Reducing the risk for endophthalmitis after cataract surgery: Population-based nested case-control study

Clear corneal incision, an important step in modern cataract surgery: a review

A clear corneal incision (CCI) is the most commonly used entrance site in modern phacoemulsification cataract surgery. Despite some initial concerns about increased endophthalmitis rates through a self-sealing CCI, recent literature suggests that the risk of infection with proper wound construction and all other necessary precautions is minimal. The technique of creating a clear corneal incision has, with recent developments in corneal imaging, undergone critical appraisal leading to a better understanding of incision architecture. Many surgeons operate through smaller incisions, and they have a wide choice of surgical instruments to create their corneal incisions. The aim of this review is to discuss the history and the current status of clear corneal incision creation, the design and materials of surgical blades, and the current trends in manufacturing and sustainability. Although disposable instruments have some advantages and are very popular, recycling, if possible, and avoiding unnecessary plastic waste are important considerations. In any case, the step of CCI is a small one for the surgeon, but a big one for the eye. That is why it has to be done with the utmost precision and in-depth knowledge is important.

Exogenous Endophthalmitis

PURPOSE

Exogenous endophthalmitis (ExE) results from microbial infection as a complication of ocular surgery, penetrating ocular trauma, and intraocular foreign bodies. We herein review the classification of ExE, etiological agents, differential diagnosis and therapeutic challenges.

METHODS

Narrative Literature Review.

RESULTS

Identification of the causative agent through ocular fluid analysis is central in the diagnostic work-up of ExE. Prompt intravitreal antimicrobial therapy is key to successful management of ExE and vitrectomy is essential in severe cases. In culture-negative cases, and in the presence of specific features, a diagnosis of sterile intraocular inflammation or toxic syndrome should be suspected.

CONCLUSION

Strict adherence to treatment guidelines may improve outcomes of ExE, however the ultimate prognosis, especially in severe cases, may depend more on the virulence of the causative organism and associated ocular complications. Accurate differential diagnosis and effective treatment are crucial elements in the management and prognosis of non-infectious masquerades of ExE.

Postoperative Endophthalmitis After Cataract Surgery: An Update

Postoperative endophthalmitis is a serious complication that can happen after cataract surgery. It occurs mainly due to invasion of the globe by microbial flora, bacteria, or fungi from the adnexa and environment during the time of surgery. All patients undergoing cataract surgery should be evaluated for any potential risk factors that can enhance the development of postoperative endophthalmitis; managing the intraoperative risk and prophylaxis protocols should be considered in order to reduce the risk of endophthalmitis. Early follow-up after cataract surgery is highly recommended to detect any sign of endophthalmitis so as to treat it immediately and ensure patient compliance on post-surgery medication and precautions to reduce the serious complications caused by late diagnosis and treatment of post-cataract endophthalmitis.

Intraoperative Cefuroxime Irrigation Prophylaxis for Acute-Onset Endophthalmitis After Phacoemulsification Surgery

Purpose

Acute-onset postoperative endophthalmitis usually compromises the visual function and anatomical integrity of the eye. The aim of this study was to evaluate the efficacy of intraoperative cefuroxime use in irrigating solution on prevention of acute-onset endophthalmitis after phacoemulsification.

Methods

This retrospective, comparative, interventional cohort study included patients who underwent phacoemulsification between January 1, 2012, and December 31, 2019. Under a uniform perioperative protocol, the patients who had surgery from January 1, 2012, to December 31, 2014, received irrigating infusion fluid containing balanced salt solution (BSS) only (group 1), and those from January 1, 2015, to December 31, 2019, received BSS with cefuroxime (1500 μg/mL) during surgery (group 2). All eyes were evaluated postoperatively, and the eyes suspected to have endophthalmitis were assessed and treated by a consultation team. The rates of postoperative endophthalmitis in these two groups were calculated.

Results

A total of 61,299 eyes were included over the eight years. Among these eyes, 11 in group 1 (0.07% of 15,948 eyes) and 5 in group 2 (0.01% of 45,351 eyes) developed endophthalmitis, and the difference was significant (P < 0.01). Five among 16 patients (31.25%) with endophthalmitis were positive in bacterial culture. The positive rate of bacterial culture was not significantly different between group 1 (4/11) and group 2 (1/5) (P > 0.05). No adverse events related to the irrigation of cefuroxime were found.

Conclusion

Intraoperative cefuroxime irrigation (1500 μg/mL) could decrease the rate of postoperative endophthalmitis after phacoemulsification by 7-fold. This study provides evidence that intraoperative irrigation with cefuroxime is effective as an antibiotic prophylaxis for endophthalmitis.

