Intraocular lens removal or not during vitrectomy for acute infectious endophthalmitis after cataract surgery

The infectious endophthalmitis is a rare but the most serious complication after cataract surgery. Removal or not of the intraocular lens (IOL) during vitrectomy in such case is controversial, without an expert consensus. In this issue, we publish an article entitled “Timely vitrectomy without intraocular lens removal for acute endophthalmitis after cataract surgery” written by Guo

. In the paper, they presented 10 eyes of 10 patients with acute endophthalmitis that occurred one to three days after cataract surgery. The causative organisms were confirmed by positive isolation of

in 5 eyes,

in 2 eyes, and

in one eye. From the photos of a representative case, corneal edema, hypopyon, and fibrin exudates in the anterior chamber were obvious with dense vitreous opacity in the infected eye. They remained IOL during vitrectomy and filled the vitreous cavity with silicone oil after thoroughly repeated irrigation. Silicone oil was removed in 9 eyes 3-6mo after vitrectomy but remained in one eye previously with

infection. No retinal detachment or ocular atrophy was observed after 25.5 months’ follow-up. The visual acuity improved remarkably in 9 eyes, while one eye remained with no light perception. They concluded that their management was safe and effective

.

While the article was reviewed, one of our reviewers did not agree with the authors’ method that without IOL removal. And one concerned that the method could mislead the surgeon’s decisions in similar situation. In order to acquire more opinions on IOL removal or not in those cases at the present time, we did a simply investigation

WeChat. We sent a questionnaire with photos of the representative case to 42 the most experienced vitrectomy surgeons in Chinese mainland.Surprisingly, there were 31 (73.8%) responses agreed with no IOL removal in the case, and 10 (23.8%) responses considered IOL removal for completely clear of pathogens. The last one responded as uncertain. They also provided with their experience and emphasized several points on the technique.We thereafter decided to publish the paper as a brief report in order to call upon more comment and discussion on this technique.

From Guo

’s

report, we could summarize their successful management for control of the infection without recurrence in all 10 cases mainly due to the following elements. First,they did the earliest intervention for the acute infection. An emergency procedure was conducted within 24h after initial diagnosis. Second, they used viscoelastics to free the capsular bag from IOL and irrigated the anterior chamber, capsular bag, front and back IOL surfaces thoroughly and repeatedly.Complete and early clearance of purulence, pathogens and toxins is the most critical procedure in the operation. Third,recent advanced micro-incision vitrectomy instruments and panoramic microscopy facilitate the manipulation to be more accurate and efficient. However, they neither mention intraocular antibiotics use and the posterior capsule cut, nor explain the necessity of silicone oil injection

. In regards to systemic and intracameral antibiotics use, as Althiabi

pointed out, the role of systemic antibiotics and vitrectomy is unclear and practice patterns vary widely. But intracameral moxifloxacin has become more widely accepted and intracameral vancomycin has been shown to be associated with retinal vasculitis

.

The necessity of silicone oil use in the case series is questionable. Several of our experienced surgeons believe that silicone oil can be used in the presence of retinal breaks,severe retinal swelling or damage, and chronic or recurrent endophthalmitis. They did not agree with silicone oil use in the reported cases. Therefore, it is important to avoid iatrogenic retinal hole during vitrectomy.

At present, the incidence of infectious endophthalmitis after cataract surgery has been significantly reduced, but it is still a serious complication. A Meta-analysis of 39 studies including 5 878 114 eyes yielded a 0.092% incidence of endophthalmitis after cataract surgery

. The incidence appeared to decrease with time (0.097% before 2000, 0.063% after 2010) and with the use of intracameral antibiotics (0.045%)

. In consideration of risk factors related with occurrence of infection, several techniques need to be emphasized, including reducing the probability of lens posterior capsule rupture, behind-the-lens washout,

, clear the capsular bag for complete viscoelastics removal, and prophylactic use of antibiotics, especially in diabetic patients

.

The severity of an acute intraocular infection can be a main consideration for strategy of various treatment. Early diagnosis and prompt surgical treatment can improve the prognosis in the affected eyes. In general, a mild inflammatory reaction in the anterior chamber can be treated with frequent eye drops and subconjunctival antibiotics. A moderate inflammation with fibrin exudates in the anterior chamber and subtle vitreous opacity can be treated with intracameral antibiotic lavage and intravitreal injection. A severe inflammation with corneal edema, hypopyon and fibrin exudates in the anterior chamber,and dense vitreous opacity or suppuration, can be treated with vitrectomy and antibiotic lavage

. The cases in Guo

’s

series could be classified as the severe inflammation in terms of severity. Moreover, the characteristics, treatment and prognosis of the endophthalmitis vary due to different pathogens with various virulence and its reaction to antibiotics. If visualization is good enough for appropriate manipulation during vitrectomy after irrigating the anterior chamber and capsule bag, IOL may not be extracted at the surgeon’s discretion. In cases with very severe inflammatory reaction, including corneal swelling and obscure, small pupil, and unclear capsule bag, it is necessary to extract IOL for subsequent appropriate vitrectomy. In a chronic or fungi infectious endophthalmitis after cataract surgery, IOL removal can be performed in most cases

.

“以器官系統為中心”（organ system-centered，OSC）的課程模式是以人體器官系統為中心，重組醫學各門學科知識，使基礎和臨床課程之間銜接更系統化和完整化，已成為國內醫學院校課程改革的重點[1]。目前我國的整合改革主要集中在基礎課程之間的水平整合及基礎與臨床課程之間的垂直整合，而在臨床學科間開展橫向整合的較少，可借鑒的經驗也較為有限。因此，我院臨床醫學系積極開展OSC臨床課程間橫向整合改革，在血液與腫瘤疾病教學過程中，積極引入CBL（case-based learning）以案例為基礎的教學方法，取得了良好的教學效果。

In Guo

’s

report, they believed that one advantage of their management without IOL removal was that it could retain uncorrected visual acuity after control of the infection and avoid secondary IOL implantation, so that reduced unnecessary medical dissension. However, the risk of endophthalmitis after cataract surgery can’t be entirely eliminated, both physicians and patients should always beware and prepare for this rare but severe complication.

ACKNOWLEDGEMENTS

在監控界面上，運行人員可進行流量自動調節，還可對閘門進行提、落、停控制，或對閘門進行定高度控制，界面顯示數據信息包括上下游水位、閘門高度等。除流程界面外，系統對閘門開高、水位、流量等重要參數的趨勢變化進行跟蹤，以趨勢圖記錄，方便分析。

Conflicts of Interest: Hui YN, None.

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