Perioperative prophylaxis for cataract surgery: Survey of ophthalmologists in the north of England

Prophylaxis against Infection in Cataract Surgery: A Survey of Routine Practice

PURPOSE

To survey the routine practice of consultant ophthalmic surgeons in the United Kingdom in preventing postoperative endophthalmitis following cataract surgery.

METHODS

This is a cross-sectional questionnaire-based study. A questionnaire was sent to consultant ophthalmic surgeons in university teaching hospital ophthalmology departments in the United Kingdom.

RESULTS

Questionnaires were sent to 391 consultant ophthalmic surgeons in 36 ophthalmology departments. The response rate was 55.0% (215 responses). Eleven (5.1%) did not perform cataract surgery routinely. Of the remaining 204 respondents, all performed phacoemulsification as routine. A total of 28 (13.7%) reported a 0% rate of postoperative infective endophthalmitis. Preoperative topical antibiotics were routinely prescribed by 12 respondents (5.9%). The most common immediately preoperative measure was the usage of povidone iodine (203 respondents, 99.5%). A total of 19 (9.3%) used an antibiotic infusion during surgery. Postoperative subconjunctival antibiotics were given by 138 (67.6%), most commonly cefuroxime. A total of 33 (16.2%) administered postoperative intracameral antibiotics. A total of 141 (69.1%) prescribed topical antibiotics after surgery, most commonly neomycin. None gave systemic antibiotics routinely pre-or postoperatively.

CONCLUSIONS

The results show a wide variation of prophylactic measures used in the United Kingdom. The routine practices adopted reflect personal preferences, and were not necessarily evidence-based. Further prospective studies are required to provide evidence for the efficacy of these prophylaxis techniques.

Perioperative prophylaxis for endophthalmitis after cataract surgery in iran

Purpose:

To describe prophylactic patterns employed against endophthalmitis after cataract surgery in Iran.

Methods:

This cross-sectional study included 486 ophthalmologists filling in a self-administered questionnaire during the 20^th Annual Congress of the Iranian Society of Ophthalmology in December 2010, Tehran, working in both private and academic medical centers. Prophylactic measures used preoperatively, intraoperatively and postoperatively and self-reported rates of endophthalmitis were assessed as the main outcome measurements.

Results:

In the preoperative phase, 75.5% of surgeons used povidone-iodine in the conjunctival sac and 71.4% of them did not use antibiotics. The rate of intraoperative prophylaxis was 61.9% either in the form of intracameral antibiotics or subconjunctival injection (mostly cephazolin or gentamicin). Only 7.8% of participants used intracameral cephalosporins. Postoperative antibiotics [mostly chloramphenicol (57%) and ciprofloxacin (28%)] were used by 94.2% of surgeons. On average, ten years of practice were required to observe one case of endophthalmitis.

Conclusion:

The surgeons in present setting used various prophylactic regimens against endophthalmitis after cataract surgery. Setting a local and evidence-based clinical practice guideline seems necessary.

Endophthalmitis prophylaxis in cataract surgery: overview of current practice patterns in 9 European countries

Data on practice patterns for prophylaxis against infectious postoperative endophthalmitis (IPOE) during cataract surgery in 9 European countries were searched in national registers and reviews of published surveys. Summary reports assessed each nation's IPOE rates, nonantibiotic prophylactic routines, topical and intracameral antibiotic use, and coherence to the European Society of Cataract & Refractive Surgeons (ESCRS) 2007 guidelines. Although the reliability and completeness of available data vary between countries, the results show that IPOE rates differ significantly. Asepsis routines with povidone-iodine and postoperative topical antibiotics are generally adopted. Use of preoperative and perioperative topical antibiotics as well as intracameral cefuroxime varies widely between and within countries. Five years after publication of the ESCRS guidelines, there is no consensus on intracameral cefuroxime use. Major obstacles include legal barriers or persisting controversy about the scientific rationale for systematic intracameral cefuroxime use in some countries and, until recently, lack of a commercially available preparation.

Efficacy of intracameral and subconjunctival cefuroxime in preventing endophthalmitis after cataract surgery

PURPOSE

To compare the efficacy of intracameral cefuroxime versus subconjunctival cefuroxime in reducing the rate of endophthalmitis after cataract surgery.

SETTING

Single-specialty eye hospital, Sunderland, United Kingdom.

METHODS

A retrospective analysis of all presumed infectious endophthalmitis cases from January 1,2000, to December 31,2006 was performed. The rate of presumed infectious endophthalmitis in patients receiving subconjunctival cefuroxime was compared with those receiving intracameral cefuroxime at the end of surgery.

RESULTS

This study included 36743 phacoemulsification cataract procedures. The mean rate of presumed infectious endophthalmitis was 0.95 per 1000 cases. The incidence of endophthalmitis was higher in the subconjunctival cefuroxime group than in the intracameral cefuroxime group; the difference was statistically significant with an odds ratio of 3.01 (95% confidence interval, 1.37-6.63).

CONCLUSION

Intracameral cefuroxime was a safe alternative to subconjunctival cefuroxime and led to a lower rate of endophthalmitis.

A survey of measures used for the prevention of postoperative endophthalmitis after cataract surgery in the United Kingdom

PURPOSE

This study investigates the current practice of United Kingdom (UK) ophthalmologists in perioperative antibiotic and antiseptic use in cataract surgery.

MATERIALS AND METHODS

A telephone interview survey was conducted with ophthalmic staff at all ophthalmic training units in the UK in October and November 2005.

