Three-Dimensional Digital Visualization System Assisted Vitrectomy for Infectious Endophthalmitis

doi:10.21203/rs.3.rs-2076616/v1

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Three-Dimensional Digital Visualization System Assisted Vitrectomy for Infectious Endophthalmitis

https://doi.org/10.21203/rs.3.rs-2076616/v1

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Purpose: To present our experiences and surgical efficacy of the three-dimensional(3D)visualization system in endophthalmitis vitrectomy.

Methods: 11 cases of endophthalmitis had undergone NGENUITY® 3D Visualization System assisted23-gauge transconjunctival vitrectomy, by a same surgeon at Xuzhou First People’s Hospital between 1 March 2020 and 31 March 2022. The efficacy of vitrectomy , best-corrected visual acuity (BCVA), intraoperative illumination, and comfort of the surgeon was investigated.

Results: The vitrectomy was finished in all cases with lower intensity of intraoperative illumination on the 3D visualizationsystem without any complications attributed to the visualization system, and none of them were abdicated or converted to the conventional microscope. All of the patients were cured after operation combined with antibiotics therapy, consistent with significantly improved BCVA(t = 4.039, p = 0.0024).

Conclusion: 3D visualizationsystem with advantages of clearer intraoperation visualization and optimized ergonomic design, is suitable for a variety of vitreoretinal surgery with good safety and efficacy, especially in the complicated and long-lasting endophthalmitis surgeries.

3D digital visualization system

endophthalmitis

vitrectomy

Three-dimensional(3D) visualization system was increasingly to be used in a variety of vitreoretinal surgeries, such as maculopathy, retinal detachment, proliferative diabetic retinopathy, and so on. But there are few reports of 3D system application in vitrectomy for endophthalmitis. This report revealed that 3D visualization system with advantages of clearer intraoperation visualization and optimized ergonomic design, is suitable for the complicated and long-lasting endophthalmitis surgeries with good safety and efficacy.

Infectious endophthalmitis is one of the most devastating eye emergencies and may lead to irreversible blindness. Pars plana vitrectomy associated with intravitreal antibiotics is recognized as an effective treatment to restore adequate control of progression and retrieve visual acuity. Inevitably, the poor clarity and contrast of fundus, vulnerable to phototoxicity, as well as the fragile tissue, stand as roadblocks to the vitrectomy in endophthalmitis.

Three-dimensional(3D) digital visualization system facilitates the vitrectomy, with the advantages of reduced retinal phototoxicity, increased depth of field, optimized ergonomics design, and display image manipulation. It was applied to vitreoretinal surgery as early as 2016, by Eckardt and Paulo[1]. Since then, 3D visualization system was increasingly to be used in a variety of vitreoretinal surgeries, such as maculopathy, retinal detachment, proliferative diabetic retinopathy, complicated ocular trauma, intraocular foreign body removal, silicone oil removal, lens complications, and so on[2]. But there are few reports of 3D system application in vitrectomy for endophthalmitis.

We report a series of endophthalmitis, one of the most complicated eye emergencies, treated by 3D visualization system assisted vitrectomy, to present our experiences and surgical efficacy of the 3D visualization system in vitrectomy to treat endophthalmitis.

This was a retrospective case series study including 11 patients, who were diagnosed as endophthalmitis and had undergone NGENUITY® 3D Visualization System (Alcon Laboratories, Inc.) assisted vitrectomy by a same surgeon using the Constellation Table-Top Vision System (Alcon Laboratories, Inc.), at Xuzhou First People’s Hospital between 1 March 2020 and 31 March 2022. This study was performed according to the Declaration of Helsinki and approved by the Ethic Committee of Xuzhou First People's Hospital. Written informed consent was also obtained from all participants. The associated video (Supplemental Video file) reveals the key steps of the technique procedure.

All patients underwent 3D visualization system assisted 23 gauge transconjunctival vitrectomy by a same surgeon. The system used a high dynamic range camera to connect to the surgical microscope, and transmitted overlapping images to the 3D screen. The surgeon, wearing polarized glasses, watched the stereoscopic view of operation on the screen. Intraoperative illumination was set at the lowest level for vitrectomy, ranged from 25–30% of maximum luminance. The procedure was the same as that under conventional microscope. If there was no posterior vitreous detachment (PVD) during the operation, the surgeon would not induce a PVD, in case of iatrogenic retinal breaks due to traction. Silicone oil, filtrated air or phosphate buffer solution tamponade was selected according to retinal and infection situation. Intravitreal injection of antibiotics was performed at the end of the operation.

