TREATMENT MODALITY: The Endophthalmitis Vitrectomy Study (EVS), a multicenter randomized clinical trial involving 420 patients with clinical evidence of endophthalmitis within 6 weeks after cataract surgery or secondary intraocular lens implantation, reported the following:

• Among cases with visual acuity of hand motions or better, there was no difference in the final visual outcome between cases treated with immediate vitrectomy and those treated with intraocular antibiotics alone after a vitreous tap.
• Among cases with visual acuity of light perception, immediate vitrectomy plus intravitreal antibiotics, compared to intraocular antibiotics alone after a vitreous tap, had a 3-times greater chance of achieving a final visual acuity of 20/40, a 2-times greater chance of achieving a final visual acuity of 20/100, and one-half the risk of developing severe visual loss of less than 5/200.
• No difference, as measured by the final visual outcome and media clarity, was observed, whether intravenous antibiotics (ceftazidime and amikacin) were used or not (1-7).

RISK FACTORS: The EVS also found that four baseline risk factors strongly associated with poor final outcome were

• worse initial visual acuity (light perception),
• small pupil size after maximal dilation,
• presence of rubeosis iridis, and
• absence of a red reflex (3).

Other important risk factors were (1) history of diabetes or glaucoma, (2) afferent pupillary defect, (3) corneal infiltrate, (4) ring ulcer, (5) abnormal intraocular pressure, (6) inability to see retinal vessels on indirect ophthalmoscopy, (7) type of organism grown in culture, and (8) a disrupted posterior capsule. Retained lens fragments, however, were not reported as a risk factor. The main cause for decrease in final visual acuity among patients with better than light perception visual acuity and those presenting with visual acuity of light perception was a macular abnormality (3).

In patients with retained cortical material after cataract extraction, marked inflammation with hypopyon can develop in the absence of infection (8). Although our patient’s second episode of endophthalmitis was culture-negative, we suspected an infectious etiology due to his clinical deterioration during treatment with intensive topical prednisolone acetate.

ACUTE POSTOPERATIVE ENDOPHTHALMITIS: According to the EVS results, if infection is suspected within 6 weeks of cataract extraction (ie, acute postoperative endophthalmitis), pars plana vitrectomy with intravitreal antibiotics is warranted only in cases presenting with light perception vision or worse, otherwise intravitreal antibiotic injection after vitreous biopsy is appropriate (6). Concern over the possible sequestration of microorganisms in the retained lens material, coupled with the desire to eliminate a potential source of noninfectious inflammation, led us to perform pars plana vitrectomy with removal of retained lens fragments and to administer intravitreal and intravenous antibiotics as well as topical prednisolone acetate, despite the patient’s visual acuity of hand motions OS during his second episode of uveitis with hypopyon.