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Results of the Endophthalmitis Vitrectomy Study: A Randomized Trial of Immediate Vitrectomy and of Intravenous Antibiotics for the Treatment of Postoperative Bacterial Endophthalmitis

Results of the Endophthalmitis Vitrectomy Study: A Randomized Trial of Immediate Vitrectomy and... Abstract Objective: To determine the roles of immediate pars plana vitrectomy (VIT) and systemic antibiotic treatment in the management of postoperative endophthalmitis. Design: Investigator-initiated, multicenter, randomized clinical trial. Setting: Private and university-based retina-vitreous practices. Patients: A total of 420 patients who had clinical evidence of endophthalmitis within 6 weeks after cataract surgery or secondary intraocular lens implantation. Interventions: Random assignment according to a 2×2 factorial design to treatment with VIT or vitreous tap or biopsy (TAP) and to treatment with or without systemic antibiotics (ceftazidime and amikacin). Main Outcome Measures: A 9-month evaluation of visual acuity assessed by an Early Treatment Diabetic Retinopathy Study acuity chart and media clarity assessed both clinically and photographically. Results: There was no difference in final visual acuity or media clarity with or without the use of systemic antibiotics. In patients whose initial visual acuity was hand motions or better, there was no difference in visual outcome whether or not an immediate VIT was performed. However, in the subgroup of patients with initial light perception-only vision, VIT produced a threefold increase in the frequency of achieving 20/40 or better acuity (33% vs 11%), approximately a twofold chance of achieving 20/100 or better acuity (56% vs 30%), and a 50% decrease in the frequency of severe visual loss (20% vs 47%) over TAP. In this group of patients, the difference between VIT and TAP was statistically significant (P<.001, log rank test for cumulative visual acuity scores) over the entire range of vision. Conclusions: Omission of systemic antibiotic treatment can reduce toxic effects, costs, and length of hospital stay. Routine immediate VIT is not necessary in patients with better than light perception vision at presentation but is of substantial benefit for those who have light perception-only vision. References 1. Zachary IG, Forster RK. Experimental intravitreal gentamicin . Am J Ophthalmol . 1976;82:604-611. 2. Peyman GA, Vastine DW, Raichand M. Symposium: postoperative endophthalmitis: experimental aspects and their clinical application . Ophthalmology . 1978;85:374-385.Crossref 3. Cottingham AJ, Forster RK. Vitrectomy in endophthalmitis . Arch Ophthalmol . 1976;94:2078-2081.Crossref 4. Forster RK. Management of infectious endophthalmitis . Ophthalmology . 1980;87:313-319.Crossref 5. Olson JC, Flynn HW, Forster RK, Culbertson WW. Results in the treatment of postoperative endophthalmitis . Ophthalmology . 1983;90:692-699.Crossref 6. Diamond JG. Intraocular management of endophthalmitis: a systemic approach . Arch Ophthalmol . 1981;99:96-99.Crossref 7. Driebe WT, Mandelbaum S, Forster RK, Schwartz LK, Culbertson WW. Pseudophakic endophthalmitis . Ophthalmology . 1986;93:442-448.Crossref 8. Mao LK, Flynn HW, Miller D, Pflugfelder SC. Endophthalmitis caused by streptococcal species . Arch Ophthalmol . 1992;110:798-801.Crossref 9. Baum J, Payman GA, Barza M. Intravitreal administration of antibiotic in the treatment of bacterial endophthalmitis, III: consensus . Surv Ophthalmol . 1982;26:204-206.Crossref 10. Axelrod JL, Newton JC, Sarakhun C, et al. Ceftriaxone . Arch Ophthalmol . 1985;103:71-72.Crossref 11. Thompson RL. Cephalosporin, carbapenem, monobactam antibiotics . Mayo Clin Proc . 1987;62:821-834.Crossref 12. Edson RS, Terrell CL. The aminoglycosides: streptomycin, kanamycin, gentamicin, tobramycin, amikacin, netilmicin, and sisomicin . Mayo Clin Proc . 1987;62:916-920.Crossref 13. Pavan PR, Brinser JH. Exogenous bacterial endophthalmitis treated without systemic antibiotics . Am J Ophthalmol . 1987;104:121-126. 14. Ferris FL III, Kassoff A, Bresnick GH, Bailery I. New visual acuity charts for clinical research . Am J Ophthalmol . 1982;94:91-96. 15. Doft BH, Lobes LA, Rinkoff JS. A technique to clear the anterior chamber media to allow pars plana vitrectomy in endophthalmitis . Ophthalmology . 1991;98:412-413.Crossref 16. Doft BH, Donnelly K. A single sclerotomy vitreous biopsy technique in endophthalmitis . Arch Ophthalmol . 1991;109:465.Crossref 17. Doft BH, Barza M. The Endophthalmitis Vitrectomy Study . Arch Ophthalmol . 1991;109:1061.Crossref 18. Snedecor GW, Cochran WC. Statistical Methods . Iowa City: Iowa State University Press; 1967. 19. Hollander M, Wolfe DA. Nonparametrical Statistical Methods . New York, NY: John Wiley & Sons; 1973:119. 20. O'Brien PC, Fleming TR. A multiple testing procedure for clinical trials . Biometrics . 1979;35:549-556.Crossref 21. Olk RJ, Bohigan GM. The management of endophthalmitis: diagnostic and therapeutic guidelines including the use of vitrectomy . Ophthalmic Surg . 1987;18:262-266. 22. Rowsey JJ, Newson DL, Sexton DJ, Harms WK. Endophthalmitis: current approaches . Ophthalmology . 1982;89:1055-1066.Crossref 23. Mandelbaum S, Forster RK. Endophthalmitis associated with filtering blebs . Int Ophthalmol Clin . 1987;27:107-111.Crossref 24. Martin DF, Ficker LA, Aguilar HA, et al. Vitreous cefazolin levels after intravenous injection . Arch Ophthalmol . 1990;108:411-414.Crossref 25. Bohigan GM, Olk RJ. Factors associated with a poor visual results in endophthalmitis . Am J Ophthalmol . 1986;101:332-334. 26. Puliafito CA, Baker AS, Haaf J, Foster CS. Infectious endophthalmitis . Ophthalmology . 1982;89:921-929.Crossref 27. Nelsen PT, Marcus DA, Bovino JA. Retinal detachment following endophthalmitis . Ophthalmology . 1986;92:1112-1117.Crossref 28. Ficker LA, Meredith TA, Wilson LA, Kaplan HJ. Role of vitrectomy in Staphylococcus epidermidis endophthalmitis . Br J Ophthalmol . 1988;72:386-389.Crossref 29. Conway BP, Campochiaro PA. Macular infarction after endophthalmitis treated with vitrectomy and intravitreal gentamicin . Arch Ophthalmol . 1986;104:367-371.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Ophthalmology American Medical Association