RESULTS

The practices of a total of 800 consultants were ascertained. Preoperatively, 795 (99.4%) surgeons used povidone-iodine to prepare the skin. In all, 558 (69.8%) instilled 5 or 10% povidone-iodine in the conjunctival sac; 47 (5.9%) gave preoperative antibiotic eyedrops. Intraoperatively, intracameral antibiotics were given either as a bolus [80 (10.0%) intracameral cefuroxime, 29 (3.6%) intracameral vancomycin] or in the irrigating fluid [33 (4.1%) vancomycin]. 48 (6.0%) gave subconjunctival gentamycin only routinely, 531 (66.4%) gave subconjunctival cefuroxime, and 39 (4.9%) gave other subconjunctival antibiotics. A single dose of topical antibiotics was given by 134 (16.8%) surgeons. Postoperatively, 515 (64.4%) used a combination steroid and neomycin eyedrop, and 213 (26.6%) gave a separate steroid and chloramphenicol eyedrop.

CONCLUSIONS

This study reveals wide variations in the choice and duration of antibiotics used by UK ophthalmologists. The predominant methods of intraoperative prophylaxis are subconjunctival cefuroxime and intracameral cefuroxime. Most surgeons used a neomycin eyedrop for postoperative prophylaxis.

Cataract surgery practice and endophthalmitis prevention by Australian and New Zealand ophthalmologists

PURPOSE

Our aim was to examine current cataract surgery practice and the methods of chemoprophylaxis used in Australia and New Zealand, and to determine if these factors were related to self-reported incidence rates of postoperative endophthalmitis.

METHODS

All Fellows and trainees of the Royal Australian and New Zealand College of Ophthalmologists were surveyed about their cataract surgery practices and methods of chemoprophylaxis for the prevention of postoperative endophthalmitis. Associations between self-reported incidence rates of endophthalmitis and clinical practice were examined using multivariate Poisson regression modelling.

RESULTS

There were 731 respondents (81.6% of 896 surveyed) to the survey. Respondents reported a total of 162,120 cataract operations and 92 cases of endophthalmitis in 2003, a cumulative incidence of 0.057%. The self-reported incidence of endophthalmitis varied from 0.034% in Victoria to 0.56% in the Northern Territory. Topical antibiotics were used preoperatively by 46.7% compared with 97.4% postoperatively; while only 44.1% used subconjunctival antibiotics. The routine use of subconjunctival antibiotic halved the self-reported incidence of postoperative endophthalmitis (incidence rate ratio 0.53, 95% confidence interval 0.30-0.92).

CONCLUSIONS

Subconjunctival antibiotics may be beneficial in the prevention of endophthalmitis after cataract surgery.

New Zealand cataract and refractive surgery survey 2004

BACKGROUND

This study examines the current practice and trends for cataract and refractive surgery in New Zealand.

METHODS

A confidential postal questionnaire was sent to all consultant ophthalmologists practising in New Zealand in 2004. Most questions were identical to the 2000 New Zealand survey, and were also similar to the 2003 survey of the American Society of Cataract and Refraction Surgeons (ASCRS).

RESULTS

From 97 surveys there was a 92% response rate. Of those surveyed, 70 were performing cataract surgery, 17 were performing refractive surgery, subtenons anaesthetic was used for cataract surgery in 60%, clear corneal or anterior limbal incision in 86%, one-piece foldable intraocular lens in 65%. For refractive surgery, use of refractive lens surgery was recommended for high refractive errors. Advice to a 45-year-old +3.00 hypermetrope wanting refractive surgery was to have laser in situ keratomileusis (88%), laser epithelial keratomileusis (6%) or clear lens extraction (6%). Ninety-four per cent of refractive surgeons in New Zealand used a wavefront analyser. Clear lens extraction was practised by 23 ophthalmologists, phakic intraocular lenses by 16 ophthalmologists.

DISCUSSION

New Zealand cataract and refractive surgery practice remains comparable to that of the members of the ASCRS. As in previous comparisons, there is a relatively low use of topical anaesthetic (New Zealand 19%vs. USA 61%vs. UK [pilot study] 33.3%). This survey showed a high uptake of wavefront analysis in refractive surgery (New Zealand 94%vs. USA 45%).

Reflective consideration of postoperative endophthalmitis as a quality marker

PURPOSE

To study the incidence of acute postoperative presumed infectious endophthalmitis (PIE) in a UK district general hospital over a 10-year period. Consideration of such departmental healthcare-associated infection frequency rates as part of reflective and comparative quality practice in the light of local concerns.

METHODS

Hospital-based retrospective case series: 12 831 cataract extraction operations from 01/01/1995 to 31/12/2004 were studied. All cases of PIE within 6 weeks of cataract surgery were ascertained and investigated in a standardised format. PIE incidence rate per 1000 cataract surgical procedures was contrasted with the existing literature.

RESULTS

Seven isolated PIE cases occurred following phacoemulsification. None followed extra-capsular extractions. The PIE rate was 0.55 [95% CI; 0.22 to 1.12] cases per 1000 cataract extractions, or one PIE case within 6 weeks of surgery in every 1833 [95% CI; 893 to 4545] cataract operations undertaken. Five cases were culture positive. Details of PIE cases are presented.

CONCLUSION

PIE incidence rates in our department are slightly lower than reported case series in similar settings. Whether this is due to a variety of preventive measures deployed locally and/or methods of case ascertainment in published studies is problematic and is discussed. Departmental benchmarking data is important in relation to rare, but critical, patient safety incidents. Collection and monitoring of endophthalmitis outcomes is of merit and may inform patient choice. Surgical site infection surveillance systems of relevance are discussed. Implications for making healthcare safer, including reflective practice are, discussed in relation to cataract care.