Infectious endophthalmitis (Figure 17.1) can occur secondary to hematogenous seeding (endogenous endophthalmitis) or from a variety of external insults to the eye – exogenous - (following intraocular surgery such as cataract or glaucoma surgery, trauma, or intravitreal injection). The decision to perform vitrectomy following endophthalmitis is controversial. Although the Endophthalmitis Vitrectomy Study (EVS) demonstrated better visual outcomes in patients with light perception vision or worse who underwent vitrectomy rather than vitreous tap and injection of antibiotics, the EVS was conducted over 20 years ago, and many surgeons now elect to operate on different criteria. The decision to pursue vitrectomy or vitreous tap and inject depends on multiple factors including the presumed virulence of the organism, the degree of anterior segment media opacity, the availability of operating room access, and the systemic comorbidities of the patient. Advances in vitrectomy techniques and equipment, such as the development of smaller-gauge Micro-incision Vitrectomy Surgery (MIVS e.g. 23-, 25- and 27-gauge), have improved the safety of the operation.
Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study: a randomised trial of immediate vitrectomy and of intravenous antibiotics for the treatment of post- operative bacterial endophthalmitis. Arch Ophthalmol. 1995; 113(12): 1479-1496.
Depending on the source, the range of causative organisms of endogenous endophthalmitis is wide. It includes:
Margo CE, Mames RN, Guy JR. Endogenous Klebsiella endophthalmitis. Report of two cases and review of the literature. Ophthalmology. 1994;101:1298–301.
Tseng CY, Liu PY, Shi ZY, Lau YJ, Hu BS, Shyr JM, et al. Endogenous endophthalmitis due to Escherichia coli: case report and review. Clin Infect Dis. 1996;22:1107–8.
If there is significant anterior chamber hypopyon and/or fibrin which will obscure the view for vitrectomy, the anterior chamber may need to be washed out first (Figure 17.2). This is often most easily performed with the vitrector cutter through a paracentesis. A paracentesis can be made for the infusion until the view is adequate to move the infusion to the pars. Pupillary dilation with viscoelastic or iris hooks may be required if there are significant posterior synechiae and a small pupil.
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