Surgical management of endophthalmitis in preterm infants with retinopathy of prematurity

Background: Combination of endophthalmitis and retinopathy of prematurity (ROP) in preterm infants is less commonly reported but is a logistically and surgically difficult clinical condition to manage. [1-5] Purpose: To describe the management of neonatal endogenous endophthalmitis (NEE) and post anti-vascular endothelial growth factor (VEGF) injection endophthalmitis (PIE) in two preterm infants with ROP. Synopsis: The first infant was suspected to have right-eye NEE at first ROP screening and treated with empirical intravitreal vancomycin (0.5mg) and ceftazidime (1.25 mg) and dexamethasone. Subsequent fundus examination revealed retinochoroidal exudates and a string-of-pearls appearance in the vitreous. Further treatment was continued with topical fluconazole and intravitreal vancomycin, ceftazidime, and amphotericin B. Intravitreal injections were repeated weekly until the infant was fit to undergo a vitrectomy under general anesthesia (GA). After lens-sparing vitrectomy, the endophthalmitis resolved, and the ROP in the right eye (Zone 2 stage 1 without plus disease) resolved spontaneously, while ROP in the left eye progressed to prethreshold (zone 2 stage 3+) and was treated with laser. The second infant had received intravitreal ranibizumab for prethreshold ROP (zone 2 stage 3+) in both eyes elsewhere and was referred for treatment of right-eye PIE. The infant underwent PPV with anterior capsular sparing lensectomy. The capsular remnant fibrosed and needed a membranectomy. Following membranectomy and removal of contracted posterior hyaloid, the retina remained attached, and endophthalmitis resolved. Highlights: Preterm infants can have NEE and ROP concurrently. [1,2] After treatment with anti-VEGF, PIE can present around a week after treatment with injection. [3-5] Intravitreal antibiotics may not resolve endophthalmitis, but they are still useful to buy time till vitrectomy can be performed under GA. Vitrectomy in preterm infants with endophthalmitis may appear aggressive, but if done carefully, it can help to deliver a satisfactory anatomical result. Video link: https://youtu.be/XGvN5rgZsqM