Current Ophthalmology Reports

https://doi.org/10.1007/s40135-018-0171-6

OCULAR MICROBIOLOGY AND IMMUNOLOGY (B JENG AND L SCHOCKET, SECTION EDITORS)

Current Strategies for Prevention and Treatment

of Postoperative Endophthalmitis
Ashley Brundrett 1 & Christopher D. Conrady 1 & Akbar Shakoor 1 & Amy Lin 1

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of review We review the prevention and treatment of postoperative endophthalmitis.
Recent findings Postoperative endophthalmitis is rare but has potentially blinding consequences. There is no consensus on
prevention, but there are a few controlled studies with methods of decreasing the infection rate, such as use of povidone iodine
and intracameral antibiotics. There remains only one randomized controlled study (Endophthalmitis Vitrectomy Study or EVS)
on the treatment of postoperative endophthalmitis, but there are retrospective studies which examine the timing and various
methods of vitrectomy and intravitreal antibiotics.
Summary The application of povidone iodine remains a proven method of preventing endophthalmitis, but evidence suggests
that intracameral antibiotics further minimize this risk. Further research is needed to define the efficacy of intravitreal antibiotics
at the time of cataract surgery. There are many questions regarding treatment, including performance of vitrectomy for eyes with
visual acuities better than light perception, smaller vitrectomy port sizes, and intravitreal antibiotics and/or oral steroids.

Keywords Endophthalmitis . Postoperative endophthalmitis . Intracameral antibiotics

Introduction perioperative preventative strategies and potential treat-

Cataract surgery is one of the most common surgeries
performed in the USA. While the risks are low, postoper-
ative endophthalmitis has gained significant attention due
to potentially poor visual outcomes [1]. Review of the
Medicare claims data in the USA in 2003–2004 and
2010–2014 found rates of endophthalmitis between 1.2
and 1.33 cases per 1000 cataract cases resulting in an
83% rise in cost compared to cases that did not develop
postoperative endophthalmitis [2, 3]. Consequently, en-
dophthalmitis and strategies to prevent the infection have
gained considerable attention due to the significant cost of
treating the infection and the substantial risk of poor vi-
sual acuities. In the following manuscript, we discuss both
This article is part of the Topical Collection on Ocular Microbiology and
Immunology
* Amy Lin
Amy.Lin@hsc.utah.edu
1
John A. Moran Eye Center, University of Utah, 65 Mario Capecchi
Dr, Salt Lake City, UT 84132, USA
ment algorithms based on the current literature available.
Part I: Preventing Endophthalmitis
Postoperative endophthalmitis is a rare but potentially devas-
tating complication after ocular surgery. Although this can
occur after any type of ocular surgery, the majority of cases
occur after cataract surgery since it is the most commonly
performed eye surgery [4]. Current practice patterns for post-
operative endophthalmitis prophylaxis including surgical
technique, aseptic protocols, and perioperative antibiotic uti-
lization vary worldwide, making it difficult to establish a stan-
dard of care [5–11]. Randomized, controlled trials are imprac-
tical given the low prevalence of postoperative endophthalmi-
tis and the very large number of patients that would be re-
quired. Current practice patterns are most influenced by the
growing evidence from published observational studies with
few controlled studies to solidify a standard of care.
Commonly used prophylactic strategies include preoperative
topical antibiotic drops, application of povidone-iodine to the
conjunctival cul de sac and the peri-ocular skin, proper

