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cell viability. Despite these challenges, vitreous biopsy remains the gold standard procedure used to establish a diagnosis and to direct treatment when infection or malignancy
is suspected.
The purpose of this study was to review the authors
experience with DVx in patients with presumed intraocular
infection or malignancy in which careful clinical and laboratory evaluation failed to identify a diagnosis. In particular,
the authors sought to determine the diagnostic yield of DVx
using tests that are widely available and commonly performed for vitreous fluid analysis. A secondary aim was to
study the visual outcomes of patients who underwent DVx.
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Results
Forty-five eyes of 44 patients were included in this study. Table 1
summarizes the baseline demographic data according to the surgical indication. Suspected preoperative diagnosis was infection in
15 eyes and malignancy in 30 eyes. Twenty patients were men
(45.4%), and the average age (standard deviation [SD]) was
6513 years (range, 38 87 years). Mean time (SD) from presentation to DVx was 4991098 days (range, 15445 days), and
mean follow-up (SD) was 340369 days (range, 8 1636 days).
Eyes with suspected chronic postoperative endophthalmitis all
underwent cataract extraction a mean (SD) of 13751829 days
(range, 425236 days) before DVx. Intraocular inflammation was
unilateral in 33 cases (73%). Bilateral DVx was performed in 1
patient. The mean number of tests performed on each vitreous
sample was 2.6. Twenty-eight (62.2%) vitreous specimens were
analyzed by culture, cytologic analysis, and flow cytometry. Sixteen (35.6%) specimens were analyzed by 2 of the 3 tests, and 1
specimen was analyzed by culture only (2.2%).
Table 1. Characteristics, Final Diagnosis, and Diagnostic Outcomes of Patients Who Underwent Diagnostic Vitrectomy for
Suspected Intraocular Infection or Malignancy
Indications for
Vitrectomy
Presumed
infection
Presumed
malignancy
Total
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No. of
Eyes
(% of
Total)
No. of
Males
Mean Age
(Range),
Yrs
Mean Time to
Diagnostic
Vitrectomy
(Range), Days
Follow-up
(Range),
Days
No.
Unilateral
Mean
No. of
Tests
Final
Diagnosis
No. Diagnosed
by Diagnostic
Vitrectomy
15 (33)
68 (4885)
275 (11710)
349 (81636)
14
2.5
30 (67)
11
64 (3887)
594 (105445)
332 (81178)
19
2.6
45 (100)
20
65 (3887)
499 (15445)
340 (81636)
33
2.6
15
Test
No. Performed
Diagnosis
Culture
Cytologic analysis
Flow cytometry
Total
35
42
34
111
2 (5.7)
6 (14.3)
7 (20.6)
15 (13.5)
Idiopathic panuveitis
Propionibacterium acnes endophthalmitis
Fungal endophthalmitis
Toxoplasmosis
Acute retinal necrosis
Metastatic testicular lymphoma
Metastatic lung carcinoma
Total
30 (66.7)
1 (2.2)
1 (2.2)
1 (2.2)
1 (2.2)
1 (2.2)
1 (2.2)
36 (80)
Visual Outcomes
Visual acuity outcomes according to final diagnosis are summarized in Table 6. The overall mean preoperative vision was 20/138
for all eyes (range, 20/25light perception). There was no significant difference between the mean preoperative visual acuity of
patients with final diagnosis of infection, malignancy, or idiopathic
uveitis. At 3 months (P0.001) and 6 months (P 0.02) after
Table 3. Final Diagnoses Confirmed by Diagnostic Vitrectomy
Diagnosis
Propionibacterium acnes
endophthalmitis
Aspergillus species
Primary intraocular lymphoma
Systemic NHL
No. (% of
All Cases)
% of Positive Diagnostic
Vitrectomy Results
1 (2.2)
11.1
1 (2.2)
6 (13.3)
1 (2.2)
11.1
66.7
11.1
Discussion
In this study, DVx with vitreous analysis established a
diagnosis in 20% of eyes that were suspected of having
posterior segment inflammation resulting from either infectious or malignant causes. In previous studies, DVx was
successful in establishing a final diagnosis in 14% to 61.5%
of cases.19 Diagnostic yield of vitrectomy depends on the
initial patient selection, the number and types of tests used,
and vitrectomy technique. Because DVx may be performed
after treatment with antibiotics or antiinflammatory medication has been attempted, microbial load and malignant
cell counts may be suppressed, yielding negative results.
Additional factors that can affect the diagnostic outcome are
a lag between collecting and processing the specimen and
the experience of the microbiologist and cytopathologist in
analyzing the vitreous. Direct comparison of various studies
therefore is difficult.
Although our diagnostic yield of microbiologic culture
and sensitivity was 5.7%, there were only 2 known falsenegative results, and the sensitivity was 50%. However, it
is possible that with longer follow-up, some cases considered to be idiopathic inflammation might have been
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Sensitivity (%)
Specificity (%)
Positive Predictive
Value (%)
Negative Predictive
Value (%)
Culture
Cytologic analysis
Flow cytometry
Total
50
66.7
83.3
63.6
100
100
100
100
100
100
100
100
94
91.7
96.6
89.5
Final Diagnosis
Infection
Malignancy
Idiopathic
Total
Mean
Preoperative
Vision (Snellen),
n 45
Mean 3-Month
Postoperative
Vision (Snellen),
n 45
Mean 6-Month
Postoperative
Vision (Snellen),
n 35
Mean 1-Year
Postoperative
Vision (Snellen),
n 24
Mean 2-Year
Postoperative
Vision (Snellen),
n 19
20/235
20/110
20/133
20/138
20/96
20/71
20/46
20/55 (P0.01)*
20/205
20/74
20/49
20/65 (P 0.02)
20/270
20/152
20/59
20/90 (P 0.56)
20/100
20/159
20/82
20/100 (P 0.61)
*P values comparing visual outcomes at postoperative follow-up time points relative to preoperative vision.
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