Management strategies in acute postcataract endophthalmitis: Insights from a 10-year real-world experience

Acute postcataract endophthalmitis is a vision-threatening emergency that requires prompt recognition and intervention. The mainstays of treatment include intravitreal antibiotics (ivAB) to sterilize the vitreous cavity and core vitrectomy to remove infectious and inflammatory debris. While the need for urgent action is well established, there remains significant debate regarding the optimal timing and role of core vitrectomy in management. The landmark Endophthalmitis Vitrectomy Study (EVS) recommends immediate vitrectomy only for eyes with presenting visual acuity of light perception (LP) or worse, while reserving ivAB alone for eyes with better initial vision.[1] However, recent literature has increasingly challenged this paradigm. Advancements in small-gauge vitrectomy techniques and improved surgical safety have led some studies to advocate for immediate vitrectomy irrespective of presenting vision.[2,3] Additionally, practice pattern surveys conducted by the Vitreoretinal Society of India suggest that although many ophthalmologists recognize the need to update EVS recommendations, most continue to follow them in routine practice.[4] Recent evidence from the Endophthalmitis Management Study has proposed an inflammation score–based approach to better stratify disease severity and guide intervention.[5] Despite this, the practical reality is more nuanced. Clinical decision-making often involves triaging patients into one of three pathways: ivAB alone, ivAB followed by deferred vitrectomy, or immediate vitrectomy. In this context, we present insights from our 10-year real-world experience managing acute postcataract endophthalmitis. Clinical Observations In our retrospective cohort of 80 eyes with postcataract endophthalmitis managed across three treatment strategies— ivAB alone, deferred vitrectomy, and primary vitrectomy—initial treatment was determined based on presenting visual acuity as per EVS guidelines. Eyes with incomplete or partial response were considered for repeat injection or deferred vitrectomy based on clinical judgment. The three treatment groups differed at baseline [Table 1]. Eyes undergoing vitrectomy—both primary and deferred—presented with more severe disease, including poorer initial visual acuity, higher grades of vitritis, and a higher proportion of referred cases. In contrast, eyes managed with ivAB alone had milder presentations.Table 1: Comparison of demographics and baseline clinical features across the three groupsAcross all groups, visual acuity improved over 3 months follow-up period [Fig. 1]. Eyes managed with ivAB alone demonstrated favorable outcomes, while those requiring vitrectomy showed comparatively slower recovery. Higher rates of retinal detachment were observed in the primary vit group at 20.8%, compared to 4.8% in the deferred vit group and 2.9% in the ivAb-only [Table 2]. However, this likely reflects the severity of the underlying infection and retinal involvement.Figure 1: Mean best-corrected visual acuity (logMAR) over time across three treatment groupsTable 2: Comparison of outcomes across the three groups.Our observations reinforce that baseline disease severity remains a key determinant of outcomes in endophthalmitis. The apparent superiority of one treatment modality over another must therefore be interpreted with caution, particularly in retrospective analyses where treatment allocation is not randomized. Our real-world experience supports a conservative initial approach in patients with presenting vision better than LP, reserving vitrectomy for those with poor response, aligning closely with EVS recommendations and real-world constraints. Limitations These observations must be interpreted in light of several limitations. The cohort was a retrospective, single-center study with inherent selection bias and nonrandomized treatment allocation. The three treatment groups differed at baseline in terms of disease severity and referral status, limiting direct comparison of outcomes. The follow-up period of 3 months may not capture all late complications. Conclusion Our findings suggest that initial treatment with ivAB followed by deferred vitrectomy, when indicated, yields visual outcomes comparable to immediate vitrectomy. In postcataract endophthalmitis, the EVS guidelines remain relevant, reserving vitrectomy for those with LP or worse, while a staged, response-guided approach also offers a safe and effective path. Authors’ contribution Dr. Aditya Kelkar contributed in concept, design, definition of intellectual content, manuscript editing, and manuscript review. Dr. Rabia Naaz contributed in data acquisition and manuscript review. Dr. Harsh Jain contributed in literature search, data acquisition, data analysis, statistical analysis, manuscript preparation and manuscript review. Dr. Jai Kelkar contributed in manuscript review. Dr. Sabyasachi Sengupta contributed in data analysis, statistical analysis, manuscript preparation, and manuscript review.