Efficacy of 0.5% Levofloxacin and 5.0% Povidone-Iodine Eyedrops in Reducing Conjunctival Bacterial Flora: Metagenomic Analysis

Bacteria associated with postoperative endophthalmitis mostly originate from the normal bacterial flora of the patient's conjunctiva and eyelids, so the incidence of endophthalmitis may be reduced by eliminating the ocular and adnexal flora before surgery. We assessed the effectiveness of eyedrops of 0.5% levofloxacin and 5.0% povidone-iodine (PVI) in reducing conjunctival bacterial flora by metagenomic analysis. A total of 2.4 × 10⁶ high-quality sequencing reads were generated from 93 conjunctival samples obtained from 31 eyes scheduled for cataract surgery before prophylactic therapy (group 1), after administration of 0.5% levofloxacin eyedrops into the conjunctival sac 8 times before surgery (group 2), and at 3 minutes after instillation of 5.0% PVI solution in the conjunctival sac (group 3) followed by surgery irrigation. The alpha diversity and beta diversity results demonstrated that group 3 had the least richness and biodiversity. Corynebacterium, Pseudomonas, Staphylococcus, Acinetobacter, and Streptococcus were predominant in all samples. The relative abundance of these bacterial species was 30.94%, 27.48%, 5.26%, 4.55%, and 2.61% in group 1, 16.32%, 44.10%, 2.19%, 5.39%, and 0.97% in group 2, and 5.90%, 65.55%, 0.39%, 5.36%, and 0.10% in group 3, respectively. The most easily and difficultly eliminated were Corynebacterium and Pseudomonas, respectively. In conclusion, the metagenomic analysis using high-throughput sequencing provides a scientific way for evaluating the effectiveness of a disinfection method from the perspective of analyzing the composition and diversity of the conjunctival microbiome. Despite the use of preoperative antisepsis regimens, the ocular surface of patients receiving cataract surgery could not be rendered completely aseptic, indicating that more strict disinfection methods need to be adopted to reduce the risk for anterior chamber contamination and endophthalmitis after cataract surgery.

Comparative analysis of the safety and efficacy of intracameral cefuroxime, moxifloxacin and vancomycin at the end of cataract surgery: a meta-analysis

BACKGROUND

Current practice methods are unclear as to the most safe and effective prophylactic pharmacotherapy and method of delivery to reduce postoperative endophthalmitis occurrence.

METHODS

A systematic review and meta-analysis using Meta-analysis of Observational Studies in Epidemiology guidelines was performed to compare the efficacy of intracameral cefuroxime, moxifloxacin and vancomycin in preventing postphacoemulsification cataract surgery endophthalmitis. A safety analysis of intracameral antibiotics was concurrently performed.

DATA SOURCES

BIOSIS Previews, CINAHL, ClinicalTrials.gov, Cochrane Library, Dissertations & Theses, EMBASE, PubMed, ScienceDirect and Scopus were searched from inception to January 2017. Data were pooled using a random effects model. All articles were individually reviewed and data were extracted by two independent reviewers. Funnel plot, risk of bias and quality of evidence analyses were performed.

RESULTS

Seventeen studies with over 900 000 eyes were included, which favoured the use of intracameral antibiotics at the end of cataract surgery (OR 0.20; 95% CI 0.13 to 0.32; P<0.00001). The average weighted postoperative endophthalmitis incidence rates with intracameral cefuroxime, moxifloxacin and vancomycin were 0.0332%, 0.0153% and 0.0106%, respectively. Secondary analyses showed no difference in efficacy between intracameral plus topical antibiotics versus intracameral alone (P>0.3). Most studies had low to moderate risk of bias. The safety analysis showed minimal toxicity for moxifloxacin. Dosing errors led to the majority of toxicities with cefuroxime. Although rare, vancomycin was associated with toxic retinal events.

CONCLUSION

Intracameral cefuroxime and moxifloxacin reduced endophthalmitis rates compared with controls with minimal or no toxicity events at standard doses. Additionally, intracameral antibiotics alone may be as effective as intracameral plus topical antibiotics.

Femtosecond laser-assisted cataract surgery, technology, outcome, future directions and modern applications

Since its introduction in 2009 femtosecond laser-assisted cataract surgery (FLACS) has promised to revolutionize cataract surgery. Despite its promise, the assessment of FLACS's perceived benefits has proven to be far more complicated than initially might have been thought. Most studies to date have not provided validation of FLACS technology as a clinically significant advancement on our current techniques. We review FLACS technology and outcomes including detailed analysis of safety, efficacy, cost effectiveness and future prospects using data from the literature and our own published clinical experience.

Post-cataract surgery endophthalmitis: Brief literature review

PURPOSE

To investigate recent evidence in prophylaxis and management of post-cataract surgery endophthalmitis.

METHODS

We conducted a literature search using Pubmed database for post cataract surgery endophthalmitis, and relevant articles were selected from original English papers published since 2015.

