Association of hospital and surgeon operation volume with the incidence of postoperative endophthalmitis: Taiwan experience

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.

A Composite Risk Score for Capsule Complications Based on Data from the Swedish National Cataract Register: Relation to Surgery Volumes

PURPOSE

To investigate case mix in relation to capsule complication, possible associations between case mix and operation volume, and change in case mix over time.

DESIGN

Register-based study.

PARTICIPANTS

Swedish patients who underwent cataract surgery between 2007 and 2016.

METHODS

Demographics and data on ocular comorbidity, intraoperative difficulties, and capsule complications were registered from 2007 to 2016 and analyzed retrospectively in relation to coded data on individual surgeons' operation volume. Single factor analysis and logistic regression were performed, and a composite risk score was created.

MAIN OUTCOME MEASURES

Risk of capsule complication, given as adjusted and composite odds ratio in relation to cataract surgery volume.

RESULTS

Preoperative and intraoperative variables significantly associated with capsule complications were best-corrected visual acuity (BCVA) ≤0.1 (decimal, adjusted odds ratio [aOR], 1.82; P < 0.001); pseudoexfoliation (PEX) (aOR, 1.53; P < 0.001); sight-threatening ocular comorbidity other than age-related macular degeneration (AMD), diabetic retinopathy, glaucoma, or cornea guttata (aOR, 1.35; P = 0.006); use of Trypan blue (aOR, 1.76; P < 0.001); mechanical pupil dilation (aOR, 1.36; P = 0.024); and iris hooks at the rhexis margin (aOR, 6.99; P < 0.001). The composite risk score was 3.09 ± 6.40 (mean ± standard deviation) for patients with capsule complication and 1.28 ± 1.66 for uncomplicated procedures (P < 0.001). High-volume cataract surgeons (≥500 procedures yearly) had a significantly lower composite risk score (mean risk score ≤1.28; range, 1.01-2.02) compared with low- and medium-volume cataract surgeons (1.34 ± 0.56; range, 1.00-4.55 and 1.49 ± 0.58; range, 1.01-5.19), respectively. During the period 2007-2016, the proportion of patients aged >88 years, patients with BCVA ≤0.1, and patients with intraoperative difficulties decreased.

CONCLUSIONS

Case mix, as calculated from a composite risk score based on preoperative and intraoperative parameters registered in the National Cataract Register (NCR), may contribute to the decrease in capsule complications from 2007 to 2016 and the lower complication rate observed in cases managed by high-volume cataract surgeons.

The effects of cement fixation on survival in elderly patients with hip hemiarthroplasty: a nationwide cohort study

BACKGROUND

Hip hemiarthroplasty (HHA) is a common treatment for hip fractures in the elderly population. Because of the fatal effects of bone cement implantation syndrome, the safety of cement utilization to enhance implant firmness in the femur is controversial. The aim of this study was to investigate the postoperative survival of elderly patients receiving HHA with and without cement fixation.

METHODS

Claim data from the National Health Insurance Database and the National Register of Deaths Database were used for analysis in this retrospective cohort study. From 2008 to 2014, 25,862 patients aged 80 years or older treated with hip hemiarthroplasty were included in the analysis. A Cox proportional risk model was used to analyse the effects of cement utilization on postoperative mortality.

RESULTS

The cemented group had a significantly higher mortality risk than the non-cemented group within 7, 30, 180 days and 1 year after the operation. The effect of bone cement on postoperative mortality was significantly stronger within 7 days than within 30, 180 days and 1 year. In addition, the male gender, age > 85 years and higher score on the Charlson Comorbidity Index were also risk factors for mortality (p < 0.05). Patients who received HHA in lower-volume hospitals had higher mortality rates within 180 days and 1 year than those in higher-volume hospitals. Compared with patients who were operated on by high-volume surgeons, those who received surgery performed by lower-volume surgeons were more likely to die within 30 days (aHR = 1.22), 180 days (aHR = 1.16) and 1 year (aHR = 1.19), respectively.

CONCLUSIONS

The postoperative mortality rate of elderly patients undergoing HHA was significantly higher in the cemented group than in the non-cemented group.

