Prevention of endophthalmitis

Abstract

We congratulate Buzard and Liapis1 on the absence of endophthalmitis following cataract surgery in their series of 5131 patients. The authors attributed this achievement to 4 factors: povidone–iodine prophylaxis, meticulous draping of the eyes, blue-line incision, and postoperative subconjunctival antibiotic injections. We would like to raise several points that may broaden the discussion. First, the lack of a control group in this retrospective study made it difficult to conclude which surgical steps effectively reduced the rate of endophthalmitis. The presumptive factors suggested by the authors were based solely on evidence from existing literature, together with logical deduction. Second, the 4 factors are commonly practiced perioperative routines. Montan and coauthors2 and Aaberg and coauthors3 have shown that the combination of these factors can effectively reduce the occurrence of postcataract endophthalmitis. However, the zero endophthalmitis rate reported in Buzard and Liapis' series compares favorably with the rate reported by Montan and coauthors (0.20%) and Aaberg and coauthors (0.09%). This suggests additional factors may account for this unusually low endophthalmitis rate. We would like to point out that all 5131 cataract surgeries were done by the same surgeon. This may contribute to the unusually low endophthalmitis rate in the study. Buzard took “meticulous” care in the surgical steps, including preoperative disinfection and draping. In addition, the mean surgery time was 10 minutes. These factors may be the reasons the results in this series stand out from those in other studies. While we fully agree with the authors that the 4 factors mentioned are critical in preventing postcataract endophthalmitis, their series of patients is a very good example that the already low incidence of endophthalmitis can be reduced further or even to zero when coupled with optimal surgical setting and excellent surgical skills provided that strict and meticulous surgical guidelines are followed. Wico W. Lai MD, FACS Hoi Fan MBBS Srinivas K. Rao FRCS Dennis S.C. Lam MD, FRCS Hong Kong, China