Monte–Carlo simulation of random clustering of endophthalmitis following cataract surgery

The Royal College of Ophthalmologists' National Ophthalmology Database Study of Cataract Surgery: Report 13, monitoring post-cataract surgery endophthalmitis rates-the rule of X

BACKGROUND

Cataract surgical safety has improved over recent decades, with endophthalmitis rates before 2006 typically 0.13-0.15% compared with the most recent UK national estimate of 0.02%. There remains, however, substantial variation in reported rates from different centres. Due to the low event rate, this disparity may not be noticed and opportunities to improve therefore be missed. We propose a method of monitoring post-cataract endophthalmitis rates that would help centres with higher rates identify this.

METHODS

A statistical tool, available to download or use online, permits comparison of local endophthalmitis rate with the estimated UK rate of 0.02%. Centres are encouraged to maintain a register of endophthalmitis cases, and when the number reaches a threshold (X cases), either in a certain time period or in a fixed number of procedures, then the centre can consider itself as an outlier and trigger local investigations to improve infection control.

RESULTS

Example outputs are offered, such as for a unit doing 5000 cataracts annually, a value of X is suggested such that the third case of endophthalmitis (X = 3) in a 12-month period would give 85% confidence, the fourth case 90% confidence and the fifth case 95% confidence that the true endophthalmitis rate for that unit was higher than the national average.

CONCLUSIONS

This statistical tool provides a basis for units to set a threshold number of cases of endophthalmitis within a given period that would trigger local processes, thus helping inform local monitoring processes for this rare but potentially catastrophic complication of cataract surgery.

Clinical features of endophthalmitis clusters after cataract surgery and practical recommendations to mitigate risk: systematic review

Intraocular transmission of exogenous pathogens in cataract surgery can lead to endophthalmitis. This review evaluates the features of endophthalmitis clusters secondary to pathogen transmission in cataract surgery. Articles reporting on pathogen transmission in cataract surgery were identified via searches of Ovid MEDLINE, EMBASE, and Cochrane CENTRAL, and a total of 268 eyes from 24 studies were included. The most common source of infectious transmission was attributed to a contaminated intraocular solution (ie, irrigation solution, viscoelastic, or diluted antibiotic; n = 10). Visual acuity at presentation with infectious features was 1.89 logMAR (range: 1.35 to 2.58; ∼counting fingers) and 1.33 logMAR (range: 0.04 to 3.00; Snellen: ∼20/430) at last follow-up. Patients with diabetes had worse outcomes compared with patients without diabetes. The most frequently isolated pathogen from the infectious sources was Pseudomonas sp. (50.0%). This review highlights the various routes of pathogen transmission during cataract surgery and summarizes recommendations for the detection, prevention, and management of endophthalmitis clusters.

Outbreak of multidrug-resistant acute postoperative endophthalmitis due to Enterobacter aerogenes

PURPOSE

To report the clinical features, management, and outcome of 7 cases of culture-proven multidrug-resistant Enterobacter postoperative endophthalmitis following cataract surgery.

METHODS

Medical records of 7 cases of acute postoperative endophthalmitis after uneventful cataract surgery were reviewed. Details regarding age, gender, visual acuity and clinical features at presentation, microbiological profile, treatment interventions, and visual acuity and clinical features at 1 week, 1 month, and 3 months follow-up were collected.

RESULTS

All patients reported decreased visual acuity and pain as presenting symptoms. All patients were resistant to intravitreal antibiotics such as vancomycin (1 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL). Culture of aqueous and vitreous sample was positive for Enterobacter aerogenes and sensitive to co-trimoxazole, cefoperazone-sulbactam, imipenem-meropenem, and piperacillin-tazobactem. Two patients with panophthalmitis and no perception of light underwent evisceration. Three patients had visual acuity of ≥6/24 at the final follow-up.

CONCLUSION

Multidrug-resistant Enterobacter acute postoperative endophthalmitis has a poor prognosis if not intercepted early.

How to promote and preserve eyelid health

Disorders of the lacrimal functional unit are common in ophthalmological practice, with meibomian gland dysfunction, blepharitis, and dry eye forming a significant part of the general ophthalmologist’s practice. The eyelid and its associated structures form a complex organ designed to protect the fragile corneal surface and improve visual acuity. This organ is subject to a number of disorders, including meibomian gland dysfunction, dry eye syndrome, anterior blepharitis, allergic and dermatological conditions, and disorders associated with contact lens use. Although commonly described separately, disorders of the lacrimal function unit are better considered as a group of interacting pathologies that have inflammatory mediators as a central feature. Eyelid hygiene, in the sense of routine cleansing and massage of the eyelids, is well accepted in the management of many disorders of the eyelid. However, a broader concept of eyelid health may be appropriate, in which eyelid cleansing is but a part of a more complete program of care that includes screening and risk assessment, patient education, and coaching. The ophthalmologist has an important role to play in helping patients persist with routine eyelid care that may be long-term or lifelong. A number of preparations exist to make routine eyelid care both more effective and more pleasant, and might also improve compliance. Several such preparations have been devised, and are being assessed in clinical studies, and appear to be effective and preferred by patients over traditional soap and water or baby shampoo.