RESULTS

Forty-nine articles were published regarding post-cataract surgery endophthalmitis from January 2015 to February 2016. A low incidence of post-cataract surgery endophthalmitis has been reported. A growing number of articles are focusing on preventing endophthalmitis using intracameral antibiotics.

CONCLUSION

Based on the current evidence, intracameral antibiotics seems to be effective in preventing endophthalmitis after cataract surgery.

Customized Clinical Practice Guidelines for Management of Adult Cataract in Iran

Purpose:

To customize clinical practice guidelines (CPGs) for cataract management in the Iranian population.

Methods:

First, four CPGs (American Academy of Ophthalmology 2006 and 2011, Royal College of Ophthalmologists 2010, and Canadian Ophthalmological Society 2008) were selected from a number of available CPGs in the literature for cataract management. All recommendations of these guidelines, together with their references, were studied. Each recommendation was summarized in 4 tables. The first table showed the recommendation itself in clinical question components format along with its level of evidence. The second table contained structured abstracts of supporting articles related to the clinical question with their levels of evidence. The third table included the customized recommendation of the internal group respecting its clinical advantage, cost, and complications. In the fourth table, the internal group their recommendations from 1 to 9 based on the customizing capability of the recommendation (applicability, acceptability, external validity). Finally, customized recommendations were sent one month prior to a consensus session to faculty members of all universities across the country asking for their comments on recommendations.

Results:

The agreed recommendations were accepted as conclusive while those with no agreement were discussed at the consensus session. Finally, all customized recommendations were codified as 80 recommendations along with their sources and levels of evidence for the Iranian population.

Conclusion:

Customization of CPGs for management of adult cataract for the Iranian population seems to be useful for standardization of referral, diagnosis and treatment of patients.

Risk factors for endophthalmitis following cataract surgery-our experience at a tertiary eye care centre in India

AIM

To determine the risk factors for acute endophthalmitis after cataract extraction in a tertiary care centre in India.

METHODS

We performed a nested case control study within a retrospective cohort. The surgical records of all patients with clinically diagnosed endophthalmitis within one month after cataract surgery, performed between January 2006 and December 2009, were reviewed. These were compared with randomly selected age and gender-matched controls, from patients having routine cataract surgery within ±1wk of the endophthalmitis case. Univariable and multivariable analysis were performed to identify risk factors for endophthalmitis.

RESULTS

Of the total 33 856 cataract surgeries performed during this period, there were 57 cases of postoperative acute endophthalmitis that met our study criteria. Thus, the overall incidence of endophthalmitis in our cohort was 1.6 per 1000 cataract extractions performed. Mean age of cases was 55.9y (SD: 10.9y) and for controls was 55.6y (SD: 9.8y). Thirty-five cases (61.4%) and 133 controls (59.6%) were males. Median time of onset of endophthalmitis was 4d (IQR 2-9d; range: 1-30d). Thirty-nine cases (68.4%) presented within 7d and 27 cases (47.4%) were culture positive. Two hundred and twenty-three age and gender matched controls were selected. In multivariate analysis, endophthalmitis was associated with posterior capsular rupture (PCR) during surgery (OR 6.98, 95%CI: 2.22-21.98), phacoemulsification via scleral incision with a foldable intraocular lens (IOL) implantation (OR 3.02, 95%CI: 1.13-8.04) and ocular co-morbidity (OR 2.32, 95%CI: 1.11-4.87).

CONCLUSION

PCR, presence of ocular co-morbidity, and phacoemulsification via scleral incision with foldable-IOL were found to be independent risk factors for acute endophthalmitis.

Antibiotic prevention of postcataract endophthalmitis: a systematic review and meta-analysis

Endophthalmitis is one of the most feared complications after cataract surgery. The aim of this systematic review was to evaluate the effect of intracameral and topical antibiotics on the prevention of endophthalmitis after cataract surgery. A systematic literature review in the MEDLINE, CINAHL, Cochrane Library and EMBASE databases revealed one randomized trial and 17 observational studies concerning the prophylactic effect of intracameral antibiotic administration on the rate of endophthalmitis after cataract surgery. The effect of topical antibiotics on endophthalmitis rate was reported by one randomized trial and one observational study. The quality and design of the included studies were analysed using the Cochrane risk of bias tool. The quality of the evidence was evaluated using the GRADE approach. We found high-to-moderate quality evidence for a marked reduction in the risk of endophthalmitis with the use of intracameral antibiotic administration of cefazolin, cefuroxime and moxifloxacin, whereas no effect was found with the use of topical antibiotics or intracameral vancomycin. Endophthalmitis occurred on average in one of 2855 surgeries when intracameral antibiotics were used compared to one of 485 surgeries when intracameral antibiotics were not used. The relative risk (95% CI) of endophthalmitis was reduced to 0.12 (0.08; 0.18) when intracameral antibiotics were used. The difference was highly significant (p < 0.00001). Intracameral antibiotic therapy is the best choice for preventing endophthalmitis after cataract surgery. We did not find evidence to conclude that topical antibiotic therapy prevents endophthalmitis.

