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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5183_Библиотеки_им_академика_М_И_Перельмана.pdf
Emergency Vitrectomy
for Beginners
19
in Endophthalmitis—The Core
Vitrectomy
Arne Viestenz, Wolfgang Schrader, Anja Viestenz
and Frank Wilhelm
Contents
19.1 Signs of Endophthalmitis .......................................... 193
References and Further Reading .......................................... 200
Endophthalmitis is one of the most visionthreatening emergencies and is considered a
clear emergency surgery indication in ophthalmology. Young ophthalmic surgeons are faced
with the challenge of quickly and efficiently
conducting the medical history, diagnostics,
team coordination, and surgical decision-making. The operation should be performed as soon
as possible to preserve any remaining vision.
A. Viestenz () · A. Viestenz
Klinik und Poliklinik für Augenheilkunde,
Universitätsklinikum Halle/Saale, Halle/Saale,
Germany
e-mail: sekretariat.augenklinik@uk-halle.de
A. Viestenz
e-mail: sekretariat.augenklinik@uk-halle.de
W. Schrader
Augenzentrum Würzburg, Würzburg, Germany
e-mail: mail@profschrader.de
F. Wilhelm
Universitätsklinikum Halle Saale, Greifswald,
Germany
19.1 Signs of Endophthalmitis
Typical signs of endophthalmitis are: pain,
photophobia, epiphora, conjunctival and ciliary injection—also with conjunctival chemosis,
periorbital soft tissue swelling, hypopyon, iris
hyperemia, vitreous infiltrates and retinal infiltrates, vision loss. Not all of these signs need to
be present; for example, only 75% of patients
with endophthalmitis experience pain—especially in patients with neuropathy (e.g., in diabetes mellitus or after cerebral/orbital radiation,
taking analgesics), pain is not a reliable leading
symptom for endophthalmitis (Fig. 19.1 ).
The absence of pain does not rule out
endophthalmitis!
It is especially important for young surgeons to
diagnose endophthalmitis. Sometimes no fundus details are visible. Standardized ultrasound
of the eye is helpful here. All four quadrants of
the globe must be examined in a standardized
manner using sonography. In the B-scan, the
position with the greatest accumulation of infiltrates is identified. At this position with the most
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2025
F. Wilhelm (ed.), Ophthalmic Surgery for Beginners, https://doi.org/10.1007/978-3-662-70287-1_19
193
194 A. Viestenz et al.
19.1.1 Medical History
A thorough medical history also helps:
• Do you have pain? Since when?
• Have you had eye surgery or any surgery
in the past few weeks? Did you possibly
not wear your eye shield or did it slip while
sleeping?
• Do you have an artificial heart valve?
• Do you have open sores on your body or in
your mouth?
• Have you had an eye injury in the past few
days or worked in the garden or workshop
Fig. 19.1 Ultrasound (B-scan) demonstrating massive
intra vitreal infiltration
and got something in your eye?
• Do you suffer from diabetes mellitus?
• Do you take immunosuppressants?
• Are you infected with HIV/AIDS?
• Do you work in agriculture or a riding stable/
do you have pets?
• Do you suffer from a tumor or have you been
treated with radiation or chemotherapy?
• For patients in the intensive care unit, it is
important to inspect venous or intra-arterial
accesses/indwelling catheters—these could be
entry points for, e.g., Candida. In the case of
confirmed endophthalmitis, the intravascular
accesses must be re-established and the catheter tip must be microbiologically analyzed.
Fig. 19.2 A-scan with vitreous buzz (78 dB = tissue
sensitivity T, T+9 dB would be 87 dB). The ultrasound
buzz starts below the endophthalmitis lower limit for
endophthalmitis
densities (highly reflective structures in the vitreous), the vitreous infiltration is then measured
using the standardized A-scan probe (tissue sensitivity T+9 dB = endophthalmitis threshold). If
swirling spikes are found in the vitreous space
below this threshold, this, combined with clinical findings and medical history, indicates the
presence of endophthalmitis (Fig. 19.2).
19.1.2 Timing of Surgery
The surgery should be performed promptly,
i.e., preferably within the next two hours. This
means that under central OR conditions, the
surgeon must emphasize the urgency of the procedure, and the next available OR slot must be
provided. If endophthalmitis is present, an infusion with antibiotics should already be administered systemically (see Magdeburg three-stage
scheme by Prof. Wolfgang Behrens-Baumann).
