Endophthalmitis after Cataract Surgery

Abstract

Hatch et al1Hatch W.V. Cernat G. Wong D. et al.Risk factors for acute endophthalmitis after cataract surgery: a population based study.Ophthalmology. 2009; 116: 425-430Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar with their large population-based study has indeed produced several benchmark statistics in the context of prevention of endophthalmitis after cataract surgery. The incidence of endophthalmitis in their cohort was 1.4 per 1000. This was compared with that of Lundstorm et al2Lundstrom M. Wejde G. Stenevi U. et al.Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location.Ophthalmology. 2007; 114: 866-870Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar who reported an incidence of 0.5 per 1000 in a cohort of over 225 000 cataract surgeries over a similar period. Hatch et al1Hatch W.V. Cernat G. Wong D. et al.Risk factors for acute endophthalmitis after cataract surgery: a population based study.Ophthalmology. 2009; 116: 425-430Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar attribute this lower incidence to study methodology, case mix, surgical technique, surgeon volume, and the definition of endophthalmitis. It is not clear in the article by Hatch et al1Hatch W.V. Cernat G. Wong D. et al.Risk factors for acute endophthalmitis after cataract surgery: a population based study.Ophthalmology. 2009; 116: 425-430Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar if intracameral antibiotics have been used as a prophylactic measure against endophthalmitis. In the Swedish study, 99% of cataract surgeries had intracameral cefuroxime. Multiple logistic regression analysis of this data showed statistically significant increased incidence of postoperative endophthalmitis when intracameral cefuroxime was not used. Majority of these cataract surgeries did not receive pre- or postoperative topical antibiotics. The National Cataract Registry of Sweden noted a reduction in the incidence of endophthalmitis following cataract surgery from 0.1% in 1998 to the current level of 0.05%. This is attributed to the uniform adoption of prophylactic intracameral cefuroxime.The higher incidence of presumed endophthalmitis in the study by Hatch et al1Hatch W.V. Cernat G. Wong D. et al.Risk factors for acute endophthalmitis after cataract surgery: a population based study.Ophthalmology. 2009; 116: 425-430Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar was statistically significant (chi square-113; P <0.0001) when compared with that by Lundstorm et al.2Lundstrom M. Wejde G. Stenevi U. et al.Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location.Ophthalmology. 2007; 114: 866-870Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar The relative risk without intracameral antibiotics is 2.9 (95% confidence interval, 2.4–3.5). Thus, the difference in incidences of endophthalmitis between these 2 studies may be due to intracameral antibiotics rather than differences in methodology, case mix, surgical technique, surgeon volume, and definition of endophthalmitis. Several smaller European studies report low incidences of postoperative endophthalmitis, similar to the study by Lundstorm et al2Lundstrom M. Wejde G. Stenevi U. et al.Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location.Ophthalmology. 2007; 114: 866-870Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar (Figure 1, available at http://aaojournal.org).Prophylaxis against postoperative endophthalmitis has evolved in the last decade, with increasing number of studies reporting a reduction in the incidence of endophthalmitis on using intracameral antibiotics. The randomized, partially masked, multicenter study by Barry et al3Barry P. Seal D.V. Gettinby G. et al.ESCRS Endophthalmitis Study GroupESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: preliminary report of principal results from a European multicenter study.J Cataract Refract Surg. 2006; 32: 407-410Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar provides strong evidence of significant reduction in the cases of postoperartive endophthalmitis in patients receiving intracameral cefuroxime compared with those receiving topical quinolones postoperatively. Lack of subconunctival arm and choice of antibiotic are criticisms against this study. Other concerns against intracameral antibiotics use are toxicity to corneal endothelial cells and lack of readily prepared antibiotic formulations. Yoeruek et al4Yoeruek E. Spitzer M.S. Saygili O. et al.Comparison of in vitro safety profiles of vancomycin and cefuroxime on human corneal endothelial cells for intracameral use.J Cataract Refract Surg. 2008; 34: 2139-2145Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar studying the toxic effects of cefuroxime and vancomycin on human corneal endothelial cells found them safe in clinically used concentrations. Recently, the role of moxifloxacin has been investigated as a better choice for intracameral antibiotic prophylaxis, due to its broader antimicrobial actions. However, so far safety studies are available