Benefits and risks of immediately sequential bilateral cataract surgery: a literature review

Immediately sequential bilateral cataract surgery (ISBCS) is a highly contended issue in ophthalmology, mainly due to the risk of bilateral endophthalmitis and financial penalties that many ophthalmologists face when performing simultaneous cataract surgeries. The purpose of this review is to understand the current status of the knowledge of ISBCS, mainly its benefits and risks and how they compare with the standard of care, delayed sequential bilateral cataract surgery. Evidence, although limited, increasingly supports ISBCS for providing faster rehabilitation, improved visual outcomes, and cost and time savings. Evidence does not support the fear of bilateral endophthalmitis resulting from the simultaneous procedure. However, stronger and greater evidence is needed before ISBCSs can be considered the standard of care. Where ISBCS can potentially create the most beneficial impact is in public eye health programmes in developing countries, but this has not yet been explored.

Long-term trends and outcomes of anterior vitrectomy in Western Australia

PURPOSE

To describe trends, risk factors and outcomes of anterior vitrectomy during cataract and intraocular lens (IOL) surgery.

METHODS

All patients 16 years and older undergoing cataract and IOL surgery in Western Australia (WA) from January 1980 to December 2001 (n = 115 815) were included. Hospital administrative data were used to identify all cataract and IOL procedures and subsequent admissions for retinal detachment, IOL dislocation, endophthalmitis and pseudophakic corneal oedema. Data were validated with chart review and analysed to identify trends and risk factors for anterior vitrectomy and the risk of subsequent complications.

RESULTS

In total, 1390 (1.2%) anterior vitrectomies were performed. The rate increased with change in surgical technique. Significant risk factors for anterior vitrectomy were age <50 years (OR 1.31), male sex (OR 1.23), IOL procedure (OR 11.45) and operations in public hospitals (OR 1.99) or rural/remote (OR 1.40) areas. Anterior vitrectomy was strongly associated with increased risk of retinal detachment (RD) (RR 18.5), endophthalmitis (RR 3.6), IOL dislocation (RR 21.1) and pseudophakic corneal oedema (RR 17.3). Retinal detachments and IOL dislocations occur earlier after anterior vitrectomy.

CONCLUSION

Anterior vitrectomy rates have remained stable since the introduction of phacoemulsification. Anterior vitrectomy is a major risk factor for serious complications compared with uncomplicated surgery, particularly RD and IOL dislocation. We identified an increasing trend in anterior vitrectomy being performed during extracapsular and IOL surgery.

Impact of intracameral cefuroxime on the incidence of postoperative endophthalmitis following cataract surgery in Ireland

BACKGROUND

Postoperative endophthalmitis (PE) is a rare complication of cataract surgery, but carries a significant risk of blindness. The European Society of Cataract and Refractive Surgeons published a landmark study in 2007 that revealed the use of intracameral cefuroxime as prophylaxis against endophthalmitis reduced its incidence by fivefold. Since the publication of these results, the use of intracameral cefuroxime in cataract surgery has become a standard practice in many institutions, including our own.

AIM

To identify the incidence rate of PE among patients undergoing cataract surgery over the 4-year period following the introduction of prophylactic intracameral cefuroxime for cataract surgery.

METHODS

A retrospective case note review of all cases of postoperative endophthalmitis that occurred between 2007 and 2011 was performed. Our results were compared with an earlier report on PE incidence rates from our institution that was conducted prior to the introduction of intracameral cefuroxime and published in 2001.

RESULTS

There were five reported cases of endophthalmitis from 2007 to 2011 from a total of 8,239 cataract procedures, giving an incidence rate of 0.06%. This compares with an incidence rate of 0.49% in the earlier study prior to the introduction of intracameral cefuroxime and represents an eightfold reduction in the incidence of PE at our hospital. Of the five cases, three were confirmed on culture and sensitivity (two of which were due to Coagulase negative staphylococci and one due to Pseudomonas aeruginosa).

CONCLUSION

The incidence of postoperative endophthalmitis has reduced by approximately eightfold since the introduction of intracameral cefuroxime following cataract surgery at our hospital in 2007. This study strongly supports the use of intracameral cefuroxime as prophylaxis against endophthalmitis in all cataract surgical cases.