If the patient has consumed food within the
19519 Emergency Vitrectomy for Beginners …
last six hours, the risks and benefits must be
weighed. An ileus induction by the anesthesia team allows the operation to be performed
within two hours.
19.1.3 Proper Posture and Monitoring Before Surgery
A supine position is obsolete for the patient
before the surgical procedure. This causes
cytokines, leukocytes, and germs to sink to the
posterior pole and can thus induce a hypopyon
on the macula. This toxic accumulation leads
to massive inflammation in the macula and not
infrequently to vascular occlusion with drastically reduced visual prognosis.
Temperature measurements should be performed regularly (at least 3 times/day) and if there
is an elevated temperature or fever, blood should
be analyzed for germs (blood culture) to detect
and quickly treat sepsis. A conjunctival or corneal swab is performed with the requirement for
germ detection and resistance testing. It is also
worthwhile to name the planned or used antibiotics. A Hertel-exophthalmometry is also useful. In
the case of orbital cellulitis or the progression of
endophthalmitis to panophthalmitis with orbital
phlegmon, the early comparison of exophthalmometer values can be diagnostically valuable.
A local therapy (every fifteen minutes) with
antibiotic eye drops (also “fortified”) combined
with polyhexanide eye drops should be performed before the surgery. Depending on the
preoperativ findings in addition to the widening
of the pupil it can be necesssary to perform the
scraping of the corneal epithelium.
19.1.4 Local Anesthesia or General
Anesthesia?
The inflammation changes the pH value towards
the acidic range, so the effectiveness of local
anesthetics decreases. To spare the patient with
endophthalmitis additional and unnecessary
pain, general anesthesia is preferred.
19.1.5 Procedure in the Operating Room
To specifically treat the infection, the germ must
be identified.
After disinfecting the surgical area and sterile draping, there are two options for tissue
sampling:
1. from the anterior and posterior chambers,
respectively.
2. from the vitreous cavity.
While anterior chamber puncture usually yields
only 200 μl of aspirate, a volume of 4 to 5 ml
can often be obtained from the vitreous, increasing the chances of detecting the germs.
It is crucial that no antibiotics or antifungals
are added to the infusion.
The authors recommend the following
procedure:
1. Before the start of the operation: Team
time-out.
2. In general anesthesia, the periocular region
(10% PVP-iodine) and the conjunctiva (5%
PVP-iodine) are disinfected. In the case of
an open wound of the eyeball, the conjunctiva and cornea are disinfected only with
1% PVP-iodine.
3. Three trocars are inserted at a distance of 3
to 4 mm behind the limbus (Figs. 19.3 and
19.4).
4. The infusion tube with the adapted three-
way stopcock is filled only with BSS. Now,
if necessary, the IOP can be managed with a
syringe filled with BSS.
5. Anterior vitrectomy via pars plana is per-
formed through a trocar.
6. A syringe (e.g., 3 ml) is adapted to the suc-
tion tube of the vitrectome and carefully
aspirated under rapid cuts of the vitrectome
(at least 4000 cuts/minute). Ideally, two
syringes are obtained: one for the search for
bacteria with a resistance profile and one
for the analysis of fungi (fungal PCR and
culture).
196 A. Viestenz et al.
Fig. 19.3 Transconjunctival positioning of trocars. The conjunctiva will be displaced with the tip of the trocars with
a distance of 3–4 mm from the limbus and with an angle of approximately 45 to 80 degrees as stepwise line through
the sclera into the vitreus cavity.
Fig. 19.4 Removal of a hypopyon from the anterior chamber with a 23 g forceps. The hypopyon will be sent for
microbiological analysis.
7. The syringe is sealed and sent for microbiological analysis.
8. Pus in the anterior chamber: Chamber
water is obtained via a paracentesis with
the Sautter cannula. If there is a tough
hypopyon in the anterior chamber, it is
removed with forceps or tube-guided forceps (Fig. 19.5).
9. Gentamycin is one option that can be used
during vitrectomy additionally in BSSsolution (Fig. 19.6).
10. Under continuous infusion, the anterior vitrectomy can now be continued from both
upper trocars.