Results of the Endophthalmitis Vitrectomy Study: A Randomized Trial of Immediate Vitrectomy and of Intravenous Antibiotics for the Treatment of Postoperative Bacterial Endophthalmitis

Archives of Ophthalmology , Volume 113 (12) – Dec 1, 1995

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9950
eISSN
1538-3687
DOI
10.1001/archopht.1995.01100120009001
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective: To determine the roles of immediate pars plana vitrectomy (VIT) and systemic antibiotic treatment in the management of postoperative endophthalmitis. Design: Investigator-initiated, multicenter, randomized clinical trial. Setting: Private and university-based retina-vitreous practices. Patients: A total of 420 patients who had clinical evidence of endophthalmitis within 6 weeks after cataract surgery or secondary intraocular lens implantation. Interventions: Random assignment according to a 2×2 factorial design to treatment with VIT or vitreous tap or biopsy (TAP) and to treatment with or without systemic antibiotics (ceftazidime and amikacin). Main Outcome Measures: A 9-month evaluation of visual acuity assessed by an Early Treatment Diabetic Retinopathy Study acuity chart and media clarity assessed both clinically and photographically. Results: There was no difference in final visual acuity or media clarity with or without the use of systemic antibiotics. In patients whose initial visual acuity was hand motions or better, there was no difference in visual outcome whether or not an immediate VIT was performed. However, in the subgroup of patients with initial light perception-only vision, VIT produced a threefold increase in the frequency of achieving 20/40 or better acuity (33% vs 11%), approximately a twofold chance of achieving 20/100 or better acuity (56% vs 30%), and a 50% decrease in the frequency of severe visual loss (20% vs 47%) over TAP. In this group of patients, the difference between VIT and TAP was statistically significant (P<.001, log rank test for cumulative visual acuity scores) over the entire range of vision. Conclusions: Omission of systemic antibiotic treatment can reduce toxic effects, costs, and length of hospital stay. Routine immediate VIT is not necessary in patients with better than light perception vision at presentation but is of substantial benefit for those who have light perception-only vision. References 1. Zachary IG, Forster RK. Experimental intravitreal gentamicin . Am J Ophthalmol . 1976;82:604-611. 2. Peyman GA, Vastine DW, Raichand M. Symposium: postoperative endophthalmitis: experimental aspects and their clinical application . Ophthalmology . 1978;85:374-385.Crossref 3. Cottingham AJ, Forster RK. Vitrectomy in endophthalmitis . Arch Ophthalmol . 1976;94:2078-2081.Crossref 4. Forster RK. Management of infectious endophthalmitis . Ophthalmology . 1980;87:313-319.Crossref 5. Olson JC, Flynn HW, Forster RK, Culbertson WW. Results in the treatment of postoperative endophthalmitis . Ophthalmology . 1983;90:692-699.Crossref 6. Diamond JG. Intraocular management of endophthalmitis: a systemic approach . Arch Ophthalmol . 1981;99:96-99.Crossref 7. Driebe WT, Mandelbaum S, Forster RK, Schwartz LK, Culbertson WW. Pseudophakic endophthalmitis . Ophthalmology . 