Postoperative endophthalmitis treatment with antibiotics associated or not with pars plana vitrectomy: a randomized clinical trial.

Background: Postoperative endophthalmitis (PSE) is a severe ocular complication that can lead to irreversible vision loss or even globe atrophy. The Endophthalmitis Vitrectomy Study (EVS) historically guided PSE management but is increasingly questioned due to advances in pars plana vitrectomy (PPV) techniques and its narrow focus on cataract surgery. This study aimed to compare PPV followed by intravitreal antibiotic injection at the end of surgery (PPV + IVAIES) with intravitreal antibiotic injection alone (IVAI) in managing PSE.

Methods: This randomized clinical trial included 35 pseudophakic patients with PSE following cataract extraction, anti-vascular endothelial growth factor (anti-VEGF) injections, or glaucoma surgeries. Participants were randomized to receive either PPV + IVAIES (n = 12) or IVAI (n = 23). Best-corrected visual acuity (BCVA) was assessed at baseline and days 7, 30, 60, and 90 post-intervention. Clinical worsening, defined as lack of improvement or progression of symptoms within 48-72 h, guided retreatment protocols. Group A (PPV + IVAIES) received repeat IVAI if required, while Group B (IVAI) underwent delayed PPV with repeat IVAI. Statistical significance was assessed using repeated measures ANOVA and logistic regression.

Results: Both groups showed significant BCVA improvement (p < 0.001). PPV + IVAIES resulted in faster recovery, with superior BCVA at day 7 (p = 0.019) and day 30 (p = 0.041). Retreatment was required in 39.1% of the IVAI group but not in the PPV + IVAIES group (p = 0.015). Subgroup analysis indicated a trend toward better early outcomes with early PPV (p = 0.029).

Conclusions: Early PPV + IVAIES provides faster visual recovery and reduces retreatment rates compared to IVAI alone. Multicenter studies are warranted to confirm these findings and refine clinical guidelines. Trial registration ClinicalTrials.gov identifier: NCT04192994.