Endophthalmitis Incidence After Vitrectomy

The overall incidence of post-vitrectomy endophthalmitis is higher than previously reported, and the routine use of prophylactic subconjunctival antibiotics as a preventative strategy is not supported, according to the key findings of the largest systematic review to date of post-vitrectomy endophthalmitis.

Robert McGrath MD reported the results of a systematic review and meta-analysis of almost two million vitrectomy procedures across the globe to assess the incidence of postoperative endophthalmitis and identify factors associated with reduced risk. The review carried out by Dr McGrath and colleagues compared the main risk factors for endophthalmitis, including instrument gauge, prophylactic antibiotics, phacovitrectomy, and intraocular tamponade.

“It is helpful to update the literature and have some actionable points that surgeons can take away to standardise practice for vitrectomy to minimise harm on a population-wide basis,” Dr McGrath said.

Key findings

The literature review identified 2,781 cases of endophthalmitis following 1,979,160 pars plana vitrectomies from 69 eligible studies, giving an overall incidence of 0.14%, or one case of endophthalmitis per 711 cases. This is higher than reported by previous reviews, Dr McGrath pointed out.

The meta-analysis compared the value of some widely used preventive measures. For example, the use of non-fluid intraocular tamponade agents was associated with a significantly lower risk of endophthalmitis (OR 0.15, 95% CI 0.09–0.27).

In contrast, the use of prophylactic subconjunctival antibiotics did not reduce the risk of endophthalmitis when compared with topical antibiotic prophylaxis (OR 0.77, 95% CI 0.36–1.64).

The study also highlighted the impact of surgical technique. While smaller-gauge vitrectomy systems showed a trend towards higher rates of endophthalmitis compared with traditional 20-gauge surgery, the difference did not reach statistical significance.

However, when the usage of smaller-gauge instruments was compared directly, 25-gauge vitrectomy was associated with a significantly higher risk of endophthalmitis than 23-gauge surgery (OR 2.03, 95% CI 1.05–3.92). More research is needed to determine the reason, but it could be related to wound suturing, Dr McGrath commented.

Combined cataract and vitreoretinal surgery (phacovitrectomy) was not associated with an increased risk of postoperative infection, the review also found.

Updated evidence base

Dr McGrath noted there remains a lack of consensus regarding best practice for preventing endophthalmitis following vitrectomy. He said the study findings reinforce that the biggest risk factor is the initial sealing of the incision in the immediate postoperative period when bacteria could enter the wound.

“The biggest modifiable factor vitreoretinal surgeons can take away is to use an air or gas tamponade for any vitrectomy, even in cases that traditionally wouldn’t necessarily need it, such as epiretinal membrane peels, diabetic haemorrhages, or oil removal cases,” he said. “It leads to quicker sealing of the wounds, less hypotony, and less risk of endophthalmitis by a magnitude of about 85%.”

While a tamponade may lead to some blurred vision in the days post-surgery, patients should be reassured that it is a safety protocol worth performing, he concluded.

The review findings have been published in Retina.

Dr McGrath spoke at the Irish College of Ophthalmologists 2026 annual conference in Galway.

Robert McGrath MD is an ophthalmologist fellow at the Mater Misericordiae University Hospital, Dublin, Ireland. r.mcgrath0019@gmail.com

1. McGrath R, Mulcahy L, Al Abri A, Whitlow S, Brennan N, Connell P. Retina, 2026 Feb 11. doi:10.1097/IAE.0000000000004810.