draping, intracameral injection of antibiotics at the end of the
surgery, and perioperative topical antibiotic drops [12].
Povidone-Iodine
The most effective evidence-based technique for preoperative
antisepsis is the application of povidone-iodine (PI) to the con-
junctival cul de sac or periocular skin before surgery [13]. While
there is consensus on the use of PI for preoperative antisepsis for
cataract surgery, the specific concentration, mode of application,
timing, and duration vary widely. Several studies demonstrate the
effectiveness of the periocular application of PI in the reduction
of postoperative endophthalmitis alone or in combination with
other prophylactic measures [14, 15]. The European Society of
Cataract and Refractive Surgery (ESCRS) recommends the ap-
plication of PI (5–10%) drops to the cornea, conjunctival sac, and
periocular skin for at least 3 min before surgery. The American
Academy of Ophthalmology (AAO) Cataract in the Adult Eye
Preferred Practice Patterns Guidelines recommend topical PI
(5%) drops to the conjunctival cul de sac preoperatively while
the Royal College of Ophthalmologists (RCOph) Cataract
Surgery Guidelines recommend a flush irrigation of PI (5%) into
the conjunctival sac [6, 16]. Neither AAO nor RCOph has rec-
ommendations for exposure time of the PI prior to surgery. A
more recent, small prospective cohort study supported the 3 min
exposure time for PI (5–10%) to the cornea, conjunctival sac, and
periocular skin with no documented cases of postoperative en-
dophthalmitis [17]. Another study showed reduced anterior
chamber contamination with irrigation of the ocular surface every
20 s with dilute PI in balanced salt solution (0.0025 and 0.025%)
compared to balanced salt solution alone after both the control
group and treatment groups were prepped with peri-ocular 10%
PI [18]. Several studies support using higher concentrations (5–
10%) and volumes (irrigation of 10 ml) of PI in the conjunctival
cul de sac, as well higher concentrations PI (10%) for the skin
and peri-ocular area [19–24]. Overall, preoperative application of
povidone iodine is widely used and considered standard of care,
but no standardized regimen of application has been established.
Perioperative Topical Antibiotics
Another commonly used method for endophthalmitis prophy-
laxis includes application of topical antibiotic drops before,
during, or after cataract surgery. The data for the role of topical
drops in the prevention of endophthalmitis are lacking without
any prospective randomized clinical trials, and there is no
clear consensus on the specific agents used or the timing.
Many clinicians favor frequent instillation initially, for a peri-
od of time, and avoid tapering the antibiotic drops to discour-
age development of antibiotic resistance. A few studies
showed a similar reduction of conjunctival flora with day of
Curr Ophthalmol Rep
surgery use versus several days preoperatively, and thus, they
did not recommend the need for topical antibiotic use before
the day of the surgery [25–27]. Obvious concerns regarding
the use of topical antibiotic drops perioperatively include pa-
tient compliance and the theoretical risk of increasing bacterial
antibiotic resistance [28–36]. Several studies have shown in-
creased resistance of conjunctival flora or vitreous isolates
with repetitive use of topical fluoroquinolones, specifically
coagulase negative Staphylococcus, a common organism as-
sociated with postoperative endophthalmitis [37].
The role and efficacy of topical drops in the reduction of
postoperative endophthalmitis is unclear and has varying re-
sults in recent observational studies. Topical fluoroquinolone
antibiotics, specifically levofloxacin, moxifloxacin, and
gatifloxacin, have been shown to have good ocular penetra-
tion, especially with repetitive instillation [38, 39]. Some stud-
ies suggest a relatively low rate of endophthalmitis with the
sole use of topical antibiotics [40–42], and a large-scale sys-
tematic review suggests that their use in addition to intraocular
antibiotics is beneficial [43]. However, the European Society
of Cataract and Refractive Surgery (ESCRS) endophthalmitis
prevention study did not show a lower rate of endophthalmitis
with topical levofloxacin in addition to intracameral antibi-
otics preoperatively. Of note, all arms of the study did receive
6 days of levofloxacin postoperatively [44]. A large, prospec-
tive study in Sweden did not show any clear benefit with the
addition of topical antibiotic drops before, during, or after
cataract surgery to the reduction of rates of endophthalmitis
[1]. A recent, large controlled observational cohort study in
California showed reduction in postoperative endophthalmitis
with preoperative topical antibiotic drop use compared to no
antibiotic prophylaxis at all [45]. However, it also showed that
the concomitant use of topical antibiotics did not add to the
effect of intracameral antibiotics on the reduction of postoper-
ative endophthalmitis. Specifically evaluating for topical drop
efficacy, they did note inferiority of aminoglycosides as com-
pared to gatifloxacin, ofloxacin, and polymyxin/trimethoprim.
Two different recent systematic reviews and meta-analysis of
controlled trials and observational studies revealed equivocal
results or lack of evidence for the efficacy of topical antibiotics
perioperatively in preventing postoperative endophthalmitis
[46, 47]. Overall, despite the common use of topical antibi-
otics perioperatively, there is no universal recommendation
for their use and will be unlikely unless more definitive evi-
dence emerges.
Intracameral/Intravitreal Antibiotics
Intracameral injection of antibiotics at the end of ocular sur-
gery has become a more common practice worldwide, with
the intention of killing any intraocular bacteria that may have
entered the eye during the procedure. A 2016 survey of
Curr Ophthalmol Rep
American Society of Cataract and Refractive Surgery
