Endophthalmitis following 25-gauge vitrectomy [9]

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used for two reasons. Firstly, this was considered a closer
simulation of what was likely to occur in a clinical
environment and secondly the risk of consequent
reduction of intraocular pressure due to repeated
indentations was reduced.
Leung and Lam make a very good point about the
subjects’ visual field status. Their visual field status was
not described as the subjects were all patients sourced
from a general ophthalmology clinic and could be
assumed to have no or minimal visual field loss.
However, those patients for whom the PPT is intended
are more likely to have glaucomatous field loss.
As a result of the wide limits of agreement there
seemed to be little merit in doing tests of reliability on
these data. Furthermore, it needs to be noted that 31% of
the subjects were unable to have their intraocular
pressures measured using the PPT as they were unable to
perceive a pressure phosphene.
When the data were analysed for those younger than
the median vs those older, the difference between the
tests and the limits of agreement were similar for the two
age groups.
ACB Molteno
Department of Medical and Surgical Sciences,
Ophthalmology Section,
University of Otago Dunedin School of Medicine, PO
Box 913,
Dunedin, New Zealand
Correspondence: ACB Molteno,
Tel: þ64 3 474 7970;
Fax: þ64 3 474 7628.
E-mail: tui.bevin@stonebow.otago.ac.nz
Eye (2005) 19, 1227–1228. doi:10.1038/sj.eye.6701736;
published online 29 October 2004
Sir,
Endophthalmitis following 25-gauge vitrectomy
Postoperative endophthalmitis remains a rare, albeit
serious, complication of ophthalmic surgery, with an
incidence of approximately 0.1%.
1,2
It is acknowledged to
be less common following vitrectomy than other
intraocular surgery and the incidence of endophthalmitis
following conventional 20-gauge vitrectomy has been
reported as 0.07% by Cohen et al.
3
in their 10-year survey
published in 1995.
The 25-gauge transconjunctival sutureless vitrectomy
(TSV) system is a relatively recent innovation
4,5
that may
have several advantages over traditional vitrectomy
surgery. We present what we believe to be the first reported
case of endophthalmitis following 25-gauge vitrectomy.
Case report
In October 2003, an 81-year-old pseudophakic gentleman
underwent a routine 25-gauge transconjunctival
sutureless vitrectomy of his right eye at Moorfields Eye
Hospital, London, after persistently complaining of
floaters. He had no predisposing ocular or systemic risk
factors for endophthalmitis. Aqueous povidine–iodine
5% was applied pre–operatively and 125 mg cefuroxime
was injected subconjunctivally at the end of the
procedure. G. chloramphenicol 0.5% qid and G. dexa-
methasone 0.1% qid were prescribed postoperatively.
At 1-day postoperatively, ocular examination revealed
minimal inflammation and an intraocular pressure of
10 mm Hg. At day 7, his visual acuity was 6/6 and the
intraocular pressure had stabilised at 14 mmHg. He was
noted to have increased anterior chamber activity and the
frequency of his topical G. dexamethasone 0.1% was
increased. The sclerostomies appeared to be healing well
at both visits.
He returned the next day with hand movements
vision, although the eye remained pain-free. There was
a marked anterior uveitis with the presence of a small
hypopyon as well as fibrin deposition on the intraocular
lens; the vitreous was also markedly cellular and
provided a poor view of the retina. B-scan ultrasound
demonstrated only dispersed vitreous opacities.
A clinical diagnosis of bacterial endophthalmitis was
made and he underwent an anterior chamber and
vitreous tap followed by standard first-line treatment
with intravitreal vancomycin 0.1 mg in 0.1 ml and
amikacin 0.4 mg in 0.1 ml. He also commenced a 7-day
course of ciprofloxacin 750 mg p.o. b.d. and a 4-week
tapering course of prednisolone at a starting dose of
60 mg p.o. o.d. Initial microscopy and gram stain of the
taps revealed no organisms.
The clinical picture improved greatly within 3 days
with resolution of the hypopyon and much of the
anterior chamber activity. Visual acuity improved to 6/12
within 1 week and 6/6 within 3 weeks. It remained 6/6
and the eye quiet at his most recent review, 3 months
postoperatively.
