Incidence Of Postoperative Endophthalmitis Research Articles

Endophthalmitis following cataract surgery and effect of different intracameral antibiotic regimes in Sweden 2011 - 2017. A national registry study.

To study the incidence, predictive factors, aetiology and visual consequences of postoperative endophthalmitis (PE) in relation to three intracameral antibiotic regimes. Swedish National Cataract Register (NCR) entries from 2011 through 2017. Observational retrospective study. PE incidence, influencing factors, bacteriology and visual outcome were analyzed with regard to the three major prophylactic IC protocols. The overall incidence of PE was 0.023% or 177 cases in 764 513 cataract procedures. Analyzed per intracameral regime, the rates of PE were 0.024% (126 cases in 514 916 surgeries) for cefuroxime, 0.020% (25 cases in 122 340 surgeries) for moxifloxacin and 0.017% (20 cases in 121 045 surgeries) for combined cefuroxime-ampicillin. Incidences were not statistically significantly different from one another. Gram-positive bacteria caused 89.0% of culture positive cases. Enterococci as pathogens were significantly more frequent with intracameral cefuroxime than with moxifloxacin, p = 0.006 or cefuroxime-ampicillin, p < 0.001, while streptococci other than enterococci were more common with moxifloxacin than with cefuroxime, p < 0.001. Bacterial susceptibility to the given antibiotics was demonstrated in 21.3% of PE cases treated with cefuroxime, which was statistically significantly lower than proportions found with cefuroxime-ampicillin, 60.0%, p = 0.015, or with moxifloxacin, 88.2%, p < 0.001. Visual outcome worse than 20/200 were similar in the groups ranging from 42.0% to 53.7%. No statistically significant differences in PE incidence or visual outcome results between treatment groups were demonstrated. However, differences in aetiology and bacterial sensitivity were found between the prophylactic intracameral treatments.

Early Endophthalmitis Incidence and Risk Factors after Glaucoma Surgery in the Medicare Population from 2016 to 2019

To determine early endophthalmitis incidence and risk factors after glaucoma surgeries in the Medicare population. Retrospective, longitudinal study. Medicare Fee-for-Service (FFS) and Medicare Advantage beneficiaries in the United States aged 65 years or older undergoing glaucoma surgery. Medicare claims were used to identify all patients who underwent glaucoma, cataract, or combined cataract/glaucoma surgery from 2016 to 2019. Endophthalmitis cases within 42 days of the index surgery were identified using the diagnostic codes. Multivariable logistic regression models were used to evaluate factors associated with postoperative endophthalmitis. The 42-day postoperative endophthalmitis incidence and risk factors associated with endophthalmitis after glaucoma surgery. There were 466 928 glaucoma surgeries, of which 310 823 (66.6%) were combined with cataract surgery. Cataract surgeries alone (n= 8 460 360) served as a reference group. Microinvasive glaucoma surgeries constituted most glaucoma procedures performed (67.8%), followed by trabeculectomy (14.0%), tube shunt (10.9%), and other procedures (7.3%). There were 572 cases of endophthalmitis identified after all glaucoma surgeries. Endophthalmitis incidence after glaucoma, combined cataract/glaucoma, and cataract surgeries alone was 1.5 (95% confidence interval [CI], 1.3-1.7), 1.1 (95% CI, 1.0-1.2), and 0.8 (95% CI, 0.8-0.8) per 1000 procedures, respectively. The median day of diagnosis of endophthalmitis was later for glaucoma surgeries (16.5 days) compared with combined cataract/glaucoma or cataract surgeries alone (8 and 6 days, respectively). Compared with microinvasive glaucoma surgery (MIGS), tube shunts were the only surgery type to be a significant risk factor for endophthalmitis for both stand-alone (adjusted odds ratio [aOR], 1.8, P= 0.002) and combined surgery (aOR 1.8, P= 0.047). The other risk factor for both stand-alone (aOR 1.1, P= 0.001) and combined (aOR 1.06, P= 0.049) surgeries was the Charlson Comorbidity Index (CCI). Age (aOR 1.03, P= 0.004) and male gender (1.46, P= 0.001) were significant risk factors for combined cataract and glaucoma surgeries. Compared with cataract surgery, early endophthalmitis incidence was higher for both glaucoma and combined cataract/glaucoma surgeries, with the highest incidence among tube shunts. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Relationship between surgical field contamination by patient's exhaled air and the state of the drapes during eye surgery