A case-control study of post-operative endophthalmitis diagnosed at a Spanish hospital over a 13-year-period

A retrospective case-control study of patients who had undergone cataract extraction at a Spanish hospital over a 13-year period was conducted to identify the risk factors for developing post-operative endophthalmitis (POE). During the study period, the type of antibiotic prophylaxis was changed from subconjunctival gentamicin to the addition of both vancomycin and gentamicin to the irrigating solution. The overall incidence of POE was 0·19% (35 cases/18 287 operations). For the period prior to the change in antibiotic prophylaxis, the incidence rate of POE was 3·4 cases/1000 operations while in the latter period the incidence rate decreased to 0·34 cases/1000 operations. All patients who presented a virulent microorganism had a final visual acuity worse than 20/200. The only significant risk factor identified was the type of prophylaxis used (odds ratio 1·97, 95% confidence interval 0·94-4·14, P = 0·07). There were no significant differences between cases and controls although choice of surgeon approached significance.

Risk factors for acute endophthalmitis following cataract surgery: a systematic review and meta-analysis

Background

Acute endophthalmitis is one of the most serious complications of cataract surgery and often results in severe visual impairment. Several risk factors for acute postoperative endophthalmitis (POE) following cataract surgery have been reported but the level of evidence and strength of association is varied. The purpose of this study was to critically appraise published reports on and to summarize clinical risk factors associated with acute POE which could be easily assessed by ophthalmologists for the introduction and implementation of preventive measure.

Methods

A systematic review and meta-analysis of observational studies was performed. Six databases were searched with no limits on the year or language of publication. Study-specific odds ratios (Ors) or relative risk (RR) of each risk factor were pooled using a random effect model.

Results

A total of 6 686 169 participants with 8 963 endophthalmitis in 42 studies were analyzed. Of the nine risk factors identified in our systematic review and meta-analysis, extra- or intracapsular cataract extraction, a clear corneal incision, without intracameral cefazolin (1 mg in 0.1 ml solution), without intracameral cefuroxime (1 mg in 0.1 ml solution), post capsular rupture, silicone intraocular lenses and intraoperative complications were found strongly associated with acute endophthalmitis. Other significant factors with a lower strength of association (risk estimates generally 1.5 or less) were male gender and old age (85 years and older).

Conclusions

Our study provides summary data on the risk factors for acute POE. Identifying patients at high risk of this sight-threatening eye disease is important from both the public health and clinical perspectives as this would facilitate detection of disease before the onset of irreversible visual loss enabling earlier intervention.

Management strategies to reduce risk of postoperative infections

Postoperative infections, although rare, are still of great concern to the ophthalmologist. The incidence of post-cataract endophthalmitis is low, with a range of .28 per 1,000 to 2.99 per 1000. In addition to intraoperative considerations such as poor wound construction, vitreous loss, topical anesthesia, and prolonged surgical time, other risk factors include preoperative factors such as a diseased ocular surface and systemic immunosuppression. Potential methods of reducing risk of endophthalmitis after anterior segment surgery are discussed and available literature is summarized.

Role of topical, subconjunctival, intracameral, and irrigative antibiotics in cataract surgery

PURPOSE OF REVIEW

To summarize current understanding of antibiotic prophylaxis in cataract surgery, with particular emphasis on available evidence and change in practice patterns over the past decade.

RECENT FINDINGS

Povidone-iodine application prior to cataract surgery remains a universal practice, and is backed by good quality evidence. Subsequent to the results of the European multicenter trial documenting decreased risk of endophthalmitis with intracameral cefuroxime injection at the end of surgery, similar benefit with intracameral antibiotic use has been reported in studies with large sample sizes from multiple centers around the world. There has been a distinct change in practice patterns in many countries, with intracameral antibiotic use becoming part of routine protocol. In the USA, topical fluoroquinolone application remains the most popular mode of antibiotic prophylaxis. A promising approach is the development of novel drug delivery methods like polymeric devices designed for sustained antibiotic release.

SUMMARY

Based on current evidence, the recommended measures for endophthalmitis prophylaxis are preoperative topical instillation of povidone-iodine and intracameral antibiotic injection at the end of cataract surgery.

Endophthalmitis following cataract surgery: the role of prophylactic postoperative chloramphenicol eye drops

PURPOSE

The main aim of the study was to assess whether omitting prophylactic postoperative topical antibiotics (chloramphenicol) influenced the risk of developing endophthalmitis after cataract surgery.

METHODS

We conducted a retrospective study including all patients who had cataract surgery at our outpatient cataract unit between 2004 and 2011. Postoperative topical antibiotics (chloramphenicol) were omitted from 2007 onwards, as was the first postoperative day review. Patients with a diagnosis of endophthalmitis after cataract surgery were extracted, and the rate of postoperative endophthalmitis (PE) before and after changing these routines was compared. The diagnosis of PE was defined as severe intraocular inflammation requiring prompt vitreous sampling for culture.

