This is a case shared by Dr. Thiago Siqueira from Niterói Brazil
This is a 45 year old female patient, submitted to phacoemulsification in the left eye. In the second day postoperatively she had worsening in the visual acuity associated with conjunctival hyperemia and hypopyon. For the treatment, on the same day a broad spectrum antibiotic injection was made. Since, the patient didn´t have clinical improvement of the inflammation and vitreits, pars plana vitrectomy and new antibiotic injection was programmed.
In cases of endophthalmitis, it is important to take a sample from the core vitreous before turning the infusion on. So, you can first place the cannulas and position the infusion line, but keep it off. If you weren't able to see the infusion cannula on the pars plana, consider placing an anterior chamber maintainer.
Then connect a 3ml syringe to the aspiration path of your vitrector and keep the mouth of the probe in the central vitreous with high cut rates. In the meantime, your assistant gently aspirates manually the undiluted vitreous sample.
The material is then immediately sent to the laboratory for Gram and Giemsa stain, as well as cultures on blood agar, chocolate agar, brain-heart infusion, Sabouraud's media and thioglycolate broth.
Here we can see that the surgeon aspirates a small sample of the central vitreous in the puppilary plane, with the pars plana infusion still turned off. Then, he changes the position of the infusion line to the anterior chamber, since it was not possible to check its position in the pars plana.
In these cases, sometimes, the poor visualization will allow only the safety removal of the core vitreous. In the beginning, try to remove the anterior vitreous holding the probe at the pupillary plane avoiding excessive movement As soon as you are able to see better the retinal vessels, try to move posteriorly your probe, and with possible, detach carefully the posterior hyaloid. PVD induction and removal of epiretinal membranes are the most difficult steps in endophthalmitis surgery because sometimes the retina is very fragile and easy to induce retinal breaks. Avoid aggressive removal of all infiltrated vitreous in the basal area.
If possible, try to remove the remaining inflammatory debris in the anterior chamber and capsular bag. In some cases the IOL and capsular complex removal can be considered.
In this case, once retinal breaks did not occur, silicone oil was not used as tamponade.
The procedure is completed by closing all incisions in a watertight manner and injecting broad-spectrum intraocular antibiotics.
Video:
Thiago Siqueira MD - Niterói Brazil
Edition:
Filipe Lucatto MD
Juliana Prazeres MD
Salvador - Brazil