Acute postcataract endophthalmitis at a referral center in northern Taiwan: Causative organisms, clinical features, and visual acuity outcomes after treatment: A retrospective cohort study

Acute-onset endophthalmitis after cataract surgery is a rare but serious complication. In this study, we identified the clinical profile of acute-onset endophthalmitis after cataract surgery using a retrospective review between January 1, 2009 and December 31, 2015 at a referral center in northern Taiwan. Twenty-five eyes of 25 patients with endophthalmitis were included; 60% were male. The mean age at diagnosis was 70.44 ± 1.66 years. The right eye was affected in 44% of patients. The mean time of cataract surgery to hospital was 12.76 ± 1.88 days. The mean time from the onset of endophthalmitis to hospital was 3.72 ± 0.78 days. Furthermore, 56% of patients received the immediate treatment of an intracameral or intravitreal injection of antibiotics at a clinic before referral. The mean initial visual acuity was 1.97 ± 0.15 logarithm of the minimum angle of resolution. The initial examination found corneal edema in 84% of patients, hypopyon in 48%, and vitritis in 88%. A total of 76% of patients underwent an initial treatment of pars plana vitrectomy and intraocular antibiotic injection (IOAI); 24% received an IOAI. The culture results of 52% (13/25) of patients were positive; 4 isolates were gram-positive, 8 were nontuberculosis Mycobacterium abscessus, and 1 was fungal. Thirteen of 25 patients had hypertension; 2 of 25 had diabetes mellitus. The mean follow-up time was 61.64 ± 8.27 days. Multiple factors influenced the final visual outcome of acute-onset endophthalmitis after cataract surgery. This study found that early referral for treatment could improve the final outcome. In addition, postcataract endophthalmitis caused by M abscessus recurs easily and has a worse visual outcome despite appropriate treatment.

Relationship between anesthesia and postoperative endophthalmitis: A retrospective study

Previous study showed that patients under general anesthesia (GA) had nasopharyngeal secretions on the face at the end of ocular surgery, especially in propofol-based total intravenous anesthesia (TIVA), it might induce postoperative endophthalmitis. Therefore, we conducted a retrospective study to compare the incidence of endophthalmitis after ocular surgery under topical, inhalation anesthesia, and propofol-based TIVA in our medical center from 2011 to 2015.A total of 21,032 patients were included, and we evaluated epidemiologic factors, systemic diseases, other ocular pathologic characteristics, complications during the surgery, technique of ocular surgery, method of antibiotic prophylaxis, vitreous culture, and vision outcome in these patients.Fifteen endophthalmitis cases among 21,032 operations reported, equaling an incidence of 0.071%. The incidence rates under topical, inhalation anesthesia, and propofol-based TIVA were 0.083%, 0.039%, and 0%, respectively (P = 0.39). Moreover, the risk of endophthalmitis under GA (0.024%) was significantly lower than topical anesthesia (0.083%) (P < 0.001). We also found that elder was the risk factor for endophthalmitis following ocular surgery.In conclusion, propofol-based TIVA or inhalation anesthesia did not increase the risk of endophthalmitis after ocular surgery. Thus, GA was not a risk factor for postoperative endophthalmitis. By contrast, elder was the risk factor for postoperative endophthalmitis.

Postcataract endophthalmitis prophylaxis using irrigation, incision hydration, and eye pressurization with vancomycin

PURPOSE

This study aimed to determine whether switching from balanced salt solution (BSS) to vancomycin 20 g/mL BSS for incision hydration and eye pressurization reduces the rate of postcataract endophthalmitis.

METHODS

This was a patient safety/quality improvement project, including all patients undergoing cataract surgery at the Kaiser Permanente Colorado Ophthalmology Department from January 2002 to December 2014. Throughout the study, patients received vancomycin 20 μg/mL in the irrigating solution. During the baseline period from 2002 to 2005, surgeons pressurized eyes and hydrated incisions with plain BSS. During the intervention period from 2006 through 2014, surgeons switched from BSS to the vancomycin/BSS irrigating solution for eye pressurization and incision hydration.

RESULTS

A total of 57,263 cataract operations were performed by 24 surgeons at seven surgical centers: 12,400 in the baseline period and 44,863 in the intervention period. The rate of post-cataract endophthalmitis declined significantly from 5/12,400 (rate: 0.4/1,000) in the baseline period to 1/44,863 (rate: 0.022/1,000) during the intervention period (odds ratio [OR]: 18.1, 95% confidence interval [CI]: 2.11-154.9; χ (2)=13.5, P=0.00024). Accounting for an estimated 2.05-fold risk reduction due to confounding variables, the risk reduction attributed to the intervention remained significant: (adjusted OR: 8.78, 95% CI: 1.73-44.5; χ (2)=10.06, P=0.0015). Since 2009, we have not experienced any cases of postcataract endophthalmitis after 32,753 operations.

CONCLUSION

We experienced a significant reduction in postcataract endophthalmitis when we switched from BSS to the vancomycin/BSS irrigating solution for incision hydration and eye pressurization. The pharmacokinetics profile indicates that this switch was important for effective prophylaxis.

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.

Antibiotic resistance in acute postoperative endophthalmitis

Acute postoperative endophthalmitis (APE) is a serious, although infrequent, complication of eye surgery that can result in significant morbidity and costs. This review addresses APE risk factors, associated bacterial pathogens, antibiotic resistance, and prevention.