Microbiological examination of the anterior chamber
and vitreous specimens revealed no bacterial or fungal
isolates at 14-days incubation.
Discussion
We believe that this case represents the first reported case
of endophthalmitis following 25-gauge vitrectomy
Correspondence
1228
Eye

surgery. It has been suggested that the 25-gauge
system may reduce the risk of endophthalmitis owing
to the smaller incision size, reduced operating time,
lack of foreign-body suture material, and reduced
conjunctival manipulation. However, the unsutured
sclerostomy wounds may provide a conduit for
bacterial ingress and the lower flow-rates of the 25-gauge
system (reduced by approximately 6 times
1
) allow
bacteria an increased opportunity to gain a foothold
perioperatively.
We believe that this case emphasises that postoperative
endophthalmitis is still a complication, albeit rare, of this
form of vitrectomy surgery.
Acknowledgements
Proprietary interest: None.
References
1 Aaberg TM, Flynn HW, Schiffman J, Newton J. Nosocomial
acute-onset postoperative endophthalmitis survey.
Ophthalmology 1998; 105: 1004–1010.
2 Mamalis N, Kearsley L, Brinton E. Postoperative
endophthalmitis. Curr Opin Ophthalmol 2002; 13(1):
14–18.
3 Cohen SM, Flynn HW, Murray TG, Smiddy WE. (The
Postvitrectomy Endophthalmitis Study Group).
Endophthalmitis after pars plana vitrectomy. Ophthalmology
1995; 102(5): 705–712.
4 Fujii GY, De Juan Jr E, Humayun MS, Pieramici DJ,
Chang TS, Awh C et al. A new 25-gauge instrument
system for transconjunctival sutureless vitrectomy
surgery. Ophthalmology 2002; 109(10): 1807–1812.
5 Fujii GY, De Juan Jr E, Humayun MS, Chang TS,
Pieramici DJ, Barnes A et al. Initial experience using the
transconjunctival sutureless vitrectomy system for
vitreoretinal surgery. Ophthalmology 2002; 109(10):
1814–1820.
SRJ Taylor and GW Aylward
Vitreoretinal Service,
Moorfields Eye Hospital, City Road,
London EC1V 2PD, UK
Correspondence: GW Aylward,
Vitreoretinal Service,
Moorfields Eye Hospital,
City Road, London,
EC1V 2PD, UK
Tel: þ44 207 253 3411.
E-mail: bill.aylward@moorfields.nhs.uk
Eye (2005) 19, 1228–1229. doi:10.1038/sj.eye.6701737;
published online 22 October 2004
Sir,
Anterior capsular phimosis with complete occlusion of
the capsulorhexis opening
We describe a case of anterior capsular phimosis with
complete occlusion of the capsulorhexis opening
following routine phacoemulsification and implantation
with an AcrysofA
ˆ
s
intraocular lens (IOL) (Alcon
laboratories, Fort Worth, TX, USA). The patient had no
relevant predisposing ocular pathology. Histologically,
the occluding membrane was composed of proliferated
fibrocytic cells, derived from residual lens epithelial cells
within the capsular bag. The extent of this exaggerated
response is very unusual in the presence of a
hydrophobic acrylic IOL.
Case report
A 90-year-old lady was admitted for daycase cataract
surgery. She underwent routine left phacoemulsification
and lens implantation with a 22.5 Dioptre AcrysofA
ˆ
s
MA30 lens. She was noted to have a small pupil of 5 mm
diameter, but did not require iris manipulation to carry
out the capsulorhexis. Her capsulorhexis was thus
slightly smaller than 5 mm but was sufficient to continue
with uneventful surgery. Her visual acuity at 1 week
was 6/18, which improved to 6/12 after a refraction at
1 month. She had dry age-related macular changes.
At 2 months after surgery she presented for right
cataract surgery and was noted to have a marked
deterioration in vision in her previously operated left
eye. She was only able to see 1/60. Examination of her
left eye revealed a markedly thickened anterior capsule
with impressive capsular contraction and complete
occlusion of the capsulorhexis opening (Figure 1).
Arrangements were made to clear the visual axis with a
surgical capsulotomy.
Figure 1 Capsular phimosis with central occluding membrane.
Correspondence
1229
Eye