11. The vitreous body should be handled gently.
However, in areas without visible retinal infiltrates, it is important to achieve posterior vitreous detachment. Great care should be taken
in areas where visibility is limited (Fig. 19.7).
12. Careful water-air exchange (only about 20%
of the vitreous volume). This fills the vitreous cavity from the lens to under the trocars
with air.
Fig. 19.5 Endophthalmitis after an injury due to a
switching to air
wooden stick. Ophthalmoscopy shows only blurry retinal vessels. The vitreous cavity is filled with blood and
strains of bacterial colonies.
BSS plus
3-way stopcock
air
infusion tube to the
eye bulb
19719 Emergency Vitrectomy for Beginners …
prevents the antibiotics or antifungals from
escaping outward (Fig. 19.5).
14. Removal of the trocars and, if necessary,
suturing with Vicryl 7-0 EKN in case of air
leakage.
15. Subconjunctival administration of steroids
and antibiotics/antifungals.
16. Bandage with antibiotic and steroid eye
ointment, postoperative local therapy should
definitely be continued in the ward!
With a bit more surgical experience, the posterior vitreous cavity can be vitrectomized using
the BIOM or a contact lens. The inexperienced
are well advised not to aspirate or peel off the
deposits on the retina.
After the surgery, the Magdeburg step
scheme 3 (endophthalmitis) should be continued.
After receiving the antibiogram/resistogram, targeted antibiotic therapy must be administered.
In the following days, the degree of infiltration in the vitreous cavity should be measured
daily (preferably 2 to 3 times) using ultrasound.
If the decibel threshold decreases, this is an indication of a worsening condition. Consequently,
vancomycin and ceftazidime can be re-administered into the vitreous cavity as intravitreal
injections after one to three days (Fig. 19.8).
Fig. 19.6 Work with the 3 way port: one tube is connected with the globe, the surgeon may choose between
BSS or air supply.
13. Now, 0.1 ml of vancomycin and 0.1 ml of
ceftazidime are administered into the vitreous cavity. In case of a strong suspicion of
fungal endophthalmitis, voriconazole and
amphotericin B are administered intravitreally. The superficial air administration
19.1.6 Special case: Endophthalmitis after Intravitreal Injections or pars plana vitrectomy
In contrast to endophthalmitis in cataract surgery, postoperative endophthalmitis in the posterior segment usually initially presents with
the accumulation of pus, while the anterior segment may appear uninflamed in the initial phase
of endophthalmitis after intravitreal injections
or ppV. Examination of the eye in mydriasis is
absolutely indicated if post- intravitreal injection
endophthalmitis is suspected! Patients often only
become sensitive to pain after a longer interval.
198 A. Viestenz et al.
core vitrectomy
BSS input via the
infusion asterisk
suction of
vitreous aspirate
via the
vitrectome
vitreous body
with pus
Fig. 19.7 Vitreous probe during core vitrectomy. The vitrectom should be used with a high cutting rate (min. 4000
cuts/min) to avoid tractional forces onto the retina with retinal breaks. The vitrectomy probe should be moved very
slowly during the shaving procedure of the vitreus base.
A risk factor for post-intravitreal injections endophthalmitis is the so-called “iodine
allergy”, which is usually just a contact intolerance of the skin. Sometimes the exposure time
Ultimately, the aspiring ophthalmic surgeon
should practise the handling of the surgical
instruments and control of the machines in the
wet lab including vitrectomy.
of Serasept or polyhexanide (Lavasept 0.04%,
applied 3 times every 10 minutes) was not long
enough, so the germs were not sufficiently
reduced.
19.1.8 Special Features: COVID
and Endophthalmitis
19.1.7 What to do if I have never performed a vitrectomy?
In this case, it must be weighed whether the
rapid transfer of the patient to a clinic with a
vitrectomy service would be better, or whether
at least the administration of vancomycin and
ceftazidime as intravitreal injection in the procedure room under gel anesthesia should be
performed to reduce the proliferation of germs
before transferring the patient to a vitrectomy
center. In any case, the vitrectomy center should
be pre-informed to avoid so-called transfer
liability.
