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Transvitreal fibrinoid reaction after vitrectomy for diabetic retinopathy may improve with drops alone
The cause of the transvitreal fibrinoid pseudoendophthalmitis was unknown in this case series.
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Patients with diabetic retinopathy in whom a severe transitory transvitreal fibrin response developed after pars plana vitrectomy were successfully treated with topical medications alone, according to a study.
Lead author Caesar Luo, MD, a vitreoretinal surgeon at Progressive Vision Institute in Pottsville, Pa., and colleagues had observed a cluster of patients with a dramatic response after vitrectomy for a variety of diabetic indications and undertook the retrospective case series of eight eyes, published in Retina.
“We published the current series not only because it helps elucidate a pseudo-infectious sequelae of diabetic vitrectomy, but also due to the apparent clustering of cases,” Luo said.
Postoperative presentation
On postoperative day 1, affected eyes presented with dense transvitreal bands that resolved completely between day 4 and day 15 after a standard eye drop regimen of atropine sulfate, gentamicin and prednisolone acetate was instituted. One patient was started on oral moxifloxacin on postoperative day 3 because resolution of transvitreal bands was slow. In this series, the cause of transvitreal fibrinoid pseudoendophthalmitis after diabetic vitrectomy is unknown.
Caesar Luo
“We attempted to clarify this question based on several factors: patient demographics, unique patient allergy/immunology, surgical indication, surgical maneuvers and intraoperative material exposure,” Luo told Ocular Surgery News.
Patients shared only two commonalities: All had type 2 diabetes and underwent 23-gauge vitrectomy.
“Our evaluation did not reveal [any other] common factor, which led us to believe that this phenomenon can occur in any diabetic vitrectomy,” Luo said.
Among noteworthy observations, Luo said that there was diffuse banding of the vitreous, without cells in the anterior chamber or vitreous. Furthermore, one patient had a reaction in both eyes separated by time, while two other patients presented with bands in only one eye after bilateral vitrectomy separated by time.
No eyes in the series had undergone previous vitrectomy, and there were no adverse events or complications.
Postoperative day 1 following vitrectomy for diabetic macular edema. Note dense transvitreal bands with visible optic nerve.
Image: Luo C
“Unfortunately, we did not find a risk factor that would preclude patients from developing transvitreal fibrinoid pseudoendophthalmitis,” Luo said.
Maximizing treatment
The patients in the series all presented on postoperative day 1, with the fundus visible through the vitreal bands, without pain or anterior chamber reaction, according to Luo.
“For these patients, we feel comfortable recommending a standard postoperative topical drop regimen with close daily follow-up,” Luo said.
Luo prescribes prednisolone acetate four times daily, gentamicin four times daily and atropine twice daily. “Any question of true endophthalmitis would warrant tap and injection or vitrectomy,” he said.
Three patients in the series underwent surgery in the contralateral eye, excluding the possibility of individual patient allergy or hypersensitivity as a cause for the reaction, Luo said.
“It is important to note that of the two patients who developed only unilateral bands, one patient had previous vitrectomy on the contralateral eye while the other had subsequent vitrectomy on the contralateral eye. This argues against vitrectomy sensitizing the immune system,” Luo said.
“In this particular subset of patients with diabetes, the study helps us characterize a particular constellation of findings that looks quite different from true endophthalmitis. While the bands do appear fibrinoid, we did not see other classic signs of infectious endophthalmitis: anterior chamber reaction, pain, vitreous cells or delayed onset after vitrectomy. This phenomenon appears more similar to a toxic anterior segment syndrome, limited to the vitreous cavity,” Luo said.
Since the study’s publication, the investigators have not detected a recurrence of the fibrinoid reaction, raising the possibility of an unknown specific toxin that caused the reaction to be clustered in time, according to Luo. – by Bob Kronemyer