Is the endophthalmitis vitrectomy study still relevant in 2022?

Abstract

AbstractEndophthalmitis is a severe intraocular inflammatory response secondary to an infectious intraocular load. Postoperative endophthalmitis (POE) is the most common type. It is most often seen after cataract surgery and intravitreal injections (IVI) but can be seen after any intraocular procedures (e.g. glaucoma surgery or pars plana vitrectomy (PPV)). A definitive approach to treatment of endophthalmitis is not uniformly agreed upon by many vitreoretinal surgeons. The current standard treatment for acute POE remains the injection of intravitreal antibiotics with the addition of PPV for severe cases.In the 1990 s, a clinical trial (Endophthalmitis Vitrectomy Study, EVS) was conducted, comparing vitrectomy (VIT) versus intravitreal antibiotics in one arm and intravenous (IV) antibiotics yes or no in the other arm for the treatment of postoperative bacterial endophthalmitis. The suggestions regarding VIT was that it is of substantial benefit for patients with an initial VA of light perception (LP) while offering VIT should not be considered in patients with hand motion or better VA (Endophthalmitis Vitrectomy Study Group 1995).While the EVS has been widely used as the guideline for management of POE, even for indications other than after cataract surgery or placement of secondary intraocular lenses (IOL), the study has come under scrutiny. Some physicians recommend early PPV, or management based on clinical assessment other than visual acuity.But so many years after the results of EVS were published, remarkable progress in vitrectomy techniques have been achieved, including the introduction of transconjunctival surgery (23‐,25‐ and 27‐gauge instrumentation), higher cutting rates, wide‐angle visualization. Preoperative povidone‐iodine antisepsis, intravitreal antimicrobial injections, improved vitrectomy instrumentation, availability of silicone oil as adjunctive treatment and newer alternative antimicrobials contribute to better outcome for patients with endophthalmitis. Further advances in the microbiology diagnosis including polymerase chain reaction (PCR) and newer molecular application of peptide nucleic acid–fluorescence in situ hybridization (PNA‐FISH) are promising diagnostic tools.All those remarkable advances that took place in the decades after the EVS was published, leads us to the conclusion, that the results of the EVS are extremely important but some of the recommendations could be reconsidered. A new randomized prospective multicenter study should be organized to address management of endophthalmitis.