In the initial phase of the COVID pandemic,
the authors observed an increase in endophthalmitis cases (by a factor of 8 after intravitreal injection), often caused by a contaminated
mouth-nose protection (MNP), but also by an
unsanitized dental status, allowing an airflow
over the operated eye through the mask. The
bandage is, in our opinion, essential for one day
after intravitreal injection when wearing an MNP.
If the patient has endophthalmitis and tested
positive for COVID, the risk of general anesthesia must be weighed with the anesthesia team.
The surgical team can operate under maximum
protection (protective clothing, FFP3 mask)
(Fig. 19.9, Tables 19.1 and 19.2).
19919 Emergency Vitrectomy for Beginners …
Fig. 19.8 Application of intravitreal injections with vancomycin and ceftazidime (0.1 ml each). The distance will be
marked 3 up to 4 mm from the limbus at the sclera (3 mm in aphakic eyes/3.5 mm in pseudophakic eyes/4 mm in phakic eyes). The injection canula will displace the conjunctiva to the middle of the marked scleral point. The cannula
will be inserted in a 45° angle into the sclera and moved more perpendicular into the vitreous cavity. Antibiotics
will be injected into the vitreous cavity after this maneuver. The cannula will be removed and the conjunctiva will
be closed with a e.g. sterile cotton tip. Alternatively, the antibiotics may be injected during a vitrectomy through the
trocars.
200 A. Viestenz et al.
Fig. 19.9 WetLabs using OR microscopes and OR machines are the best preparing stress test for exhausting situations during surgery ( crossref. Chap. 7.2). For example: The Halle Ophthalmo-Trauma Course (HOT) of the
DOG and the International Society of Ocular Trauma, Prof. Schrader trains a resident.
Table 19.1 Injection of antibiotics into the anterior
chamber or vitreous cavity in endophthalmitis. The dosage of the IVI-medication must be reduced to a level 1/4
to 1/5 if gas or silicone oil into the vitreus cavity.
Active ingredient Administration in AC or
Vancomycin 1 mg in 0.1 ml
Ceftazidime 2.25 mg in 0.1 ml
Dexamethasone
Voriconazole
Amphotericin B
VC with approx. 4/5 BSS
filling
400 μg in 0.1 ml
100 μg in 0.1 ml
5–7.5 μg in 0.1 ml
Table 19.2 Systemical antibiotics (maximum therapy
according to Magdeburg Three-Stage Plan according to
Behrens-Baumann)
Against grampositive bacteria
Preparation Vancomycin
Daily dose
In case of resistance Daptomycin
www.kaug.ovgu.de/Zuweiser/Leitlinien
(e.g.,
Vancomycin
Lederle)
2 × 1 g iv 3 × 2 g
(Cubicin)
1 × 1500 mg iv
Against
gram-negative bacteria
Ceftazidime
(e.g., Fortum)
Imipenem
References and Further Reading
1. Barry P, Behrens-Baumann W, Pleyer U, Seal D
(2007) ESCRS Guidelines on prevention, investigation and management of post-operative endophthalmitis. Version 2. Published by The European
Society for Cataract & Refractive Surgeons. ISBN
0-9550988-0-7
2. Behrens-Baumann W (2004) Antiinfektiva bei
Augenverletzungen. Klin Monatsbl Augenheilkd
221:674–676
3. Behrens-Baumann W, Augustin A, Dick B, Fabian
E, Huber-Spitzy V, Klauß V, Kramer A, Pitten FA,
Pleyer U, Zeitz J (2003) Leitlinie zur Prophylaxe und
Therapie von Endophthalmitiden. Hyg Med 28:447–
460. (Erratum 511), (Leitlinie der Deutschsprachigen
Gesellschaft für Intraokularlinsen-Implantation und
refraktive Chirurgie, DGII 2005)
4. Behrens-Baumann W (2011) Zur Prophylaxe und
Therapie der postoperativen Endophthalmitis.
20119 Emergency Vitrectomy for Beginners …
ESCRS-Studie und „Early Vitrectomy Study“ in der
Kritik. Ophthalmologe 108:1062–1066
5. Behrens-Baumann W, Finis D, MacKenzie C,
Roth M, Geerling G (2015) Keratomykose –
Therapiestandards und aktuelle Entwicklungen. Klin
Monatsbl Augenheilkd 232:754–764
6. Endophthalmitis Vitrectomy Study Group (1995)
Results of the Endophthalmitis Vitrectomy Study.