(ASCRS) members found that 40% of respondents were cur-
rently injecting an intracameral antibiotic at the conclusion of
surgery, and more than 30% plan to do so in the next
12 months [48]. The use of intracameral antibiotics for en-
dophthalmitis prophylaxis is increasing with growing evi-
dence of its efficacy. In the 2014 ASCRS survey, the majority
of those not using intracameral prophylaxis reported that this
was due to the lack of an approved and reasonably priced
commercial preparation and concern for the risk of dilution
errors or contamination [7]. In countries without access to
commercially approved preparations, there are potential risks
for incorrect dosing, formulation, and preparation [49–52].
Intraocular injection is intended to achieve a higher concen-
tration of antibiotic in the eye that is theoretically long-lasting
[53–55]. Recent evidence shows promising results with the
use of intracameral antibiotics at the conclusion of the surgery,
yet instillation of cefuroxime intracamerally is the only anti-
biotic demonstrating level 1 evidence of reducing postopera-
tive endophthalmitis. In a multi-center, prospective random-
ized study conducted by the ESCRS, they showed an almost
5-fold reduction in the groups receiving intracameral
cefuroxime intracamerally as compared to the control group
[56]. While several large observational studies showed similar
results with use of cefuroxime [1, 57–62], one large prospec-
tive cohort study in India noted only a non-statistically signif-
icant decrease in the rate of postoperative endophthalmitis
with use of intracameral cefuroxime [63]. Other commonly
used agents including vancomycin, moxifloxacin, and
cefazolin have demonstrated similar reductions in endophthal-
mitis in several observational studies [64–69]. Intracameral
vancomycin was previously a popular agent for intracameral
injection, but many have abandoned its use with recent reports
of the rare but devastating complication of hemorrhagic oc-
clusive retinal vasculitis [70•, 71]. Moxifloxacin has become a
popular alternative therapy, especially in regions without com-
mercially prepared agents. In a large retrospective study of
over 600,000 surgeries, intracameral injection of
moxifloxacin demonstrated a 7-fold decrease in postoperative
endophthalmitis for phacoemulsification and 3.5-fold de-
crease for manual small incision cataract surgery [72••].
The replacement of topical drops with intraocular instillation
of antibiotics is a controversial topic. While several studies have
shown that some intracameral injections likely achieve effective-
ly high concentrations of antibiotic in the anterior chamber [53,
55, 73, 74], it is unclear what length of time they maintain a
therapeutic concentration. There is a concern for postoperative
influx of fluid into the anterior chamber with self-sealing clear
corneal incisions especially with low intraocular pressures until
complete wound healing [41, 75–77]. Ideally, at the conclusion
of surgery, the presence of effective concentrations of antibiotic
in the eye after surgery should be adequate to prevent endoph-
thalmitis to reduce the need for topical antibiotics or sustained
release antibiotics. Transzonular delivery of compounded antibi-
otics is a recently developed technique for postoperative endoph-
thalmitis prophylaxis. A one-time injection of compounded an-
tibiotic and steroid is injected into the anterior vitreous, via a
transzonular approach, at the conclusion of the case. Studies
performed in rabbit models have shown that intravitreally admin-
istered medications provide higher intraocular concentrations for
longer durations [78]. A recent retrospective study with over
1500 eyes demonstrated the efficacy and safety of a
compounded formulation of triamcinolone, moxifloxacin, and
vancomycin administered by a transzonular injection after the
intraocular lens implantation step in cataract surgery [79].
While this demonstrates the potential for a transition to dropless
cataract surgery to prevent postoperative endophthalmitis, more
evidence will be necessary.
Concluding Thoughts on Prevention
In postoperative endophthalmitis prevention, the use of
povidone-iodine perioperatively is effective in limiting postoper-
ative endophthalmitis, although the methods of application still
vary widely. Topical antibiotics are also commonly used before,
during, or after surgery; however, there are no randomized con-
trolled trials demonstrating their efficacy. While growing evi-
dence suggests that instillation of intracameral antibiotics at the
conclusion of cataract surgery is generally safe and effective in
reducing postoperative endophthalmitis, the complete eradication
of topical antibiotic use perioperatively is controversial. Newer
technology, such as intravitreally administered medications at the
conclusion of the surgery, might be a viable alternative and allow
transition to dropless cataract surgery, although more definitive
data will be required.
Part II: the Basis of Endophthalmitis
Treatment—the EVS
Endophthalmitis can be a devastating postoperative complica-
tion or the result of disseminated systemic infection (Fig. 1)
[80, 81]. In those that develop the disease, 40% of patients
after cataract surgery and over 90% in trabeculectomy bleb-
associated endophthalmitis develop severe vision loss
resulting in visual acuities worse than 20/200 [1, 82]. The best
treatment of postoperative endophthalmitis is prevention as
discussed extensively earlier; however, despite the use of the
most stringent sterile techniques, endophthalmitis can still oc-
cur, with highest rates reported following secondary intraocu-
lar lens placement [83]. When endophthalmitis does develop,
prompt detection and treatment is of utmost importance to
improve visual outcomes as prognosis is dependent on pre-
senting visual acuities, time-to-treatment from when symp-
toms developed, and the organism isolated [84, 85]. As such,
 Curr Ophthalmol Rep

