Controversies in the management of endophthalmitis: a 5-year retrospective cohort study

Background and purpose Post-operative endophthalmitis has a risk of vision loss if the treatment is delayed. Managing endophthalmitis based on visual outcome has become controversial. This study primarily aimed to evaluate the effectiveness of early pars plana vitrectomy (PPV) combined with intravitreal antibiotics in improving visual acuity and reducing complications in patients with post-operative endophthalmitis. Secondary objectives included identifying prognostic factors influencing visual outcomes after PPV, assessing the effectiveness of different intravitreal antibiotic regimens on visual recovery, and evaluating the role of steroid as adjunctive therapy in influencing visual outcome and controlling inflammation. Methods A 5-year retrospective cohort study was conducted, reviewing medical records of patients diagnosed with post-operative endophthalmitis between 2019 and 2023. Data collected included patient demographics, medical and surgical history, culture results, treatments administered, baseline best-corrected visual acuity (BCVA), and BCVA outcomes within three months after vitrectomy. Results 40 eyes of 40 patients with acute post-operative endophthalmitis underwent early PPV followed by intravitreal antibiotics. Median logMAR BCVA improved from 2.0 at presentation to 0.4 three months post-vitrectomy (p < 0.05), with a mean final logMAR BCVA of 0.94 +/- 1.13. No significant difference was observed in visual outcomes or complication rates between patients treated with intravitreal vancomycin and ceftazidime versus moxifloxacin monotherapy. Univariate analysis identified high intraocular pressure (p = 0.004, beta = 2.42), hypopyon (p = 0.01, beta = 1.79), and a history of surgery more than seven days prior (p = 0.032, beta = 1.74) as significant predictive of visual outcomes. Multivariate analysis confirmed intraocular pressure (p = 0.008, beta = 2.55) and surgical history (p = 0.045, beta = 1.84) as independent predictors. Baseline BCVA, fibrin, retinal findings, and symptom onset were not significantly associated with outcomes. Neither antibiotics regimen nor steroid use significantly influenced treatment results. Conclusion This study supports performing early PPV combined with intravitreal antibiotics as an effective primary treatment to improve visual outcomes in post-operative endophthalmitis. Negative prognostic factors included hypopyon, elevated intraocular pressure, and a surgical history of more than seven days. Management should prioritize clinical signs over microbiological culture results to prevent delays in treatment.