RESULTS

Seven thousand one hundred and twenty-three and 8131 cataract surgeries were performed in the following periods: January 2004 through December 2006 (period 1) and January 2007 through December 2010 (period 2), respectively. Five cases of PE were identified in period 1 (0.070%) and four patients in period 2 (0.049%). The median time between cataract surgery and onset of symptoms was 6 days in period 1 and 4.5 days in period 2. Median time for intervention was 7 and 5 days postsurgery, respectively.

CONCLUSION

We found no difference in the frequency of PE following cataract surgery when changing the postoperative topical medication from a mixture of corticosteroids and antibiotics to only corticosteroids.

Postcataract surgery endophthalmitis in the United States: analysis of the complete 2003 to 2004 Medicare database of cataract surgeries

OBJECTIVE

To estimate endophthalmitis incidence after cataract surgery nationally and at the state level in 2003 and 2004 and to explore risk factors.

DESIGN

Analysis of Medicare beneficiary claims data.

PARTICIPANTS

We evaluated billed claims for cataract surgery and endophthalmitis diagnosis and treatment for all Medicare fee-for-service beneficiaries in 2003-2004.

METHODS

Cataract surgeries were identified by procedure codes and merged with demographic information. Cataract annual surgical volume was calculated for all surgeons. Presumed postoperative endophthalmitis cases were identified by International Classification of Diseases-9 Clinical Modification Codes on claims within 42 days after surgery. Endophthalmitis rates and 95% confidence intervals (CI) were calculated at state and national levels. Logistic regression was used to investigate the association between developing endophthalmitis and surgery location and surgeon factors.

MAIN OUTCOME MEASURES

Endophthalmitis incidence and risk factors.

RESULTS

We included 4006 cases of presumed endophthalmitis, which occurred after 3 280 966 cataract surgeries. The national rate in 2003 was 1.33 per 1000 surgeries (95% CI, 1.27-1.38) and decreased to 1.11 per 1000 (95% CI, 1.06-1.16) in 2004. Males (relative risk [RR], 1.23; 95% CI, 1.15-1.31), older individuals (RR, 1.53; 95% CI, 1.38-1.69; ≥85 compared with 65-74 years), blacks (RR, 1.17; 95% CI, 1.03-1.33), and Native Americans (RR, 1.72; 95% CI, 1.07-2.77) had increased risk of disease. After adjustment, surgeries by surgeons with low annual volume (RR, 3.80; 95% CI, 3.13-4.61 for 1-50 compared with ≥1001 annual surgeries) and less experience (RR, 1.41; 95% CI, 1.25-1.59 for 1-10 compared with ≥30 years), and surgeries performed in 2003 (RR, 1.20; 95% CI, 1.13-1.28) had increased endophthalmitis risk.

CONCLUSIONS

Endophthalmitis rates are lower than previous yearly US estimates, but remain higher than rates reported from a series of studies from Sweden; patient factors or methodologic differences may contribute to differences across countries. Patient age, gender, and race, and surgeon volume and years of experience are important risk factors.

Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis

This distillation of the peer-reviewed scientific literature on infection after cataract surgery summarizes background material on epidemiology, etiology, and pathogenesis, describes the roles of surgical technique and antibiotic prophylaxis in prevention, and discusses diagnostic and therapeutic interventions in cases of suspected endophthalmitis.

Efficacy and tolerability of a combined moxifloxacin/dexamethasone formulation for topical prophylaxis in phacoemulsification: an open-label single-arm clinical trial

Background. The use of a fixed-combination antibiotic corticosteroid for infection prophylaxis in Asian patients undergoing phacoemulsification has not been reported. Methods. A 15-day, open-label, single-arm trial of 64 patients for phacoemulsification with intraocular lens (IOL) implantation is described. Patients applied moxifloxacin 0.5%/dexamethasone 0.1% (Vigadexa) eye drops four times daily before and until 15 days after surgery. Anterior chamber (AC) reaction, visual acuity, ocular pain and signs, and intraocular pressure (IOP) were assessed at baseline and on postoperative days 1, 3, 8, and 15. Results. At day 15, 55 (91.7%) patients scored 0 (<5 cells) in AC reaction. No surgery-related infection occurred. Mean best-corrected visual acuity improved 0.5 logMAR from baseline to 0.0 logMAR (P < .0001). Mean IOP remained at 12-13 mm Hg over the 15-day treatment. Only 2 patients (3.1%) reported minimum ocular pain. Two (3.1%) patients were shifted to prednisolone acetate for severe inflammation. At the end of the study period, 8.3% were given fluorometholone for 1 week for AC reaction grade >0. No drug-related adverse event was reported. Conclusion. Following phacoemulsification and IOL implantation, the topical combination moxifloxacin 0.5%/dexamethasone 0.1% was effective in preventing infection and controlling inflammation and was well tolerated.