only on animal models.A 2007 survey of the American Society of Cataract and Refractive Surgery members found that 77% of respondents were not using intracameral antibiotics as a prophylactic measure against postoperative endophthalmitis.5Chang D.F. Braga-Mele R. Mamalis N. et al.Prophylaxis of postoperative endophtalmitis after cataract surgery: results of the 2007 ASCRS member survey.J Cataract Refract Surg. 2007; 33: 1801-1805Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar A major concern among the respondents was lack of commercially available antibiotic preparation appropriate for intracameral use. In a United Kingdom survey,6Gore D.M. Angunawela R.I. Little B.C. United Kingdom survey of antibiotic prophylaxis practice after publication of the ESCRS Endophthalmitis Study.J Cataract Refract Surg. 2009; 35: 770-773Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar 61% of respondents did not use intracameral antibiotics as a routine prophylactic measure to prevent endophthalmitis due to similar concerns.In summary, there is strong research evidence that intracameral antibiotic prophylaxis reduces the incidence of endophthalmitis after cataract surgery. Despite this evidence, there is reluctance to accept this practice. To date, none of the studies have reported toxic corneal effects due to intracameral antibiotics. In view of the clear protective effect on prevention of postoperative endophthalmitis, ophthalmologists need to accept the positive role of intracameral antibiotics and adopt it in practice. Not giving intracameral antibiotics after cataract surgery should be considered as a risk for development of endophthalmitis. Hatch et al1Hatch W.V. Cernat G. Wong D. et al.Risk factors for acute endophthalmitis after cataract surgery: a population based study.Ophthalmology. 2009; 116: 425-430Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar with their large population-based study has indeed produced several benchmark statistics in the context of prevention of endophthalmitis after cataract surgery. The incidence of endophthalmitis in their cohort was 1.4 per 1000. This was compared with that of Lundstorm et al2Lundstrom M. Wejde G. Stenevi U. et al.Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location.Ophthalmology. 2007; 114: 866-870Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar who reported an incidence of 0.5 per 1000 in a cohort of over 225 000 cataract surgeries over a similar period. Hatch et al1Hatch W.V. Cernat G. Wong D. et al.Risk factors for acute endophthalmitis after cataract surgery: a population based study.Ophthalmology. 2009; 116: 425-430Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar attribute this lower incidence to study methodology, case mix, surgical technique, surgeon volume, and the definition of endophthalmitis. It is not clear in the article by Hatch et al1Hatch W.V. Cernat G. Wong D. et al.Risk factors for acute endophthalmitis after cataract surgery: a population based study.Ophthalmology. 2009; 116: 425-430Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar if intracameral antibiotics have been used as a prophylactic measure against endophthalmitis. In the Swedish study, 99% of cataract surgeries had intracameral cefuroxime. Multiple logistic regression analysis of this data showed statistically significant increased incidence of postoperative endophthalmitis when intracameral cefuroxime was not used. Majority of these cataract surgeries did not receive pre- or postoperative topical antibiotics. The National Cataract Registry of Sweden noted a reduction in the incidence of endophthalmitis following cataract surgery from 0.1% in 1998 to the current level of 0.05%. This is attributed to the uniform adoption of prophylactic intracameral cefuroxime. The higher incidence of presumed endophthalmitis in the study by Hatch et al1Hatch W.V. Cernat G. Wong D. et al.Risk factors for acute endophthalmitis after cataract surgery: a population based study.Ophthalmology. 2009; 116: 425-430Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar was statistically significant (chi square-113; P <0.0001) when compared with that by Lundstorm et al.2Lundstrom M. Wejde G. Stenevi U. et al.Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location.Ophthalmology. 2007; 114: 866-870Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar The relative risk without intracameral antibiotics is 2.9 (95% confidence interval, 2.4–3.5). Thus, the difference in incidences of endophthalmitis between these 2 studies may be due to intracameral antibiotics rather than differences in methodology, case mix, surgical technique, surgeon volume, and definition of endophthalmitis. Several smaller European studies report low incidences of postoperative endophthalmitis, similar to the study by Lundstorm et al2Lundstrom M. Wejde G. Stenevi U. et al.Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location.Ophthalmology. 