0.09% with the use of perioperative antibiotic prophylaxis

[97, 98]. Despite endophthalmitis being a rare event, it is an
unfortunate and devastating risk of intraocular surgery. While
there is clear guidance from the EVS in regard to management
of APE in specific situations (Table 1), what should the clini-
cian do if the patient does not fit inclusion criteria of the EVS?
In a retrospective study, patients with a poor red reflex at
presentation or those that did not improve after 24 h of med-
Fig. 1 Hypopyon in a case of endophthalmitis ical therapy underwent a complete PPV. Ninety-one percent of
eyes in this series had final visual acuities of 20/40 or better
early or developing clinical features of endophthalmitis such [99]. The authors hypothesized that the removal of the nidus
as worsening postoperative inflammation, hypopyon, or reti- of infection including proinflammatory cytokines resulted in
nal vasculitis are critical hallmarks of the disease that should the better outcomes [99]. Similar findings have been found in
prompt immediate action as treatment should not be delayed diabetic patients who are more likely to achieve 20/40 or bet-
for organism recovery [80]. ter vision when a PPV was performed with vision better than
Upon reviewing current literature, the management of en- light perception at presentation [100]. A retrospective study
dophthalmitis can vary tremendously depending on the inciting from the UK showed that more patients with count fingers or
source (i.e., intravitreal injection, trabeculectomy bleb, cataract worse vision that underwent a PPVat diagnosis of APE had an
surgery, and endogenous sources). This is due to only one ran- improvement from initial visual acuity than those patients
domized, controlled trial (RCT): the Endophthalmitis Vitrectomy managed by EVS guidelines [101••]. Without additional pro-
Study (EVS), published on the topic [86]. Patients were included spective studies, it is difficult to recommend treatment strate-
in this study if they developed endophthalmitis within 6 weeks of gies beyond those given by the EVS; however, these retro-
cataract surgery, had vision better than light perception, and in- spective studies would suggest that visual outcomes may be
traocular inflammation did not totally obscure visualization of the better when PPVs are done with better presenting visual acu-
iris [86]. Unfortunately, patients that did not fit these specific ities than that found in the EVS. In cases that do not fall under
criteria were excluded from the study such as cases of severe the umbrella of the EVS, either extrapolating results to the
inflammation or non-cataract intraocular surgery. While the study current clinical case at hand or using previously cited retro-
has its obvious limitations, the findings of the EVS have become spective data does not seem unreasonable.
the foundation of treatment for postoperative endophthalmitis.
Current practice guidelines based on the EVS recommend
collection of a vitreous specimen for microbial analysis (either Table 1 Inclusion and exclusion criteria of the EVS
PCR or culture-based methods) with the highest rates of identi-
fication from samples taken by pars plana vitrectomy (PPV) The EVS
Inclusion Exclusion
[87]. This is done concurrently with intravitreal injection of
broad-spectrum antimicrobials such as vancomycin and ceftazi- Endophthalmitis within Known eye disease limiting vision
dime that have minimal retinal toxicity [88–91]. Repeat dosing 6 weeks of surgery to 20/100 or worse
may be required in order to maintain bactericidal concentrations Cataract or secondary IOL Prior intraocular surgery other than
of drugs within the vitreous longer than the 48–72 h reported placement surgery cataract/intraocular lens surgery
after a single injection [92]. The simultaneous injection of dexa- Visual acuity 20/50 to LP Prior penetrating ocular trauma
methasone to rapidly reduce intraocular inflammation at time of Visualization of at least Previous injection of intravitreal
presentation may be of some benefit [93, 94]. While this practice parts of the iris antibiotics
has become the standard of care, it is based off of anecdotal Cornea clear enough to Prior PPV
perform PPV
evidence and retrospective data without further evaluation in an Hypopyon or sufficient Moderately high retinal or
RCT [95•, 96]. In the following sections, we will examine the inflammation to obscure choroidal detachment
management of acute postoperative endophthalmitis (APE) and 2nd-order arterioles
chronic postoperative endophthalmitis (CPE) as a means to focus Probable intolerance to any
study drugs
discussion on a broad topic that is limited by the lack of RCTs.
Strong suspicion of fungal
endophthalmitis
Age younger than 18 years
Acute Postoperative Endophthalmitis Unsuitability for surgery
Unlikely to follow-up
Endophthalmitis following cataract surgery is an infrequent
event with large centers identifying rates as low as 0.053– IOL intraocular lens, LP light perception, PPV pars plana vitrectomy
Curr Ophthalmol Rep
In trabeculectomy bleb-associated endophthalmitis (BAE),
the presentation is also usually one of rapidly developing vi-
sion loss and eye redness but differs from APC in that it can
develop weeks to months to even years after the initial surgery
with a yearly risk of 1.3% [102]. Streptococcus and
Staphylococcus species are the most commonly isolated or-
ganisms, and in a majority of cases, a bleb leak is identified
[103–106]. Unfortunately, the EVS excluded patients from the