1986;93:442-448.Crossref 8. Mao LK, Flynn HW, Miller D, Pflugfelder SC. Endophthalmitis caused by streptococcal species . Arch Ophthalmol . 1992;110:798-801.Crossref 9. Baum J, Payman GA, Barza M. Intravitreal administration of antibiotic in the treatment of bacterial endophthalmitis, III: consensus . Surv Ophthalmol . 1982;26:204-206.Crossref 10. Axelrod JL, Newton JC, Sarakhun C, et al. Ceftriaxone . Arch Ophthalmol . 1985;103:71-72.Crossref 11. Thompson RL. Cephalosporin, carbapenem, monobactam antibiotics . Mayo Clin Proc . 1987;62:821-834.Crossref 12. Edson RS, Terrell CL. The aminoglycosides: streptomycin, kanamycin, gentamicin, tobramycin, amikacin, netilmicin, and sisomicin . Mayo Clin Proc . 1987;62:916-920.Crossref 13. Pavan PR, Brinser JH. Exogenous bacterial endophthalmitis treated without systemic antibiotics . Am J Ophthalmol . 1987;104:121-126. 14. Ferris FL III, Kassoff A, Bresnick GH, Bailery I. New visual acuity charts for clinical research . Am J Ophthalmol . 1982;94:91-96. 15. Doft BH, Lobes LA, Rinkoff JS. A technique to clear the anterior chamber media to allow pars plana vitrectomy in endophthalmitis . Ophthalmology . 1991;98:412-413.Crossref 16. Doft BH, Donnelly K. A single sclerotomy vitreous biopsy technique in endophthalmitis . Arch Ophthalmol . 1991;109:465.Crossref 17. Doft BH, Barza M. The Endophthalmitis Vitrectomy Study . Arch Ophthalmol . 1991;109:1061.Crossref 18. Snedecor GW, Cochran WC. Statistical Methods . Iowa City: Iowa State University Press; 1967. 19. Hollander M, Wolfe DA. Nonparametrical Statistical Methods . New York, NY: John Wiley & Sons; 1973:119. 20. O'Brien PC, Fleming TR. A multiple testing procedure for clinical trials . Biometrics . 1979;35:549-556.Crossref 21. Olk RJ, Bohigan GM. The management of endophthalmitis: diagnostic and therapeutic guidelines including the use of vitrectomy . Ophthalmic Surg . 1987;18:262-266. 22. Rowsey JJ, Newson DL, Sexton DJ, Harms WK. Endophthalmitis: current approaches . Ophthalmology . 1982;89:1055-1066.Crossref 23. Mandelbaum S, Forster RK. Endophthalmitis associated with filtering blebs . Int Ophthalmol Clin . 1987;27:107-111.Crossref 24. Martin DF, Ficker LA, Aguilar HA, et al. Vitreous cefazolin levels after intravenous injection . Arch Ophthalmol . 1990;108:411-414.Crossref 25. Bohigan GM, Olk RJ. Factors associated with a poor visual results in endophthalmitis . Am J Ophthalmol . 1986;101:332-334. 26. Puliafito CA, Baker AS, Haaf J, Foster CS. Infectious endophthalmitis . Ophthalmology . 1982;89:921-929.Crossref 27. Nelsen PT, Marcus DA, Bovino JA. Retinal detachment following endophthalmitis . Ophthalmology . 1986;92:1112-1117.Crossref 28. Ficker LA, Meredith TA, Wilson LA, Kaplan HJ. Role of vitrectomy in Staphylococcus epidermidis endophthalmitis . Br J Ophthalmol . 1988;72:386-389.Crossref 29. Conway BP, Campochiaro PA. Macular infarction after endophthalmitis treated with vitrectomy and intravitreal gentamicin . Arch Ophthalmol . 1986;104:367-371.Crossref

Journal

Archives of OphthalmologyAmerican Medical Association

Published: Dec 1, 1995

References

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