Serious adverse events after cataract surgery

PURPOSE OF REVIEW

Over the past several decades, there have been many advances in the equipment, instrumentation and techniques of performing cataract surgery. This review will address the impact of these advances on the safety profile of cataract surgery.

RECENT FINDINGS

Recent studies have demonstrated a decline in the risk of serious postoperative adverse events (endophthalmitis, suprachoroidal hemorrhage, retinal detachment) following cataract surgery. Factors that increase the risk of serious complications from cataract surgery include patient-related factors (male sex, concomitant diabetic retinopathy, same day cataract surgery combined with another intraocular surgery, tamsulosin use) and surgeon-related factors (low surgical volume, limited experience, operating on patients who are most prone to adverse events).

SUMMARY

Cataract surgery continues to be a very well tolerated surgical procedure with few patients experiencing serious sight-threatening adverse events. Studies in the literature have helped surgeons identify patients who are at high risk for surgical complications and develop strategies to limit surgical complications when operating on these patients. As multifocal intraocular lenses, femtosecond laser technology, and other surgical innovations continue to gain popularity, it will be interesting in the coming years to determine whether there will be a continued reduction in complications of cataract surgery.

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.

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.

Incidence of endophthalmitis after cataract surgery in Japan

PURPOSE

To estimate the incidence rate of endophthalmitis after cataract surgery performed by Japanese surgeons.

METHODS

A sample of 20% of members of the Japanese Society of Ophthalmic Surgeons was randomly selected. Each member was sent a postal survey asking for information on the number of cataract surgeries performed in 2003 and the number of postsurgery cases of endophthalmitis.

RESULTS

Replies were received from 78.7% (513/652) of survey recipients. The total number of cataract surgeries was 100 539, among which 52 cases of endophthalmitis occurred, resulting in an overall incidence rate of 0.052%. Incidence rates were 0.049% (38/78 170) for scleral incision phacoemulsification and 0.043% (9/20 894) for clear corneal incision phacoemulsification, with no significant difference between groups. The average annual volumes of surgery were 210 and 280 cases for surgeons who preferred scleral incision and clear corneal incision, respectively. There was a significant difference between volumes (Student's t-test, p < 0.01). The incidence of endophthalmitis was significantly lower with high-volume (> 300 cases/year) surgeons than with low-volume (< or = 300 cases/year) surgeons (0.040% versus 0.066%, chi-square test, p < 0.05).

CONCLUSIONS

The incidence of endophthalmitis after cataract surgery in Japan as estimated by a postal survey was low (0.052%) and consistent with rates reported previously. Surgeons who preferred clear corneal incision performed significantly more surgeries annually, but the incidence of endophthalmitis was similar between scleral and clear corneal incision phacoemulsification surgery.

Visual Outcomes and Associated Risk Factors of Cataract Surgeries in Highly Myopic Taiwanese

AIMS

The purposes of this study are to describe the visual outcome of highly myopic eyes undergoing cataract surgery, to investigate associated risk factors for poor postoperative vision and to assess the postoperative complication frequency among the myopic Taiwanese population.

METHODS

We conducted a retrospective, noncomparative case series study at the Department of Ophthalmology, Zhongxing Branch, Taipei City Hospital, Taiwan. High myopia was defined as axial length > or =26.0 mm. The main study outcomes were visual acuity for the initial 6-month postoperative period (including visual acuities and improvement of postoperative vision) and postoperative complications (including subsequent cataract formation and postoperative retinal detachment).

RESULTS

Fifty-two highly myopic eyes were enrolled between January 2002 and December 2004. The mean follow-up interval was 43.3 +/- 20.2 weeks (range 25-103). Thirty-two eyes (61.5%) had good postoperative visual improvement (> or =4 lines of Snellen chart). Thirty-seven eyes (71.2%) achieved good postoperative vision (20/40 or better). Fifteen eyes (28.8%) demonstrated poor postoperative vision. Pre-existing maculopathy was an independent risk factor for failure to achieve good postoperative vision [odds ratio (OR): 6.84, 95% confidence interval (CI): 1.12-41.8] and improvement (OR: 16.1, 95% CI: 2.2-119.9). Diabetic history was considered another independent risk factor for poor postoperative vision (OR: 15.6, 95% CI: 0.97-267.6). Six eyes (11.5%) developed subsequent posterior capsular opacification requiring Nd:YAG laser capsulotomy. Two eyes (3.8%) developed retinal detachment during follow-up.

CONCLUSIONS

Most highly myopic eyes achieved good visual improvement and good postoperative visual acuity after cataract surgery. Pre-existing maculopathy was an independent risk factor of postoperative visual improvement and status. It is crucial to examine retinal status prior to cataract surgery to prevent poor vision improvement, poor postoperative vision or retinal complications.