study that developed endophthalmitis from blebs. As such,
clinicians have been required to use smaller retrospective stud-
ies for guidance or by generalizing findings from the EVS. In
acute BAE cases that develop within 1 month of surgery (only
a small portion of cases), organisms are similar to cataract
cases and could be reasonably treated like APE [103, 107].
With that said, the organisms in late-onset BAE appear to be
more destructive than in cataract surgery-associated endoph-
thalmitis resulting in worse visual outcomes [108, 109].
Consequently, retrospective studies have suggested that those
patients undergoing a PPV had a better visual prognosis than
those patients that do not [106, 109]. Unfortunately, these
results were not corroborated by another retrospective study
and despite clearance of the pathogen with or without PPV,
visual prognosis is usually poor [107]. Thus, it is unclear as to
the best management of BAE and future RCTs are needed.
Indolent Postoperative Endophthalmitis
In comparison to APE, CPE is less common and the patient
presentation and isolated organisms usually differ. In the
chronic form of the disease (defined as greater than 6 weeks
after surgery) [110], some responsiveness to topical steroids
initially is not uncommon and the organisms isolated appear
less virulent [84]. Propionibacterium acnes is the most com-
mon organism isolated and best studied. Most would advocate
that the management of CPE is similar to APE with a vitreous
biopsy and injection of broad spectrum antibiotics at presen-
tation [111]. Unfortunately, recurrence is not uncommon with
rates as high as 50% with medical management [112]. Thus,
others have advocated, with the support of a small retrospec-
tive study, performing a PPV with partial capsulectomy and
injection of intravitreal antibiotics at time of presentation to
significantly reduce rates of recurrence and effectively cure
the disease [113]. In refractory cases to even this more aggres-
sive approach, the study further advised the removal of the
entire capsular bag and intraocular lens resulting in a 100%
cure rate [113]. A smaller retrospective study with similar
design as the previous study noted recurrence in four of nine
patients initially treated with PPV with partial capsulectomy, a
much higher rate than the 19% found in the larger study [112,
113]. Two small case series have suggested that irrigating the
capsular bag with antibiotics alone may be enough to eradicate
chronic, low-grade, non-P. acnes infections [114, 115].
Consequently, the management of CPE appears to be more
surgical than APE; however, no RCT has been performed to
confirm these findings and give clear guidance to the clinician.
Should We Treat Postoperative
Endophthalmitis with Systemic Antibiotics?
Other sources of endophthalmitis such as endogenous endoph-
thalmitis (EE) are managed with some distinct differences than
postoperatively. The most common and best understood cause of
EE is Candida species [116–118]. As such, Candida will be used
in the following discussion of EE. Less than 2% of patients with
culture-proven candidemia will develop EE in one prospective
study [119]. However, EE requires more than intravenous (IV)
therapy due to worse visual outcomes compared to peripheral
chorioretinitis that can be managed with IV therapy alone [119,
120•]. Due to this, current infectious disease guidelines recom-
mend prolonged IV therapy with PPV in patients developing
significant vitritis [118, 120•]. While intraocular inoculation is
pathologically much different than postoperative cases, can EE
guide treatment of postoperative cases? When the EVS was orig-
inally published, many of the antimicrobials with reasonable
intraocular penetrance were not available and the IV antibiotics
used in the EVS had poor gram-positive coverage (i.e., amikacin
and ceftazidime) despite a majority of organisms identified being
gram-positive [86, 121, 122]. The authors concluded that IV
antibiotics did not significantly alter the course of disease, but
this conclusion is likely subject to revision due to improper
targeted therapy and the emergence of other antibiotics with bet-
ter intraocular penetrance [86]. Consequently, should IV/oral an-
timicrobials become adjuvants to topical and intravitreal therapy
or used to supplant topical therapy in cases of poor patient com-
pliance with medicated drops?
While fungal endophthalmitis following intraocular sur-
gery is exceedingly rare in the USA, other areas of the world
see the organism more frequently and its management may
shed light on therapies once considered obsolete [111, 123,
124]. While a small, retrospective case series showed that
postoperative Candida endophthalmitis could be managed
with PPV and intravitreal therapy alone, the use of IV therapy
is an alternative to repeated intravitreal injections once thera-
peutic concentrations have been achieved due to sufficient
intraocular penetration of voriconazole, caspofungin, and flu-
conazole [125–127]. This is supported by a case report of
postoperative fungal endophthalmitis effectively treated with
topical and IV antifungals alone [128]. Lastly, data from the
EVS noted a statistically significant 50% reduction in retinal
detachment rates with IV antibiotics compared to those that
did not receive the therapy, but similar visual outcomes [129].
While the authors did not speculate on an underlying mecha-
nism, could there have been an additional therapeutic benefit
with IVantibiotics [129]? Unfortunately, the use of IVand oral