MRSA and cataract surgery - reflections for practice

INTRODUCTION

Postoperative bacterial endophthalmitis is a devastating complication of cataract surgery. Methicillin-resistant Staphylococcus aureus (MRSA) endophthalmitis is rare. Recent debate over MRSA screening in United Kingdom (UK) National Health Service (NHS) hospital services has implications for cataract patients and ophthalmology services.

AIMS

To discuss issues for clinical practice as based on reflective experience at a UK district general NHS hospital in relation to care of MRSA-positive cataract patients.

METHODS

Retrospective case series and reflective practice.

RESULTS

Three cases presented highlight practice points around cataract patients colonized with MRSA. Known or determined MRSA-colonized patients should be treated with anti-microbial agents at time of cataract surgery known to be active against MRSA. Preventative treatment with intracameral vancomycin or intravenous teicoplanin alongside appropriate topical treatments may be of merit. Importantly fluoroquinolones, often prescribed by cataract surgeons, may have a selective effect favoring the proliferation of MRSA.

CONCLUSION

MRSA screening may cause unnecessary delays in cataract care and may represent a patient safety concern in its own right. Patients colonized with MRSA may safely undergo cataract surgery provided there is no evidence of periorbital infection and provided appropriate infection control and antibiotic prophylaxis measures are used. The well-prepared cataract surgeon needs to be aware of developments in infection control and should liaise with local clinical microbiology colleagues in relation to bacterial resistance to antibiotics.

Prophylaxis of postoperative endophthalmitis following cataract surgery: current status and future directions

Endophthalmitis is an uncommon but potentially devastating intraocular infection that can occur after routine cataract surgery. Although a broad spectrum of organisms have been shown to cause acute postoperative endophthalmitis, most cases are caused by Gram-positive bacteria, which may be introduced at the time of surgery from colonization of adjacent conjunctiva or eyelid skin. Risk factors for the development of endophthalmitis following cataract surgery include patient age, intraoperative surgical complications and poor wound construction. There are several antibacterial strategies employed to prevent postoperative endophthalmitis, with topical, intracameral and subconjunctival delivery being the most common. Worldwide, there seems to be significant regional variance in the type and method of prophylactic antibacterial regimens; for example, topical fluoroquinolones are commonly used in the US, while intracameral cephalosporins are employed widely in Europe. The optimal antibacterial strategy for the prevention of endophthalmitis should be safe, inexpensive and broad in microbiological activity spectrum, while not requiring patient compliance for its effectiveness.

Complications of cataract surgery

Modern cataract surgery is safe in more than 95 per cent of patients. In the small number of cases where a serious complication occurs, the most common is an intra-operative posterior capsular rupture. This can lead to vitreous loss or a dropped nucleus and can increase the risk of post-operative cystoid macular oedema or retinal detachment. Post-operatively, posterior capsular opacification is the most common complication and can be readily treated with a YAG capsulotomy. The most devastating complication is endophthalmitis, the rate of which is now significantly decreased through the use of intracameral antibiotics. As a clinician, the most important step is to assess the patient pre-operatively to predict higher risk individuals and to counsel them appropriately. In these patients, various pre- or intra-operative management steps can be taken in addition to routine phacoemulsification to optimise their visual outcome.

Standing phacoemulsification: a prospective audit of 20 consecutive cases

PURPOSE

To audit the surgical and postoperative complications and the visual outcomes of standing phacoemulsification and compare these with the results of conventional seated phacoemulsification.

SETTING

District general hospital, Sidcup, England.

DESIGN

Prospective comparative case series.

METHODS

This prospective audit comprised consecutive patients having standing phacoemulsification; a control group was drawn from all conventional phacoemulsification procedures on the same operating lists. One eye per patient was included. Demographic and surgical data, complications, and preoperative and postoperative visual acuity and intraocular pressure were recorded. Paired and unpaired t tests were used to compare mean values, and the chi-square test with Yates correction or the Fisher exact test was used to compare frequencies.

RESULTS

Twenty patients requiring standing phacoemulsification and 89 control patients were enrolled over a 32-month period. The 2 groups were similar in characteristics except the standing group was younger (68.2 years versus 78.0 years) (P<.005) and had a longer axial length (23.8 mm versus 23.1 mm) (P<.05). No patient in the standing group and 6% of patients in the control group had operative complications, although the difference between groups was not statistically significant. The rates of postoperative complications were comparable. Pinhole-corrected distance visual acuity was similar (6/12 or better: 90% in standing group and 94% in control group; 6/6 or better: 55% and 44%, respectively). Best-case analyses were similar between groups (6/12 or better, 100% versus 98%; 6/6 or better, 58% versus 51%).

CONCLUSIONS

Standing phacoemulsification was as safe as conventional seated surgery when performed by the same experienced surgeon. Visual results were excellent.

