T Pearl

Traumatic endophthalmitis is a surgical indication; pharmaceutical treatment is to be employed in addition to, not instead of, vitrectomy.

Vitrectomy for endophthalmitis, especially if it is of traumatic origin, is technically one of the most challenging indications. The difficulty is due to the often hazy media and to the intricacy in distinguishing between yellowish layers of vitreous, which may have blood streaks mimicking retinal

4 Even though the in-vivo sensitivity may be different.

5 Bactec Peds Plus F, Becton Dickinson, Sparks, Maryland.

blood vessels, and a detached, necrotic, nonperfused retina, which may not bleed when injured. It is mandatory for the surgeon to take a slow, cautious approach, similar to that described in Chap. 2.12. The surgical steps are outlined in Table 2.17.2.

Table 2.17.2 Vitrectomy for traumatic endophthalmitis: surgical steps

Surgical step

Comment

Scrape the corneal epithelium

Most of the corneal edema resides in the epithelium; removing this layer is alone sufficient to dramatically increase visibility

Drying the corneal stroma

If the stroma is also hazy, applying a shield wetted with 40% glucose for a few minutes usually reduces the edema (see Chap. 2.9 for further options)

Cleaning of the AC

An AC maintainer is necessary to prevent hypotony. Gentle aspiration through a paracentesis is sufficient to remove white and red blood cells and most of the debris. The angle should also be irrigated. In the vast majority of eyes a fibrinous membrane is covering the angle, iris, and lens; this must be removed, using forceps, or aspiration with a blunt cannula or the vitrectomy probe. Irrigation of the AC may have to be repeated during surgery because the inflammatory debris may reaccu-mulate. The fibrinous membrane may also reform, especially in children; this must be removed as often as needed

Enlarging the pupil

Unless the sphincter has been damaged, the pupil is small; if not dilated, visibility of the posterior segment remains poor, even if wide-angle viewing is employed. If adrenaline does not achieve dilatation, iris retractors must be used (see Chap. 2.9)

Preparing the sclerotomies

These are made using the standard method.1 The infusion must not be opened until the cannula's proper location is confirmed. A long cannula2 should be considered

1 Currently it is not recommended to use small-gauge vitrectomy for traumatic endophthalmitis.

Table 2.17.2 (continued)Vitrectomy for traumatic endophthalmitis: surgical steps

Surgical step

Comment

Dealing with the lens

Even if uninjured, the lens may have to be extracted to allow unhindered vitrectomy.3 If an IOL is present, a large posterior capsulectomy should be created to allow irrigation of the bag. The surfaces of the IOL may have to wiped repeatedly

Performing vitrec-tomy

A careful antero-posterior approach is used, keeping the vitrectomy probe close to the visual axis4 but nasal to it. Very slow progression is necessary, and it is crucial to go deep before going wide (see Chap. 2.12)

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