Sir,

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 innovation4, 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. dexamethasone 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 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 times1) 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.