2007; 114: 866-870Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar (Figure 1, available at http://aaojournal.org). Prophylaxis against postoperative endophthalmitis has evolved in the last decade, with increasing number of studies reporting a reduction in the incidence of endophthalmitis on using intracameral antibiotics. The randomized, partially masked, multicenter study by Barry et al3Barry P. Seal D.V. Gettinby G. et al.ESCRS Endophthalmitis Study GroupESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: preliminary report of principal results from a European multicenter study.J Cataract Refract Surg. 2006; 32: 407-410Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar provides strong evidence of significant reduction in the cases of postoperartive endophthalmitis in patients receiving intracameral cefuroxime compared with those receiving topical quinolones postoperatively. Lack of subconunctival arm and choice of antibiotic are criticisms against this study. Other concerns against intracameral antibiotics use are toxicity to corneal endothelial cells and lack of readily prepared antibiotic formulations. Yoeruek et al4Yoeruek E. Spitzer M.S. Saygili O. et al.Comparison of in vitro safety profiles of vancomycin and cefuroxime on human corneal endothelial cells for intracameral use.J Cataract Refract Surg. 2008; 34: 2139-2145Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar studying the toxic effects of cefuroxime and vancomycin on human corneal endothelial cells found them safe in clinically used concentrations. Recently, the role of moxifloxacin has been investigated as a better choice for intracameral antibiotic prophylaxis, due to its broader antimicrobial actions. However, so far safety studies are available only on animal models. A 2007 survey of the American Society of Cataract and Refractive Surgery members found that 77% of respondents were not using intracameral antibiotics as a prophylactic measure against postoperative endophthalmitis.5Chang D.F. Braga-Mele R. Mamalis N. et al.Prophylaxis of postoperative endophtalmitis after cataract surgery: results of the 2007 ASCRS member survey.J Cataract Refract Surg. 2007; 33: 1801-1805Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar A major concern among the respondents was lack of commercially available antibiotic preparation appropriate for intracameral use. In a United Kingdom survey,6Gore D.M. Angunawela R.I. Little B.C. United Kingdom survey of antibiotic prophylaxis practice after publication of the ESCRS Endophthalmitis Study.J Cataract Refract Surg. 2009; 35: 770-773Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar 61% of respondents did not use intracameral antibiotics as a routine prophylactic measure to prevent endophthalmitis due to similar concerns. In summary, there is strong research evidence that intracameral antibiotic prophylaxis reduces the incidence of endophthalmitis after cataract surgery. Despite this evidence, there is reluctance to accept this practice. To date, none of the studies have reported toxic corneal effects due to intracameral antibiotics. In view of the clear protective effect on prevention of postoperative endophthalmitis, ophthalmologists need to accept the positive role of intracameral antibiotics and adopt it in practice. Not giving intracameral antibiotics after cataract surgery should be considered as a risk for development of endophthalmitis. Appendix Endophthalmitis after Cataract Surgery: A Nationwide Prospective Study Evaluating Incidence in Relation to Incision Type and LocationOphthalmologyVol. 114Issue 5PreviewTo establish the nationwide rate of postoperative endophthalmitis (PE) after cataract extraction (CE) and to study the relationship between PE and type of incision and other possible risk factors. Full-Text PDF Risk Factors for Acute Endophthalmitis after Cataract Surgery: A Population-based StudyOphthalmologyVol. 116Issue 3PreviewTo identify risk factors for suspected acute endophthalmitis after cataract surgery. Full-Text PDF Author replyOphthalmologyVol. 117Issue 4PreviewOur study used administrative data to estimate the rate of acute suspected endophthalmitis in Ontario, Canada. From over 440 000 consecutive cataract cases between 2002 and 2006, we found a rate of 1.4 per 1000.1 Excluding cases that were in combination with any eye procedure other than anterior vitrectomy on the same day reduced the rate to 1.18 per 1000. In comparison, Lundstrom et al2 found a rate of 0.48 per 1000 between 2002 and 2004 in their sample of over 225 000 cases in Sweden. Full-Text PDF Author replyOphthalmologyVol. 117Issue 4PreviewWe fully agree with Dr Deepa Anijeet's opinion regarding the value of intracameral antibiotics with reference to the article by Hatch et al.1 Dr Anijeet makes the assumption that diverging prophylactic practices are responsible for the statistically significant differences in endophthalmitis rates found between the Ontario study (1.4 per 1000 operations) by Hatch et al1 and a cited all-Swedish study (0.48 per 1000 operations) coming from our group.2 Since the Ontario investigation makes no mention of the prophylactic protocols used, the assumption cannot be confirmed. Full-Text PDF