Data, such as operation duration, organism, tamponade, preoperative and final best-corrected visual acuity (BCVA) were collected. The length of antibiotics use after vitrectomy was recorded in days, while follow-up was in months. The decimal visual acuity (VA) was converted to logarithm of the minimum angle of resolution (logMAR) equivalents for analysis following the formula: logMAR = − log(decimal VA)[3]. The VAs of counting fingers, hand movement, and light perception were converted to 2.10, 2.40 and 2.70, respectively[4]. Statistical analysis was performed using Graphpad Prism 9.0 (GraphPad Software). Continuous datas were presented as the mean ± standard deviation (SD). The comparison of preoperative and final VA was performed using paired t-test. The level of statistical significance was defined as p < 0.05.

The clinical datas of the cases are summarized in Table 1. Vitrectomy was finished in all cases on the 3D visualization system without any complications attributed to the visualization system, and none of them were abdicated or converted to the conventional microscope. The length of follow-up after vitrectomy ranged from 2 to 14 months (5.455 ± 3.012). Among these cases, one was endogenous endophthalmitis secondary to liver abscess, another one was postoperative infection after cataract surgery, and the residual 9 cases were caused by trauma. Intravitreal injection of antibiotics before vitrectomy was performed in 8 of the 11 cases. After vitrectomy combined with antibiotics therapy, all of them were cured. The length of antibiotics use after vitrectomy, which can be considered as a cure time, ranged from 1 to 21 days (6.727 ± 5.968). Silicone oil tamponade was used in 5 cases, and removed before final follow-up in 4 cases, except for the endogenous endophthalmitis. The mean LogMAR BCVA prior to vitrectomy was 2.122 (± 0.6618), and improved significantly to 1.233 (± 0.9391) at final follow-up (t = 4.039, p = 0.0024) (Fig. 1).

Regarding the treatment of endophthalmitis, antibiotics are the essential, while vitrectomy is the most key. Vitrectomy can enhance the curative ratio of endophthalmitis by removing pathogenic microorganisms, toxins, inflammatory substances, turbid medium, and guide the selection of sensitive antibiotics by sampling vitreous for culture, create an environment conducive to the dispersion of antibiotics in the eye. Moreover, it is an important tool in the management of proliferative vitreoretinopathy, retinal detachment and other visual threatening complications secondary to endophthalmitis. In this study, all the 11 patients were cured after vitrectomy and antibiotics treatment. The mean BCVA was significantly improved at the final follow-up.

In recent years, with the introduction of minimally invasive gauge scleral incision, high-speed cutters and wide-field viewing systems, vitrectomy has improved significantly. Even so, the poor visualization and long duration of operation in vitrectomy of endophthalmitis make the surgeon's manipulation and physical ability face great challenges. The turbid refractive medium, including corneal edema, lens opacity and vitreous empyema, reduces the intraocular brightness and forces the surgeon to increase the intraocular illumination, which brings extra phototoxicity. Furthermore, after long-term of low-headed viewing through the eyepieces, the surgeon suffers neck discomfort and visual fatigue.

The 3D visualization system, with advantages such as clearer intraoperation visualization, wide-field view, optimized ergonomic design, is more suitable for the complicated and long-lasting endophthalmitis surgery. In addition, it also has particular benefits, including illumination, reduced retinal phototoxicity, increased depth of field, enhanced surgical team communication and education. It can improve the brightness and clarity of the image by real-time digital signal processing. According to Eckardt’s study[1], with the increase of electronic amplification of the camera’s signal gain, the image presents the increase of brightness and digital noise. The image brightness of 20% light intensity and Gain 3 is the same as that of 80% light intensity and Gain 1, which is about 4 times the intensity of the light source without amplification of the camera’s signal. With the advantage of greater brightness, Todorich et al. used scleral transillumination technique for visualization with 3D Heads-Up display during vitrectomy surgery[5]. All of our 3D surgeries for endophthalmitis were illuminated at 25 ~ 30% of light intensity and and Gain 3, which is significantly brighter than the conventional microscope with 50 ~ 55% light intensity. So the 3D visualization system can provide brighter image with a lower light intensity than the traditional microscope, which can reduce the phototoxic damage to the retina.

