Endophthalmitis following 27-Gauge Pars Plana Vitrectomy for Vitreous Floaters

Lin Z.^a · Wu R.H.^a · Moonasar N.^b

^aThe Eye Hospital, School of Ophthalmology and Optometry, Wenzhou Medical University, Wenzhou, China
^bOphthalmology Department, University of the West Indies, St. Augustine, Trinidad and Tobago

Abstract

Purpose: To report a case of Staphylococcus epidermidis endophthalmitis following 27-gauge pars plana vitrectomy for symptomatic vitreous floaters. Methods: The clinical course and imaging findings, including fundus optomap, and spectral domain optical coherence tomography of a 24-year-old male patient were documented. Results: The patient, with a preoperative best-corrected visual acuity (BCVA) of 1.0, developed endophthalmitis following 27-gauge pars plana vitrectomy for symptomatic vitreous floaters. After a series of treatments, including emergent vitreous tap and silicone oil injection, antibiotic treatment, and silicone oil removal, the patient regained a BCVA of 0.6. Conclusion: Although rare, the potential risk of endophthalmitis should be explicitly discussed with patients considering surgical intervention for vitreous floaters.

© 2016 The Author(s) Published by S. Karger AG, Basel

Disclosure Statement

The authors declare that they have no conflicts of interest.

FAQ’S FOR YOUNG PEOPLE WITH EYE FLOATERS

By DrJohnson | June 11, 2013 | Floaters | 21 |

I am contacted by young people from all over the world suffering the angst and anxiety caused by persistent and unrelenting moving shadows in their vision. As my practice has evolved over the last several years I have come to accept the conclusion and realization that most young people with eye floaters are not good candidates for treatment with the YAG laser. Those who we think might be exceptions are often proved not to be exceptions at all. Those who is been told they have had a posterior vitreous detachment(PVD) at the young tender age of 30 end up not having a PVD at all. In some cases it is just the phrase that their local eye doctor uses to describe floaters. I am starting to run out of different and unique ways of responding to these general inquiries. The typical e-mail message or comment goes something like this:

“I am  X years old and my floaters look like [ insert description of crystal worms, squiggly lines and dots here ]. My eye doctor told me that my eye is perfectly healthy but that nothing could be done. Do you think I am a candidate for treatment with the laser? Do you think they will get worse/get better over time?  Is there something I can take to make it better?”

Although I empathize with this patients frustration and their hopeful and optimistic search for some solution to the problem, in attempting to answer this question specifically to them, I would be entering into a doctor-patient relationship without having had the opportunity of meeting the patient or examining the eye. This puts me at a distinct disadvantage as well as to some medicolegal risk. If you are reading this because I responded to your inquiry and directed you here, please do not be offended by any lack of personal attention to your important questions. You will more likely learn more from this more extensive post then you would from a brief e-mail reply.

The following, in no particular order of organization or importance, are some important ideas, observations, and answers to your questions about floaters in younger patients. They will hopefully answer your questions as well as the questions you have not yet thought of.

