VBS VI: Endophthalmitis Session

Ru-ik Chee, MD
Vitreoretinal Surgery Fellow
Illinois Eye and Ear Infirmary, University of Illinois at Chicago

A panel of Dr. David Eichenbaum, Dr. Damien Rodger and Dr. Jeffrey J. Tan moderated the session on Endophthalmitis: Minimizing Risk and Optimizing Outcomes.

The session started off with an important update on hemorrhagic occlusive retinal vasculitis (HORV) by Dr. Harry Flynn. HORV is a devastating condition that has been linked to the use of intraocular vancomycin, which has been increasingly used by cataract surgeons for the prophylaxis of post-operative endophthalmitis.

IMG_4455

Dr. Flynn went through a series of articles that culminated in the black box warning issued by the US Food and Drug Administration in October 2017 that intraocular vancomycin is not indicated for the prophylaxis of endophthalmitis.

It was noted that intraocular vancomycin is indeed indicated and frequently used in the treatment, but not prophylaxis, of endophthalmitis. In the ensuing discussion, early treatment with intravitreal steroids was advocated. Conversely, systemic steroids have not been shown to be beneficial thus far.

Dr. Christina Weng proceeded to present a case of postoperative endophthalmitis after cataract surgery that was complicated only by a small posterior capsule tear. In Dr. Weng’s surgical video, multiple large clumps of white material were seen swirling around the vitreous cavity during vitrectomy, likened to the appearance of a ‘snow globe.’

Unfortunately, diffuse severe retinal necrosis was already present. In an effort to salvage the globe, a complete retinectomy was performed, before the globe was filled with silicone oil and intravitreal antibiotics. Silicone oil is often useful in surgical management of endophthalmitis cases, as it does not typically support microbial growth.

Dr. Homayoun Tabandeh then shared some of his vivid ‘Endophthalmitis Nightmares’ with surgical videos of three postoperative endophthalmitis cases. One case followed cataract extraction, another after trabeculectomy, and the last following penetrating keratoplasty. In all three cases, severe extensive retinal hemorrhages were noted, and there was a discussion of distinguishing HORV from severe manifestations of endophthalmitis from virulent organisms.

Dr. David Almeida demonstrated surgical techniques he uses in cases of infectious endophthalmitis. He often utilizes a five-cannula setup. Two additional limbal cannulas allow for convenient and stable access for infusion and instrumentation of the anterior segment.

Endoph

Dr. Dilraj Grewal concluded the session with his talk and discussion on how thorough a vitrectomy needs to be in patients with endophthalmitis. The main goal in endophthalmitis vitrectomy is to debulk infected or purulent material, often progressing systematically from anterior to posterior. Further administration of antibiotics and use of silicone oil should be performed as indicated. Undiluted intraocular samples should be obtained to guide further management.

RETINA Roundup VBS VI Coverage:
3/27/2018  VBS VI: Historic Delivery of Gene Therapy for LCA
3/27/2018  VBS VI: Surgical Adventures – Curing One Eye at a Time
3/26/2018  VBS VI: Retinaws
3/26/2018  VBS VI: Complications Session
3/26/2018  VBS VI: Women of VBS Breakfast
3/26/2018  VBS VI: Endophthalmitis Session
3/25/2018  VBS VI: Retina Caliente
3/25/2018  VBS VI: Lifetime Mentorship Award: Jay Duker
3/24/2018  VBS VI: Surgical Adventures – Bridging the Gap
3/24/2018  VBS VI: Real World Retina – Practice Management, Private Equity, Advice for Young Retina Specialists
3/24/2018  VBS VI: Medical Retina
3/24/2018  VBS VI: Live Surgery Session
3/23/2018  VBS VI: Fellows’ Forray
3/24/2018  VBS VI: Welcome to Miami