Modern Endophthalmitis Control: The Complete Early Vitrectomy for Endophthalmitis (CEVE) Protocol and Surgical Prophylaxis

Abstract

This article presents an overview of endophthalmitis, a severe intraocular inflammatory condition that can develop following surgery, intravitreal injections (IVIs), or ocular trauma. Endogenous cases may also arise, particularly in patients with compromised immune systems. A broad spectrum of pathogens, including bacteria, fungi, and viruses, can be involved, with some displaying high virulence. Given the rapid progression and potential for vision-threatening complications or systemic involvement such as sepsis, immediate and appropriate intervention is essential. Surgical management, especially vitrectomy, plays a central role in treatment. The Complete Early Vitrectomy for Endophthalmitis (CEVE) protocol has demonstrated high effectiveness, particularly when integrated into outpatient ophthalmic surgical practices. This review describes the protocol's practical application in such settings. In addition, it discusses preventive strategies for ocular surgery and injections, with a particular focus on the judicious use of antimicrobial agents. Incorrect antibiotic use, including unnecessary prescribing, inadequate dosing, or prolonged treatment, remains a leading contributor to the development of antimicrobial resistance and warrants critical evaluation. In summary, the CEVE approach appears to offer broad efficacy across different causes of endophthalmitis. Povidone-iodine (PI) remains the most effective agent for perioperative antisepsis. The use of prophylactic antibiotics should be confined to brief, high-potency topical therapy following intraocular procedures, including cataract surgery and phacovitrectomy. Current evidence does not support the routine use of prophylactic antibiotics after intravitreal injections due to minimal benefit and the risk of promoting resistant organisms.

Keywords: antibiotics; endophthalmitis; management algorithm; ocular surgery; povidone-iodine; prevention; vitrectomy.

Figure 1. Acute postoperative endophthalmitis (preoperative photograph)

Note the thick "blanket" of pus covering the macula. Preoperative picture taken by Małgorzata Ozimek, MD, PhD, in Prof. Zagorski Eye Surgery Centre in Nowy Sącz (Eidon FA, CenterVue, Padua, Italy)

Figure 2. Endophthalmitis management in a one-day clinic setup

The image was created by Aleksandra Kardaszewska, MD, based on a decision-making tree in the standard operating procedure of endophthalmitis in the OCHO Medical Group

Figure 3. Decision-making tree for endophthalmitis

In both options, vitrectomy seemed to be the default strategy in efficient endophthalmitis management. A schematic diagram was created by Aleksandra Kardaszewska, adapted from Kuhn [1], and reviewed and consulted with Ferenc Kuhn, the author of the concept PPV: pars plana vitrectomy

Figure 4. Diagram representing CEVE definition

Diagram made by Agnieszka Kudasiewicz-Kardaszewska, MD, PhD, with the use of Canva AI (Canva, Sydney, Australia)

Figure 5. Surgical field after disinfection

The skin is prepared with 10% PI and the ocular surface with 5% PI. A sterile drape and speculum have been applied. Eyelashes are isolated using surgical foil. Intraoperative picture taken by Małgorzata Ozimek, MD, PhD, in Prof. Zagorski Eye Surgery Centre in Nowy Sącz PI: povidone-iodine