The 3D visual system has optimized ergonomic design, which is considered to be a great improvement over traditional microscope. Traditional microscopes require long-term of low-headed viewing through the eyepieces, resulting in neck discomfort and visual fatigue, which is particularly evident in the complicated and long-lasting endophthalmitis surgery. According to a survey of musculoskeletal disorders among ophthalmologists, the occupation-related musculoskeletal pain, particularly of the neck, has significant association with the number of hours they spent performing surgery[6]. The 3D visual system enables surgeons to lift their heads and relieve musculoskeletal discomfort. Moreover, it allows surgeons to operate at higher magnification level on larger display screens and view with equal comfort in all regions of the surgical field, which can effectively alleviate visual fatigue. Nevertheless, the operation still requires certain degree of tension on upper body, and leads to shoulder pain in the surgeon after a prolonged operation maintaining such a rigid posture.

In addition to visual and ergonomics design advantages, the security and validity of 3D system have been confirmed by several reports. Comparing to the traditional microscope, the 3D system does not increase the operation time, is suitable for almost all types of vitreoretinal diseases and a variety of complex surgical operations. The effectiveness and safety are not inferior to the traditional microscope system[2]. However, there is a lack of study on 3D system assisted vitrectomy for endophthalmitis. We report a series of endophthalmitis vitrectomy using 3D visual system. Through these surgical experiences, we find that the advantages of 3D visual system are also suitable for the complicated endophthalmitis vitrectomy. The intraoprative illumination, setting at 25 ~ 30% of maximum luminance, is significantly lower than that required for conventional microscopic. The decreased intraocular illumination intensity can reduce light damage to the fragile retina secondary to endophthalmitis.

Some surgeons have difficulty switching from traditional microsurgery to 3D surgery, complaining of a series of discomforts called “3D asthenopia”. Many factors, such as exotropia and complicate vergence-accommodation conflicts, may lead to the so called “3D asthenopia”[7, 8]. Correspondingly, the “comfort zone” varies from one situation to another and from one group of people to another[9, 10]. Generally, the 3D system is preferred to traditional microscopy for the good visual clarity and more comfortable experience[11, 12]. In our report, the surgeon was well adapted to 3D visual system. Instead, when returned to the microscope, the surgeon became cautious due to the limitation of the small field of view in the microscope leading to a prolonged procedure.

Limited by the low incidence of endophthalmitis, this is a retrospective study with a few cases and lack of control group. However, by dealing with the complicated endophthalmitis vitrectomy, we find that the 3D visualization system is not an equivalent substitute for traditional microscope, it has advantages such as clearer intraoperation visualization, wide-field view, optimized ergonomic design. It is commendable for a variety of vitreoretinal surgeries with good safety and efficacy, especially the complicated and long-lasting endophthalmitis vitrectomy.

Competing interests

The authors declare that they have no competing interests.

Funding support:

This study was supported by the Young Medical Key Talents Foundation of Jiangsu（QNRC2016365）, and Xuzhou Municipal Health Commission Project (XWKYHT20200017), and Xuzhou Municipal Health Commission Project (XWKYSL20210257), The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Acknowledgements:

Not applicable.

Authors’ contributions

HL generalized the idea of the new technique and revised the manuscript. SL contributed to the design and supervised the project. LG performed the surgery and draft the manuscript. JC and ZZ contributed to the acquisition and analysis of data. SJ and YL interpreted the results and edited the photos. All authors read and approved the final manuscript.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study was performed following the guidelines of the Declaration of Helsinki and approved by the Ethic Committee of Xuzhou First People's Hospital. We have obtained written informed consent from all study participants.

Consent for publication

Not applicable.

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Table 1 is available in the Supplementary Files section.

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Three-Dimensional Digital Visualization System Assisted Vitrectomy for Infectious Endophthalmitis

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