The prevalence of EBE could be as high as 90 % in patients with diabetes, cardiac disease and malignancy. According to the major review of Timothy L. Jacksonand associates, 56 % of 267 patients had comorbidities that predisposed to infection. The most common condition was diabetes, particularly in association with klebsiella liver abscess [4].

Patients presented with systemic infections such as liver abscess, meningitis, and endocarditis may subsequently develop EBE.

Cheng and associates conducted a retrospective search for 23 septic metastatic lesions of 187 consecutive patients with pyogenic liver abscess that there were 60.8 % of endophthalmitis, 43.4 % of pulmonary abscess, 26 % of brain abscess or purulent meningitis, 21.7 % bacteriuria or prostatic abscess and 8.6 % of osteomyelitis and pyogenic arthritis [5].

Our case was a male diabetic patient with poor glycemic control whose septic metastatic lesions were subdural abscess, endogenous endophthalmitis with subretinal abscess and liver abscess.

The presentations of fundus with endophthalmitis may be nonspecific such as vitritis, retinal hemorrhages, nerve fiber layer infarction, retinitis, perivasculitis, and subretinal exudation. Manifestation such as subretinal abscess was quite rare. The most common bacterial subretinal abscess which caused by Norcardia is seen in patients with underlying immunosuprression [6, 7]. Other causes are rare. There were three individual case reports demonstrated involving Pseudomonas aeruginosa [8], Streptococcus Viridans [9], and pneumoniae [10]. The vision of those cases after treatment was variable. However, the prognosis of most cases was poor. Eddie W. Harris and associates [11] reported a case of klebsiella endophthalmitis with subretinal abscess promptly intervened with extensive retinectomy, complete abscess excision and intravitreal antibiotic therapy resulted in relatively better vision than previous cases.

In our case, we performed pars plana vitrectomy with intravitreal injection of antibiotics of ceftazidime (2 mg/0.1 ml) and amikacin (0.4 mg/0.1 ml) without retinectomy considering the limited size of subretinal abscess (four disc areas). We observed that the margin of subretinal abscess became well demarcated and the central part firmed gradually after surgery. The subretinal abscess resolved, only mottled retinal pigment epithelium left.

The modality of treatment and visual prognosis of subretinal abscess combined with endogenous endophthalmitis depends on its severity, such as turbidity of vitritis, location and extent of subretinal abscess and retinal exudation. Theoretically, advantages of vitrectomy include removal of the infection organisms, endotoxins and vitreous membranes that could lead to retinal detachment; clearing of vitreous opacities; collection of abundant material for culture and possibly better distribution of intravitreal antibiotics. The more extensive the surgery is, the more exudation and inflammatory substance would accumulate on the retina and in the vitreous cavity, which may interfere with the identification between infection progression and inflammation flares up. However, if subretinal abscess is really large and high, vitrectomy combined with retinectomy to remove adequate abscess should be considered to decrease the amount of bacteria and to facilitate infiltration of antibiotics. Intravitreal injection of antibiotics combined with appropriate amount of steroids should also be considered after surgery to decrease surgery-related inflammation.

Subretinal abscess is an extremely rare presentation of metastatic endophthalmitis. It is difficult to develop appropriate treatment guidelines of endophthalmitis complicated by subretinal abscess. Our experience in this case demonstrated if the size of the subretinal abscess is smaller than four disc areas, pars plana vitrectomy with intravitreal injection of antibiotics without retinectomy could be considered to avoid further retinal detachment.