The coronavirus disease (COVID-19) pandemic has led to a dramatic increase in facemask use. Consequently, it has been reported that exhaled airflow toward the eyes can cause the dispersal of bacteria into the eyes, potentially increasing the incidence of postoperative endophthalmitis. In addition to wearing a facemask, gaps between the surgical drape and skin can also direct exhaled airflow toward the eyes. Here, we aimed to examine how the risk of contamination varies depending on the state of the drapes. We used a carbon dioxide imaging camera to visualize changes in exhaled airflow under different drape conditions and a particle counter to evaluate changes in the number of particles around the eye. The results revealed airflow present around the eye and a significant increase in the number of particles when the nasal side of the drape was detached from the skin. However, when a metal rod called “rihika” was used to create space above the body, the airflow and number of particles were significantly reduced. Thus, if drape coverage becomes incomplete during surgery, exhaled airflow toward the eye may contaminate the surgical field. On hanging up the drape, airflow can escape in the direction of the body, potentially preventing contamination.

Influence of discontinuation of prophylactic antimicrobial agent for trabeculectomy

BackgroundThere is no unified view of the necessity of prophylactic antimicrobial agents in trabeculectomy. Preoperative prophylactic antimicrobial agent injection and cefazolin sodium (CEZ) for trabeculectomy were discontinued at the Hiroshima University Hospital. In this study, we evaluated whether discontinuation of preoperative administration of CEZ in ophthalmology affects the incidence of postoperative infections.MethodsWe retrospectively investigated patient background, concomitant medications, subconjunctival dexamethasone sodium phosphate (DEX) injection at the end of the surgery, and the incidence of infective endophthalmitis within 6 weeks after surgery in the CEZ and non-CEZ groups. We also performed propensity score matching for background matching. Statistical analysis was performed using the Mann-Whitney U-test and Fisher’s exact test.ResultsThe incidence of postoperative endophthalmitis was not significantly different between 629 and 751 patients in the CEZ and no-CEZ groups, respectively (0 in the CEZ group and 2 in the no-CEZ group, P = 0.504). More patients in the CEZ group were taking diabetes drugs preoperatively (P = 0.028) and fewer patients were receiving subconjunctival DEX at the end of surgery (P < 0.001) than those in the non-CEZ group. Propensity scores were calculated using the risk factors for postoperative infection as covariates, and matching (580 patients in the CEZ group and 580 patients in the non-CEZ group) showed no significant difference in the incidence of postoperative endophthalmitis (P = 0.500).ConclusionsThere was no significant difference in the incidence of endophthalmitis after trabeculectomy between the CEZ and non-CEZ groups, suggesting a decreased need for CEZ injections before trabeculectomy.

Endophthalmitis prophylaxis in cataract surgery and intravitreal injection in Europe

AbstractEndophthalmitis is a significant complication of cataract surgery and intravitreal injections (IVI), leading in severe cases to blindness. The improvements of surgical technology, techniques and procedures have significantly reduced the incidence of postoperative infections in recent years; however, it is impossible to eliminate this problem completely. The incidence of post‐cataract endophthalmitis varies among several countries from 0.03% to 0.7%. The recommendations of the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO), have set the maximum acceptable level of postoperative endophthalmitis (POE) after cataract extractions at 0.05%. Awareness about risk factors and prevention measures is necessary for ophthalmic surgeons. Surgical complications (wound leak, posterior capsule rupture, vitreous loss or zonular complications) are related with higher incidence of postoperative endophthalmitis. Elderly patients (&gt;85 years), those with clear corneal incisions versus scleral tunnel incisions, and those without intracameral injection of cefuroxime have also a higher risk of infection.The available evidence suggests that intracameral antibiotic lowers the POE. Of the two most commonly used IC antibiotics, moxifloxacin and cefuroxime, there is no clear evidence that one is better than the other. Vancomycin is not recommended for routine ICAP because of both the risk of HORV (extremely low) and concerns regarding the use of an indispensable agent to treat multi‐drug‐resistant endophthalmitis as routine prophylaxis. Topical antibiotics may not provide an additional benefit, as has been suggested by several studies.In IVI, perioperative antibiotics cannot be considered the standard of care, as there is no evidence of prophylactic effects with regard to POE when using perioperative antibiotics. Topical administrations of 5% povidone‐iodine over at least 30 s into the conjunctival sac is recommended. Current clinical practices include minimized physician/patient talking during IVI, wearing of surgical face masks, and using face masks for nurses, technicians and physicians.

