The article by Shirodkar and associates highlighted many new aspects of endophthalmitis. Information regarding partial or complete capsulectomy and intraocular lens removal or exchange is especially useful to the eye specialists handling such cases. Another factor different from earlier studies is the mean time between operation and presentation. In the present study (conducted from 2000 through 2009 in the United States), it was 9 days for acute-onset disease and 343 days for delayed-onset disease, whereas in the Endophthalmitis Vitrectomy Study, conducted from 1990 through 1994 in the United States, it was 6 days (all 420 cases occurring within 6 weeks after operation), and in European Society of Cataract and Refractive Surgeons Endophthalmitis Study (conducted from 2004 through 2005 in Europe), it was 5 days. It seems that the mean time is increasing (like a decreasing incidence of endophthalmitis) probably because of better prophylaxis in the form of antibiotics. Similarly, delayed-onset cases in the European Society of Cataract and Refractive Surgeons Endophthalmitis Study were 3% (1/29) versus 22% (26/118) in the present study. So, more cases are landing now in the delayed category, perhaps again because of better prophylaxis.

Information regarding prophylaxis is missing from this study. Prophylactic measures must have changed, because the study spans 10 years. Thus, the different organisms may be there as a result of different prophylactic routines. Moreover, there is no mention of systemic antibiotics (oral clarithromycin, intravenous vancomycin, ceftazidime/amikacin) used in the management of endophthalmitis, which might have influenced the visual outcome.

The authors treated delayed- and acute-onset inflammation as being 2 different entities. In fact, the 2 are extremes of 1 wide spectrum. Although there are definite differences at the extreme end cases (as confirmed by the authors), many cases can land in either category, depending on the immune state (history of steroids, diabetes etc.), surgical complications, and the extent of prophylaxis. Had the authors mentioned these factors, it would have given a more comprehensive picture. Figures compared above in the first paragraph also support the logic that if the ratio of acute-onset disease is decreasing, it is because of the dampening effect of the better prophylaxis. In brief, it would be too simple to associate onset and visual outcome of endophthalmitis with the type of organisms only, without taking into consideration other factors.