a at the be to organisms gram-positive cases, of 80% in pathogens causative pathogens gram-negative by followed (9%). fungi and (11%) staphylococci coagulase-negative and class common most the was following cataract surgery, intravitrealsurgery, cataract following surgery.filtering or injection, to3 within acutely presents usually It 21 (n cases endophthalmitis from direct inoculation of an organisman of inoculation direct from exogenous, (ie, body the outside from typicallyendogenous), to opposed as ENDOPHTHALMITIS MANAGING INFECTIOUS INFECTIOUS MANAGING SURGICAL TECHNIQUES FOR FOR TECHNIQUES SURGICAL I TODAY

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Despite the importance of the EVS findings, it can be argued that the EVS data may reflect the use of older, large- gauge PPV techniques and may not be applicable to the smaller-gauge micro- incisional vitrectomy surgery (MIVS) techniques widely performed today.9 Similarly, our retrospective study of endophthalmitis after intravitreal injection may include selection bias of more severe pathology that proceeded directly to surgical intervention. Due to these confounding variables, it may be that early MIVS for endophthalmitis can be of significant benefit at remov- ing infectious material and vitreous debris. In selected cases, surgery may improve infection clearance and opti- Figure 1. The standard three-port posterior vitrectomy technique is modified with two additional trocar-cannulas at mize visual outcomes. the corneal limbus. This enables anterior infusion placement, which is preferred in cases in which the media does not allow a posterior infusion line to be verified and checked. The second limbus cannula can be used for the vitrector or PREFERRED APPROACH forceps for anterior chamber washout and membranectomy of inflammatory membranes. The infusion line can then be Our preferred management for infec- moved to the pars plana for posterior vitrectomy, or posterior vitrectomy can be performed with the anterior fusion in tious endophthalmitis is to, first, as soon place. The video (see next page) demonstrates the technique in its entirety. as possible, perform a vitreous biopsy (tap) via a short 25-gauge needle on a 3-mL or 5-mL syringe. A smaller gauge needle, such as 27-gauge or 30-gauge, can be used in an eye that has already undergone vitrectomy surgery. We typi- cally remove a vitreous sample as large as the vitreous liquefaction will allow, up to the volume of fluid that may be subse- quently injected (ie, 0.2 to 0.3 mL). This is followed by injection with intravitreal antibiotics at the pars plana in the clinic setting. The antibiotics we use most commonly are intravitreal ceftazidime 2.25 mg/0.10 mL and van- comycin 1.00 mg/0.10 mL. In patients with known serious penicillin allergy, intravitreal amikacin 400 µg/0.10 mL can Figure 2. Limbal vitrectomy allows effective membranectomy of anterior chamber membranes and other consolidated be considered. Intravitreal dexametha- inflammatory and infectious material. Here, using platform forceps, membranes are dissected and removed from sone 400 µg/0.10 mL is also sometimes the pseudophakic intraocular , enabling improved visualization during vitrectomy. considered when there is a significant inflammatory component and when the SURGICAL TECHNIQUE anterior segment inflammatory reaction suspicion for atypical organisms is low. Our surgical technique for endophth- and/or media opacity. The anterior If no clinical improvement is seen almitis includes a three- or five-trocar infusion line is especially important in symptoms, vision, and/or examina- setup using three standard pars plana when an anterior chamber washout is tion, we typically perform PPV within trocar-cannulas with or without two necessary. Similarly, a second anterior 48 to 72 hours of initial presentation anterior corneal limbal trocar-cannulas limbal cannula is useful for secondary with the idea that the vitreous acts as (Figure 1). The latter two ports are instrumentation to remove fibrin and a culture medium for microorganisms typically necessary in eyes with severe inflammatory membranes with the vit- to proliferate. endophthalmitis that have significant reous cutter and/or small gauge retinal

APRIL 2018 | RETINA TODAY 25 . - - Arch J Fr - . Am J Ophthalmic Surg Retin Cases Brief Rep Dev Ophthalmol . 2010;128(9):1136-1139. D h . . 2017;174:155-159. . 2017;96(50):e8701. . 2015;46(6):643-648. BIT.LY/ALMEIDA0418 Arch Ophthalmol Am J Ophthalmol Medicine (Baltimore) . 2018;125(1):66-74. . 2016;10:167-172. . 2014;45(2):143-149. Ophthalmology Ophthalmic Surg Lasers Imaging Retina Clin Ophthalmol 2016;165:88-93. 1995;113(12):1479-1496. 2015;38(10):941-949. WATCH IT NOW WATCH IT s VIDEO Private practice, Retina Consultants of Southern Private practice, Retina Consultants of Southern [email protected] Financial disclosure: Consultant (Alcon, Allergan, Private practice, VitreoRetinal Surgery, PA, in Private practice, VitreoRetinal Surgery, PA, in [email protected] Financial disclosure: Consultant (Alcon, Allergan, California, Redlands, California, and Assistant California, Redlands, California, and Assistant Professor, Loma Linda University and Veterans Affair Hospital of Loma Linda in California Citrus Therapeutics, Eyenuk, Ophthotech, Regeneron, Tyrogenex) Minneapolis, Minnesota Citrus Therapeutics, Genentech, Regeneron)     ERIC K. CHIN, MD n n n degeneration. 5. Rayess N, Rahimy E, Storey P, et al. Postinjection endophthalmitis rates and characteristics following intravitreal bevacizumab, ranibizumab, and aflibercept. Ophthalmol. 6. Fileta JB, Scott IU, Flynn HW. Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. Lasers Imaging Retina 7. [no authors listed]. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Ophthalmol. 8. Yannuzzi NA, Si N, Relhan N, et al. Endophthalmitis after clear corneal cataract surgery: outcomes over two decades. 9. Almeida DR, Chin EK, Shah SS, et al. Comparison of microbiology and visual outcomes of patients undergoing small-gauge and 20-gauge vitrectomy for endo phthalmitis. 10. Chin EK, Almeida DR, Strohbehn AL, et al. Elevated following pars plana vitrectomy due to trapped gas in the posterior chamber. 2016;10(4):334-337. 11. Martiano D, L’helgoualc’h G, Cochener B. Endoscopy-guided 20-G vitrectomy in severe endophthalmitis: Report of 18 cases and literature review [article in French]. Ophtalmol. 12. Wong SC, Lee TC, Heier JS. 23-Gauge endoscopic vitrectomy. 2014;54:108-119. 13. Pan Q, Liu Y, Wang R, et al. Treatment of Bacillus cereus endophthalmitis with endoscopy-assisted vitrectomy. DAVID R.P. ALMEIDA, MD, MBA, P n n n 1. Almeida DR, Miller D, Alfonso EC. Anterior chamber and vitreous concordance in en 1. Almeida DR, Miller D, Alfonso EC. Anterior dophthalmitis: implications for prophylaxis. after intravitreal injection of vascular2. Xu K, Chin EK, Bennett SR, et al. Endophthalmitis and visual outcomes [publishedendothelial growth factor inhibitors: management online ahead of print February 21, 2018]. 3. Gregori NZ, Flynn HW, Schwartz SG, et al. Current infectious endophthalmitis rates af ter intravitreal injections of anti-vascular endothelial growth factor agents and outcomes of treatment. 4. Daien V, Nguyen V, Essex RW, et al. Incidence and outcomes of infectious and noninfectious endophthalmitis after intravitreal injections for age-related macular