A randomized trial of immediate vitrectomy and of
intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol
113:1479–1496
7. Kuhn F, Mester V, Morris R (2004) A proactive treatment for eyes with perforating injury. Klin Monatsbl
Augenheilkd 221:622–628
8. Narang S, Gupta V, Dogra MR, Pandav SS, Das S
(2003) Role of prophylactic intravitreal antibiotics in
open globe injuries. Indian J Ophthalmol 51:39–44
9. Pleyer U, Mondino BJ, Adamu SA et al (1992)
Immune response to staphylococcus epidermidisinduced endophthalmitis in a rabbit model. Invest
Ophthalmol Vis Sci 33:2650–2663
10. Roth M et al (2019) Das Deutsche Pilz-KeratitisRegister. Erste Ergebnisse einer multizentrischen
Erhebung. Ophthalmologe. https://doi.org/10.1007/
s00347-019-0871-9
11. Schrader W (1990) Endogene Candidaendophthalmitis.
Frühzeitige Diagnose und frühzeitige Vitrektomie.
Fortschr Ophthalmol 87:331–335
12. Schrader WF (2004) Epidemiologie bulbuseröffnender
Augenverletzungen: Analyse von 1026 Fällen über 18
Jahre. Klin Monatsbl Augenheilkd 221:629–635
13. Viestenz A, Schrader W, Behrens-Baumann W
(2008) Traumatic Endophthalmitis Prevention Trial
(TEPT). Klin Monatsbl Augenheilkd 225:941–946
14. Viestenz A, Wilhelm F, Schrader W (2018)
Einführung in die OphthalmoChirurgie – Teil 9:
Verletzungen des Auges – was ist zu tun bei der
Erstversorgung? Ophthalmo Chir:317–324
15. Viestenz A, Schrader W, Wilhelm F, BehrensBaumann W (2022) Vitrektomie. In: Schargus M
(Eds) Einführung in die Ophthalmochirurgie. Dr.
Reinhard Kaden, Mannheim, pp 189–200
16. Viestenz A, Heichel J, Viestenz A (2022) Hygiene
und Sterilität im OP. In: Schargus M (Eds)
Einführung in die Ophthalmochirurgie. Dr. Reinhard
Kaden, Mannheim, pp 217–224
17. www.kaug.ovgu.de/Zuweiser/Leitlinien
My First Phaco—How Do I Prepare?
Christian Schäferho and Thomas Neuhann
Contents
20.1 Preparation before Surgery ........................................ 203
20.2 Microscope .................................................... 204
20.3 Phaco Machine ................................................. 204
20.4 Selection of Patients ............................................. 204
20.5 Checking the Indication .......................................... 205
20.6 Draping the Patient .............................................. 205
20.7 Inserting the Eyelid Speculum ..................................... 205
20.8 Paracentesis.................................................... 205
20.9 Main Incision .................................................. 206
20.10 Viscoelastics ................................................... 206
20.11 Preparation of the Capsulorhexis ................................... 206
20.12 Capsulorhexis .................................................. 206
20.13 Hydrodissection and Hydrodelineation............................... 207
20.14 Phacoemulsification, Divide and Conquer ............................ 207
20.15 Irrigation/Aspiration ............................................. 209
20.16 Polishing the Capsule ............................................ 209
20.17 Implantation of the Posterior Chamber Intraocular Lens ................. 210
20.18 Removing the Viscoelastic ........................................ 211
20.19 Sealing the Incision and the Paracenteses............................. 211
20.20 Postoperative Antibiosis .......................................... 211
20.21 Femtosecond Laser Cataract Surgery (see also Sect. 21.2 ) ............... 212
Further Reading ....................................................... 212
20
C. Schäferhoff ()
Esslingen, Germany
e-mail: schaeferhoff@me.com
T. Neuhann
München, Germany
e-mail: prof@neuhann.de
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2025
F. Wilhelm (ed.), Ophthalmic Surgery for Beginners, https://doi.org/10.1007/978-3-662-70287-1_20
20.1 Preparation before Surgery
A precise knowledge of the anatomy as well
as the individual surgical steps is essential
for the success of the operation (Chap. 2).
Complications, which always occur (no matter
203