• The floaters that young people have are not the same as the floaters that older people have. The floaters that young people have do not “age” and become the floaters that older people have. If you are 30 years old there is no reason to believe that in 10 years time your floaters will then become treatable with the YAG laser.
• There are no scientific studies or publish articles that address this problem of floaters in younger patients adequately. All of my comments or recommendations are based on my understanding of the anatomy of the eye, and my observation and examination of people with bothersome vitreous condensations in both the younger and older age groups.
• In my experience, most eye care providers are not particularly interested in eye floaters. They do not think about them much, and in our education, training, and general practice not much time or attention is given to eye floaters. There is no standardized way of describing floaters and there is no common language amongst these professionals to describe the type, location, density, and or behavior of these vitreous densities in the eye. As such, I have not found it helpful to review the medical charts provided by other doctor’s offices. this is not in any way meant to diminish distiller capacity of these eye doctors, it is just to say I have not found them to be helpful in the context of determining whether somebody is a candidate for treatment or not with my laser.
• Simply put, a floater is caused by condensation or clumping of the (usually individual ) protein strands interspersed throughout the vitreous fluid. The collagen that makes up these floaters is “sticky” in its natural state. The stickiness is probably due to intermolecular attraction. When these protein strands have stuck together, they are very difficult to separate.
• Floaters are not made up of living, breathing cells. Unlike other living cells in the body, they do not have an active metabolism. They do not take up oxygen, and they do not respirator carbon dioxide. They do not imbibe nutrients, sugars, minerals, medications, herbs, etc. They are for all intents and purposes fairly inert material. As such, I do not believe that they will be responsive to oral or subsequent blood borne nutrients or supplements.
• Collagen proteins that make up your eye floaters have been in your eye your entire life. It was not secreted into your eye. It is not made up of abnormal or foreign proteins. They do not bother your otherwise healthy eye. There is no reason the body’s immune system or any other system meant to get rid of abnormal material would recognize your floater as abnormal. There is no natural turn-over of vitreous material or filtration system that would normally clear that material out
• Tiny little microscopic floaters are suspended in place by a complex system of elastic fibers. They are neutrally buoyant. They do not sink from gravity. There is no reason to believe that in a young person, your floaters will sink to the bottom of your eye and out of your visual field or otherwise disappear like your eye care providers suggested would happen.
• Based on my experience with examining younger patients with floaters, the floaters typically reside less than 2 mm away from the retina and often quite a bit closer than that. Although it may appear to be floater sufferer that the floaters are moving quite a bit, the actual movement within the eye may be just a couple of millimeters and typically they remain about the same distance away from the retina and do not move far enough away to allow for treatment with the laser. It is not safe to discharge the laser that close to the retina. This is the primary reason why I cannot treat most younger people with eye floaters.
• Did your eye doctor described you as having had a posterior vitreous detachment? I doubt it and would be very surprised if that were true. Posterior vitreous detachments are very rare in younger patients. I have found that some doctors use that term as a generic description of floaters.
• Is it possible to diagnose somebody with floaters without actually seeing the floaters? Why yes.It is by a “diagnosis of exclusion”. when you go to your local eye care provider complaining of “moving shadows in your vision”, the standard of care And general obligation of that eye doctor is to “rule out” any condition that could blind you, or for which they could be sued for medical malpractice if they were to miss the diagnosis. Essentially this means that they are obligated to look very carefully at your retina for any retinal pathology such as retinal holes, tears, or early detachments. Once those conditions have been eliminated as possibilities, and based on the patient’s description of moving shadows, is quite simple to make the diagnosis of vitreous floaters. The microscopically small vitreous condensations often seen by young patients are extraordinarily difficult to find on eye examination. I believe many doctors will “imply” that they have seen the floater when they are actually diagnosing it by exclusion.
• Just because your doctor actually does see some vitreous irregularities does not guarantee that what they are seeing is responsible for your symptoms. There are some eye floaters that I call “smoke screen floaters” that can easily confuse the examiner (including myself) at times. Occasionally these floaters are noticeable in the middle part of the eye where they can safely be treated. They may also have this similar shape or  morphology consistent with what the patient describes. More than a few times, I have successfully treated these only to find that the patient is still seeing the exact same floater. The floater may eventually be found upon closer examination as a microscopic condensation sitting less than 1 mm away from the retina. If you think you are an exception because your doctor told you they could clearly see your floaters, you may be wrong and are of not that exceptional after all.
• If you have asked me if you are floaters will get worse, I cannot answer you.
• If you have asked me if you are floaters will get better with time, I cannot answer you
• If you have asked me what you can take or supplement for your floaters to get better, I cannot answer you.
• If you have asked me if I am familiar with Vitreox or any number of other patent remedies or herbal concoctions, I will tell you that may have not been proven to help. I have more extensive thoughts on this topic. You can read it here.
• If you are asking me if there is anybody close to where you live who treat eye floaters, I have already provided that information here.
• On the main landing page of my website in bold and in red there is a link to the page that describes my fees. On every other page as well as from the menu there is a link to the page on my website that describes my fees. If you are still having trouble finding that information, please click the following link for information about fees.
• If you are considering a surgical vitrectomy or floater-only vitrectomy (FOV) as it is sometimes referred to, there are a few things you should know. I consider the vitrectomy as the “gold standard” procedure. If the intent is to remove all of your vitreous, then it stands the best chance to remove all of the floaters along with it. The FOV is an invasive surgical procedure that alters some of the fluid dynamics and protective effects of the vitreous fluid. After surgery, there is a fairly high incidence of formation of lens cataract which may require more surgery. If a cataract surgery is necessary, you will lose the normal focusing and accommodating behavior of the eye. The two eyes will no longer be balanced for focus. In addition, because most younger people have not had a posterior vitreous detachment, the process of the vitrectomy may transmit traction to the retina and put that patient at higher risk of retinal detachment caused by the surgical procedure. That risk goes down somewhat when somebody has had a PVD. The practical reality, though, is that retina specialists are generally reluctant to offer the FOV because they do not consider floaters to be enough pathology to justify the risk. This is true even with very prominent and impressive appearing floaters in older people, and would be even more true when the floaters in question are essentially imperceptible and very difficult to document their very presence. The medical legal risk to the surgeon is too high to justify and invasive procedure for something they can even see. So although the surgical vitrectomy is a theoretical option, you would be very hard-pressed to find somebody willing to perform that procedure on you even if you were directly asking for it.

Is there any reason, then, that a young person would even consider coming to visit Doctor Johnson at Vitreous Floater Solutions? It is possible that there might be some value in coming to visit Doctor Johnson for a thorough evaluation of a young person floaters. It may be that although your local eye care provider competently examined your eyes, they were not able to definitively prognosticate as to whether or not you have floaters that are potentially treatable. Because my practice is exclusively dedicated to treating floaters and I have experienced in treating floaters, I can more definitively describe the problem and determine whether your particular condition is treatable with the laser. I should at least be able to remove the uncertainty that may accompany your condition. Knowing for sure that it is, or is not treatable may help you move towards accepting your condition and moving on with your life rather than always wondering what really is going on and whether you are one of the few exceptions to the rule. -Dr. Johnson