- - 10 - n Although 11-13 PPV for acute infectious endophth- infectious acute for PPV Endoscopic vitrectomy can facilitatecan vitrectomy Endoscopic A compressible medium such as airas such medium compressible A acute infectious endophthalmitis in ain endophthalmitisinfectious acute manner. efficacious and safe a useful alternative surgical option inoption surgical alternative useful a segmentanterior inadequate with eyes seg anterior advanced or visualization scarring. ment SHARING STRATEGIES todue challenging be can almitis anteriorthe in inflammation severe significantcreates which chamber, andpearls surgical The opacity. media arehere presented techniques surgical managesurgeons retina help to meant silicone oil can provide a stable, long- stable, a provide can oil silicone tamponade. acting incavity vitreous the of visualization todue visibility poor settingof the anterioror inflammation significant studiesSeveral opacification. segment endoscopic of utility the shown have outcomes favorable with techniques cases. recalcitrant in endoscopicadditional requires this thewith familiarity and equipment providemay it technique, endoscopic or gas in the anterior chamber canchamber anterior the in gas or or visualization postoperative limit pupillaryto due IOP elevated to lead closure. angle cases, some in or, block therewhich in instances in Moreover, chamberanterior the of shallowing is bag IOL–capsular unstable angle, post–cataractin found complexes undergomay endophthalmitis surgery airunder displacement significant areorganisms atypical When gas. or progressivesevere with encountered, hypotony,or inflammation, infection, choice of tamponade agent can alsocan agent tamponade of choice siliconeor gas, nonexpansile air, include using avoid typically We needed. as oil escapeseasily often it because gas or air theunless chamber, anterior the into orbreaks retinal by complicated is case lim valved of Use detachment. retinal chamberanterior the in cannulas bal gasof regress any minimize to help can nec is this if chamber anterior the into anticipated. or essary ------2018 APRIL

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After PPV, we typically leave theleave typically we PPV, After In aphakic eyes, posterior segment posterior eyes, aphakic In A small amount of hemorrhage may hemorrhage of amount small A Inflammation of the anteriorthe of Inflammation A Tano or DDMS Diamond-DustedDDMS or Tano A ultrasound imaging to confirm wheth confirm to imaging ultrasound attachedare and retina the er the with entry safe ensure to 360° for instrumentation. plana pars thehowever, fluid-filled; cavity vitreous limbal anterior infusion cannula. infusion anterior limbal performedeasily be can vitrectomy place,in trocars limbal the only with access.plana pars for need the without B-scanpreoperative recommend We be reinserted to the conventional infero conventional the to reinserted be pos a and cannula, plana pars temporal terior vitrectomy can then be performed. infusionplana pars the which in cases In avisualized, optimally be cannot still performedbe can vitrectomy posterior theto connected line infusion the with capsular membrane removal, making themaking removal, membrane capsular increasinglypole posterior the of view mediathe When (Video). challenging posterior the and improved is clarity bal the visualized, better be can pole canline infusion solution saline anced removal (Figure 2). Care should beshould Care 2). (Figure removal whichiris, the to trauma avoid to taken sub a to lead and hyphema cause may pole. posterior the of view optimal after iris from seen be barriers to an early safe and effectiveand safe early an to barriers theof visualization poor to due PPV limbalevent, this In pole. posterior toplatform preferred the is vitrectomy membra chamber anterior perform andmembranes remove to nectomy vitreousbefore visualization improve intraocular pressure (IOP), the cornealthe (IOP), pressure intraocular intention be to have may epithelium opti to intraoperatively scraped ally view. posterior the mize becan opacity media and segment Membrane Scraper (Bausch + Lomb;+ (Bausch Scraper Membrane abradeto used be can Synergetics) on present membranes fibrinous any anof surface posterior or anterior the pres is one if (IOL), lens intraocular isedema corneal When (Video). ent highor inflammation to due present grasping forceps (Figure 2). (Figure forceps grasping RETINA TODAY

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