antibiotics has not been studied since the EVS but likely needs
to be reassessed due to the emergence of 4th-generation
fluoroquinolones that have better intraocular penetration and
broad-spectrum bactericidal activity than prior generations in
rabbit and human eyes [130, 131].
The Case for Steroids
The use of periocular, intraocular, or systemic steroids in acute
endophthalmitis is not universally accepted practice, as con-
cern for attenuating the host immune response during an in-
fection seems counter-productive. Experimental endophthal-
mitis models have shown that time-dependent dosing of intra-
vitreal dexamethasone or triamcinolone in combination with
intravitreal antibiotics decrease intraocular inflammation
resulting in a better preservation of electroretinographic re-
sponses; however, larger initial inoculums of organisms used
in another study have raised concern for a deleterious effect of
intraocular steroids [132–136]. Based off of laboratory find-
ings, three RCTs were proposed to evaluate the efficacy of
intraocular steroids, and they have not shown an improvement
in visual outcomes despite a statistically significant reduction
in inflammation [137–139]. These data need to be re-assessed
as the largest study of the three included a total of 63 patients
[137]. Could there be a steroid effect, even if small, that could
improve visual outcomes with certain organisms, with less
severe inflammation, or in specific clinical settings (bleb-as-
sociated endophthalmitis)? Retrospective studies have shown
that the use of intravitreal dexamethasone in bleb-associated
endophthalmitis improves short-term visual acuity outcomes
[140]. Thus, it is plausible that both the infection and the
inflammation need to be treated emergently, but a large RCT
has not been performed to support this hypothesis.
Future Directions
There are still many questions remaining in regard to the best
management of postoperative endophthalmitis. While the
EVS has become the foundation of treatment, no study has
effectively evaluated whether all types of postoperative en-
dophthalmitis should be treated the same. Additionally, no
large RCT has looked at the efficacy of intravitreal and/or oral
steroids in combination with broad-spectrum antimicrobial
therapy. Lastly, and the most controversial, with the use of
smaller port sizes, should the initial vision guidelines for
PPV be altered? A small, retrospective study showed that
visual outcomes are better with smaller port sizes (25 gauges)
and that fewer complications and additional interventions
were required compared to 20-gauge PPV [141]. Given better
intraocular penetration of antibiotics and smaller vitrectomy
port sizes compared to when the EVS was performed, along
Curr Ophthalmol Rep
with multiple therapeutic questions still unanswered, a large
RCT to update the EVS needs to be performed to help guide
clinicians in treatment algorithms.
Conclusions
In conclusion, endophthalmitis is an unfortunate complication
of intraocular surgery. Perioperative measures to prevent the
development of APE/CPE and rapid recognition and treat-
ment are critical to limiting permanent vision loss related to
the sight-threatening inflammatory disease.
Funding This work was supported in part by an Unrestricted Grant from
Research to Prevent Blindness, Inc., New York, NY, to the Department of
Ophthalmology & Visual Sciences, University of Utah. This source of
financial support had no role in the study design; the collection, analysis,
or interpretation of data; in the writing of the report; or the decision to
submit the article for publication.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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