Fine-tuning the treatment of postoperative endophthalmitis

Brazilian researchers conducted a comparative study (NCT04192994) that found that pars plana vitrectomy followed by an intravitreal antibiotic injection at the end of surgery (PPV + IVAIES) was superior to intravitreal antibiotic injection alone (IVAI) for managing postoperative endophthalmitis.¹ Co-authors of the study, Vinicius Campos Bergamo, MD, and Luis Filipe Nakayama, MD, PhD, are from the Retina Division, Department of Ophthalmology, Vitreoretinal Surgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.

(Image credit: AdobeStock/Siniehina)

Management of postoperative endophthalmitis has depended on the Endophthalmitis Vitrectomy Study (EVS) for decades²; it showed that PPV was beneficial for patients with a best-corrected visual acuity (BCVA) of light perception at the initial presentation and that treatment with IVAI should be more effective for patients with better levels of initial BCVA, the investigators said.

The EVS was published in 1995, and considerable technologic advances have been introduced since then, ie, advancements in current PPV techniques, including 23-gauge (G) and 25-G instrumentation, 20,000 cuts/minute vitreous cutters, improved and safer surgical tools, and wide-angle viewing systems. As a result, the EVS recommendations are undergoing increased scrutiny.^3-7 

The EVS included patients in whom postoperative endophthalmitis developed after cataract surgery and the study findings were used to guide the management of other types of postoperative endophthalmitis, including intraocular infection after intravitreal injections, which recently has become increasingly common.^8,9 However, emerging evidence supports the value of early PPV in managing postoperative endophthalmitis.^10,11 

Randomized clinical trial

The study under discussion sought to elucidate the role of early PPV+ IVAIES to manage postoperative endophthalmitis compared to IVAI.

The study included 35 pseudophakic patients who developed postoperative endophthalmitis after cataract extraction, anti-vascular endothelial growth factor (anti-VEGF) injections, or glaucoma surgeries; 12 patients were randomized to PPV + IVAIES and 23 patients to IVAI. The BCVA was measured at baseline and days 7, 30, 60, and 90 post-intervention.

The investigators defined clinical worsening as a lack of improvement or progression of symptoms within 48 to 72 hours, which guided retreatment protocols. The 12 patients randomized to PPV + IVAIES received repeat IVAI if required; the patients randomized to IVAI underwent delayed PPV with repeated IVAI.

The BCVA improved significantly with both treatments (P < 0.001).

The investigators reported, “PPV + IVAIES resulted in faster recovery, with superior BCVA at day 7 (P = 0.019) and day 30 (P = 0.041). Retreatment was required in 39.1% of the IVAI group but not in the PPV + IVAIES group (P = 0.015). Subgroup analysis indicated a trend toward better early outcomes with early PPV (p = 0.029).”

The investigators concluded, “Performing early PPVs was associated with significantly better and faster BCVA recovery and lower retreatment rates compared to IVAI. Although a trend toward improved long-term BCVA was observed in the PPV group, this difference did not reach significance. These findings suggest that early surgical intervention with PPV provides substantial benefits in the management of PSE, particularly in reducing the risk of therapeutic failure. Further multicenter studies are required to validate these results.”

References

1. Bergamo VC, Nakayama LF, de Moraes NSB, et al.Postoperative endophthalmitis treatment with antibiotics associated or not with pars plana vitrectomy: a randomized clinical trial.Int J Retin Vitr. 2025;11;https://doi.org/10.1186/s40942-025-00640-1

2. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol. 1995;113:1479–1496.

3. Kuhn F, Gini G. Ten years after... are findings of theEndophthalmitisvitrectomystudy still relevant today? Graefes Arch Clin Exp Ophthalmol.2005;243:1197–1199.

4. Relhan N, Forster RK, Flynn HW Jr. Endophthalmitis: then and now. Am J Ophthalmol. 2018;187:xx–xxvii.

5. Sen AC, Mehta SM, Sule A, et al. Immediate vitrectomy vs tap and inject in eyes with acute post-cataract endophthalmitis and visual acuity ≥HM: a randomized clinical trial. Retina. 2023; https://doi.org/10.1097/IAE.0000000000003759.

6. Bergamo VC, Nakayama LF, Moraes NSBD, Yu MCZ, Höfling-Lima AL, Maia M. Bacterial endophthalmitis following anti-VEGF intravitreal injections: a retrospective case series. Int J Retin Vitr. 2023;9:58.

7. Panahi P, Mirzakouchaki-Borujeni N, Pourdakan O, Arévalo JF. Early vitrectomy for endophthalmitis: are EVS guidelines still valid? Ophthalmic Res.2023;66:1318–1326.

8. Israilevich RN, Mansour H, Patel SN, et al. Risk of endophthalmitis based on cumulative number of anti-vascular endothelial growth factor intravitreal injections. Ophthalmology.2024; https://doi.org/10.1016/j.ophtha.2023.12.033.

9. Thinggaard BS, Pedersen F, Kawasaki R, et al. Risk of post-injection endophthalmitis peaks within the first three injections of anti-vascular endothelial growth factor therapy: a nationwide registry-based study. Acta Ophthalmol. 2024; https://doi.org/10.1111/aos.16727.

10. Clarke B, Williamson TH, Gini G, Gupta B. Management of bacterial postoperative endophthalmitis and the role of vitrectomy. SurvOphthalmol. 2018;63:677–693.

11. Almanjoumi AM, Combey A, Romanet JP, Chiquet C. 23-gauge transconjunctival sutureless vitrectomy in treatment of post-operative endophthalmitis. Graefes Arch Clin Exp Ophthalmol. 2012;250:1367–1371.