Incidence of post-cataract endophthalmitis at Aravind Eye Hospital: outcomes of more than 42,000 consecutive cases using standardized sterilization and prophylaxis protocols

PURPOSE

To report the incidence of postoperative endophthalmitis at a high-volume eye hospital in southern India using a modified cost-effective sterilization protocol.

SETTING

Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India.

METHODS

In this retrospective observational series at a single eye hospital, records of patients who had cataract surgery using a modified sterilization protocol from January 2007 through August 2008 and developed postoperative endophthalmitis within the first 3 postoperative months were drawn from a computerized database. The patient's socioeconomic status, the surgeon's experience, and the type of cataract procedure performed were analyzed as possible risk factors using the chi-square test/Fischer exact test.

RESULTS

During the study period, 42426 cataract surgeries were performed. From these, 38 cases of presumed postoperative endophthalmitis were identified (incidence 0.09%). Thirty-five of the 38 cases were in the manual large- and small-incision extracapsular cataract extraction (ECCE) group, which had a statistically higher rate than the phacoemulsification group (P = .016). There was no statistical difference in the endophthalmitis rates between private patients and charity patients for either surgical method (manual ECCE or phacoemulsification).

CONCLUSIONS

The modified sterilization and asepsis protocol adopted to facilitate high-volume cataract surgery in a clinical setting appeared to be safe and effective in preventing postsurgical endophthalmitis. Despite a 3:1 ratio of manual ECCE to phacoemulsification and the elimination of certain traditional sterilization practices, the rate of endophthalmitis in this generally underserved patient population with multiple risk factors for infection was comparable to that reported in other modern settings.

Quality of life after postoperative endophthalmitis

PURPOSE

The aim of this study is to determine if postoperative endophthalmitis adversely affects quality of life after cataract surgery.

METHODS

We compared quality of life in patients who developed endophthalmitis after cataract surgery between 1 January and 31 December 2003 with those who had uncomplicated surgery. The National Eye Institute VFQ-25 (VFQ-25) and EuroQol EQ-5D (EQ-5D) questionnaires and time trade-off utility scores were used to compare self-perceived general health and vision-related quality of life between groups. Linear regression was used to model differences between groups after adjusting for age, gender and visual acuity in the better eye.

RESULTS

Nineteen postoperative endophthalmitis cases were compared with 30 who had uncomplicated cataract surgery. Following surgery the mean composite VFQ-25 score was 13.5% (95% confidence interval [CI]: 6.0-26.4, P < 0.01) lower in endophthalmitis cases. Endophthalmitis patients reported significantly lower (P < 0.05) general vision, near vision, peripheral vision, mental health and role difficulties subscales scores after adjusting for age, sex and visual acuity. No significant differences were found in other subscales. Mean time trade-off utility and all EQ-5D scores were similar except for mobility (95% CI: 0.04-0.68, P < 0.05).

CONCLUSIONS

Endophthalmitis after cataract surgery negatively impacts on self-perceived vision-related quality of life, resulting in poorer psychological well-being and ability to maintain a role in daily life.

Efficacy of intraoperative vancomycin in irrigating solutions on aqueous contamination during phacoemulsification

Purpose:

To study the efficacy of adding vancomycin in irrigating solutions, in comparison to topical antibiotic given preoperatively for a day, during phacoemulsification, in reducing the anterior chamber (AC) contamination.

Settings and Design:

This was a prospective, interventional, hospital-based study.

Materials and Methods:

This was a study involving 400 eyes of 400 paitens, undergoing routine phacoemulsification between January 2004 and June 2006. The patients were non-randomly assigned to two groups: Group 1 included 180 patients, who received topical ciprofloxacin eye-drops (four-hourly) for a day preoperatively and Group 2 included 220 patients, who underwent phacoemulsification with vancomycin (20 µg/ml) in the irrigating solution. Anterior chamber aspirate obtained at the end of the surgery was sent for microbial workup. The number of positive cultures in both the groups was determined.

Statistical analysis:

This was performed using Chi-square test.

Results:

Aqueous samples showed microbial growth in 38 (21.1%) out of 180 eyes in Group 1 and in 17 (7.7%) out of 220 eyes in Group 2 (P = 0.001). Coagulase-negative staphylococcus was the most common organism in both the groups. Aqueous samples from four eyes in group 1 showed multiple organisms, while none of the sample from group 2 showed more than one organism. None of the eyes in either group showed fungal contamination. One patient in Group 1 developed endophthalmitis, and the causative organism was Alcaligenes faecalis. All patients were followed up for a minimum of six months (range: 6 to 14 months and mean: 9.3 months).

Conclusion:

Addition of vancomycin in irrigating solutions is more efficacious in reducing AC contamination in comparison to topical antibiotic administered a day preoperatively.