Endophthalmitis

Abstract

I read with great interest the excellent article in the April 2007 issue1Moshirfar M. Feiz V. Vitale A.T. et al.Endophthalmitis after uncomplicated cataract surgery with the use of fourth-generation fluoroquinolones A retrospective observational case series.Ophthalmology. 2007; 114: 686-691Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar on the rate of endophthalmitis after uncomplicated cataract surgery in patients treated with fourth-generation fluoroquinolone eyedrops. The authors noted that there were no differences between topical moxifloxacin- and gatifloxacin-treated groups in the incidence rate of endophthalmitis. The overall incidence in this article was 0.06% to 0.1% (about 1 in 1000), based on the clinical diagnosis. This study was a retrospective nonrandomized design, and cases with capsular rupture were excluded, which is a major risk factor for endophthalmitis. The reader needs to be aware that incidence rates can be reported as clinical diagnosis or as culture positive in the literature. The clinical diagnosis rate will always be greater because this term includes culture positive, toxic anterior segment syndrome, etc. In general, 50% to 80% of the time there is a positive culture for clinical cases. In an article I published recently, the incidence was even lower, 0.03% (1 in 3000) of culture positive comparing topical antibiotic versus no antibiotic before cataract surgery.2Bohigian G. A retrospective study of the incidence of culture-positive endophthalmitis after cataract surgery over a 14-year period (1990-2003) and the use of preoperative antibiotics.Ophthalmic Surg Lasers Imaging. 2007; 38: 103-106Crossref PubMed Scopus (9) Google Scholar There were no differences between the groups. This was also a retrospective nonrandomized study using a third-generation fluoroquinolone, ciprofloxacin. The point is to compare incidence rates of endophthalmitis and the definition carefully. Second, in the Moshirfar et al study there were 2 groups; however, there was no control group receiving a placebo. In an ideal scientific world there would be. The standard of care is becoming the use of preoperative antibiotics, mainly due to medicolegal concerns, animal models, and logical reasoning. It is difficult, even in an academic center and any clinical studies approved by an institutional review board, to do a pure scientific study with no treatment at all. I certainly understand this issue. However, do we really have any evidence-based studies that preoperative and postoperative antibiotics really do help? There are no good studies that demonstrate that the use of preoperative or postoperative antibiotics reduces the incidence of endophthalmitis in modern small-incision cataract surgery.3Liesegang T.J. Use of antimicrobials to prevent postoperative infection in patients with cataracts.Curr Opin Ophthalmol. 2001; 12: 68-74Crossref PubMed Scopus (64) Google Scholar It would be almost an impossible task to design a study in today’s world because of the low incidence of endophthalmitis, multiple factors, pharmaceutical companies’ product pushing, and the current medicolegal climate. Much of what we are urged to do is certainly based on logic and reasoning but not always evidence-based medicine. However, being logical does not mean it is true. Author replyOphthalmologyVol. 115Issue 2PreviewWe have reviewed the letter sent by Dr Bohigian. The author brought up 2 main points pertaining to the findings of our study regarding the rate of endophthalmitis after uncomplicated cataract surgery. Full-Text PDF