to report the occurrence of endophthalmitis after trabeculectomy for glaucoma that was treated by vitrectomy without bleb closure and recurred 3 times after an initial clinically inapparent period of about 2 years . four years after the trabeculectomy , an endophthalmitis with staphylococcus epidermidis as the causative organism occurred and was treated with a pars plana vitrectomy ( 20-gauge ) and a combined antibiotic and anti - inflammatory drug regimen . the bleb was not covered during the emergency procedure because the filtering bleb was heavily infected and filled with pus . as the filtering bleb healed nicely and the filtering function was restored , the filtering bleb was left as it was , and best - corrected visual acuity initially recovered to 0.8 . after 22 months , the endophthalmitis recurred , this time with enterococcus faecalis as the causative organism . its treatment required a total of four further vitrectomies ( 23-gauge ) , each accompanied by the same antibiotic and anti - inflammatory drug regimen that had been applied previously . however , the visual acuity could not be preserved , and the eye is blind with defective light projection . the literature suggests an aggressive surgical approach to endophthalmitis , and the present case report confirms this . since the visual prognosis of eyes after endophthalmitis is poor , the course of treatment for endophthalmitis after trabeculectomy should emphasize recurrence prophylaxis rather than address glaucoma symptoms and therefore include safe bleb leak coverage . glaucoma surgery , albeit showing a generally encouraging efficacy and safety profile , is faced with a classic dilemma : the more effective a surgical method , the more likely are bleb - related infections . the filtering bleb as such hampers the protective function of the conjunctiva against microbial invasion due to its stretching and thinning , and the trabeculectomy provides a potential migration path for microorganisms from the bleb via the anterior chamber into the vitreous ; moreover , adjuvant antifibrotic agents as well as sub - optimal surgical proceedings in terms of bleb placement and patching increase the likelihood for a clinical manifest infection , i.e. blebitis and/or endophthalmitis [ 1 , 2 ] . endophthalmitis is the most severe and most dreaded infectious complication in ocular surgery and can occur with a substantial delay of several years after surgery . the spectrum of causative organisms is broad and includes typical skin bacteria as well as nosocomial pathogens that may unveil hospital hygiene deficiencies [ 2 , 3 , 4 , 5 , 6 ] . while the treatment of endophthalmitis with regular- and small - gauge vitrectomy is possible [ 7 , 8 ] , there are no established standard operating procedures [ 9 , 10 ] , and the visual outcome is generally poor even if the eye itself can be preserved [ 2 , 3 , 4 , 11 , 12 ] . the latter statement is especially true with regard to recurrent and/or chronic endophthalmitis [ 13 , 14 , 15 ] , and therefore recurrence prophylaxis should have a very high priority in treatment decision - making . a 73-year - old caucasian female underwent trabeculectomy ( without mitomycin ) for glaucoma that had occurred approximately 15 years after buckling surgery for retinal detachment . almost exactly 4 years after the trabeculectomy , an endophthalmitis with staphylococcus epidermidis as the causative organism occurred . the endophthalmitis was treated with a pars plana vitrectomy ( 20-gauge ) and a combined antibiotic and anti - inflammatory drug regimen , using intravitreal vancomycin 1.0 mg , amikacin 0.4 mg and dexamethasone 1.0 mg . the bleb was not covered during the emergency procedure because the filtering bleb was heavily infected and filled with pus . postoperative local treatment comprised moxifloxacin , chloramphenicol and prednisolonacetat drops every 30 min and latanoprost at night . systemic treatment comprised imipenem 500 mg 3 times per day , ciprofloxacin 500 mg 3 times per day and prednisolone acetate 100 mg / day for 3 days , the latter subsequently phased out by a dose reduction of 20 mg every 3 days . since the filtering bleb healed nicely and the filtering function was restored , it was decided to leave the filtering bleb as it was . after an initial remission of approximately 22 months , the endophthalmitis recurred , this time with enterococcus faecalis as the causative organism . its treatment required a total of four further vitrectomies ( 23-gauge ) , each accompanied by the same antibiotic and anti - inflammatory drug regimen that had been applied previously . three days before the second vitrectomy for recurrent endophthalmitis , the visual acuity was still 0.6 , but it deteriorated to light perception immediately before the procedure . before and after subsequent vitrectomies for recurrent endophthalmitis , the patient was at best able to count fingers , and ultimately the eye remained blind with defective light projection . antifibrotic agents such as mitomycin are causally involved in the majority of cases of post - trabeculectomy endophthalmitis , but the present case underlines the fact that it can occur without antifibrotic adjuvants . the sporadic occurrence of endophthalmitis after ocular surgery procedures is no sign of erroneous proceeding as such , although it may indicate technical and/or hygienic faults . however , the literature suggests that an aggressive surgical approach to endophthalmitis is warranted [ 1 , 13 ] , and the present case report confirms this . recurrent endophthalmitis is an unmistakable sign of persistence of microorganisms in the eye or , more likely , a re - infection after primarily successful treatment . therefore , the initial treatment approach should place special emphasis on the avoidance of loci minoris resistentiae for germ invasion . this is obviously contradictory to the treatment goals of glaucoma where the construction of the filtering bleb facilitates germ invasion . however , since the visual prognosis of eyes after endophthalmitis is poor [ 2 , 3 , 4 , 11 , 12 ]  and even much more so after recurrence [ 13 , 14 , 15 ]  , the course of treatment for endophthalmitis after trabeculectomy should emphasize recurrence prophylaxis and therefore include a safe bleb leak coverage .
purposeto report the occurrence of endophthalmitis after trabeculectomy for glaucoma that was treated by vitrectomy without bleb closure and recurred 3 times after an initial clinically inapparent period of about 2 years.methodsinterventional case report and short review of the pertinent literature.resultsa 73-year - old caucasian female underwent trabeculectomy ( without mitomycin ) for glaucoma . 
 four years after the trabeculectomy , an endophthalmitis with staphylococcus epidermidis as the causative organism occurred and was treated with a pars plana vitrectomy ( 20-gauge ) and a combined antibiotic and anti - inflammatory drug regimen . 
 the bleb was not covered during the emergency procedure because the filtering bleb was heavily infected and filled with pus . 
 as the filtering bleb healed nicely and the filtering function was restored , the filtering bleb was left as it was , and best - corrected visual acuity initially recovered to 0.8 . 
 after 22 months , the endophthalmitis recurred , this time with enterococcus faecalis as the causative organism . 
 its treatment required a total of four further vitrectomies ( 23-gauge ) , each accompanied by the same antibiotic and anti - inflammatory drug regimen that had been applied previously . 
 however , the visual acuity could not be preserved , and the eye is blind with defective light projection.conclusionsthe literature suggests an aggressive surgical approach to endophthalmitis , and the present case report confirms this . since the visual prognosis of eyes after endophthalmitis is poor , the course of treatment for endophthalmitis after trabeculectomy should emphasize recurrence prophylaxis rather than address glaucoma symptoms and therefore include safe bleb leak coverage .