The Effect of Antibiotic Use in Surgery on the Incidence of Postsurgical Cataract Endophthalmitis

Endophthalmitis is a rare complication that can occur either endogenous or exogenous. Postsurgical endophthalmitis remains the primary exogenous etiology. Its complications remain formidable and involve the functional prognosis see anatomical eye. All interest of the question resides in preoperative prevention by incising on the measures of asepsis and antisepsis and per operatory by administering the antibiotic. Intracameral cefuroxime reduces the incidence of postoperative endophthalmitis of similar or slightly increased efficacy compared to the intravenous tract.

Evaluation of the effect of gentamicin in surgical perfusion solution on cataract postoperative endophthalmitis

ObjectiveTo evaluate the effect of gentamicin in surgical perfusion solution on endophthalmitis incidence after cataract surgery.MethodsA retrospective analysis of endophthalmitis incidence was conducted in two groups of patients who underwent cataract surgery, with (Group B) or without gentamicin (Group A) in the surgical perfusion solution. Endophthalmitis incidence, the isolated pathogenic bacteria strains and their antibiotic sensitivity, and the drug-resistant genotype of the pathogens were examined.ResultsThe incidence of endophthalmitis in patients of group A was 0.8‰. Thirteen pathogenic bacterial strains were isolated from the patient samples in group A, including 8 strains of Staphylococcus epidermidis, 1 Staphylococcus aureus, 1 Streptococcus pneumoniae, 1 Streptococcus bovis, 1 Enterococcus faecium and 1 Morganella sp. The incidence of endophthalmitis in group B patients was 0.2‰, which was significantly lower than that in group A (P<0.05). Five strains of pathogenic bacteria were successfully isolated, including 2 strains of Enterococcus faecium, 1 Enterococcus faecalis, 1 Staphylococcus epidermidis and 1 Staphylococcus aureus. There was no significant difference in the proportion of Staphylococcus strains in all isolated bacteria between the two groups (P > 0.05). However, the proportion of Enterococci isolated in group B samples was higher than that in group A (P < 0.05). There were more gentamicin-sensitive strains than levofloxacin-sensitive strains identified (P < 0.05). Interestingly, aminoglycoside-inactivating enzyme resistance gene was detected in Enterococcus strains.ConclusionOur data suggest that gentamicin-containing perfusion solution can reduce the incidence of postoperative endophthalmitis in cataract patients. However, the selective pressure imposed by gentamicin may facilitate the development of aminoglycoside-resistant Enterococcos strains.

Increased incidence of endophthalmitis after vitrectomy relative to face mask wearing during COVID-19 pandemic

Background/aimsTo determine the incidence and causative pathogens of endophthalmitis after vitrectomy during strict face mask wearing in the COVID-19 period.MethodsThis was a retrospective multicentre study including 31 ophthalmological institutions of...

Incidence of infectious complications following strabismus surgery

A total of 167 cases (0.111%) of infectious complications (endophthalmitis, orbital cellulitis, preseptal cellulitis, and postoperative infection) were identified in patients after strabismus surgery. The incidence of postoperative endophthalmitis was approximately 1 per 13,700 strabismus surgeries (0.007%) among 151,011 strabismus surgeries in US claims databases.

The effect of postoperative oral antibiotic therapy on the incidence of postoperative endophthalmitis after phacoemulsification surgery in dogs: 368 eyes (1997-2010).

PurposeTo assess the effectiveness of postoperative administration of oral antibiotics at reducing the incidence of endophthalmitis following phacoemulsification cataract extraction in dogs.MethodsMedical records of the University of Tennessee College of Veterinary Medicine were reviewed for cases having undergone phacoemulsification and divided according to whether or not they had received oral antibiotics postoperatively. Records were then evaluated for a diagnosis of endophthalmitis and incidence rates between the group receiving postoperative oral antibiotics and the group not receiving postoperative oral antibiotics were compared.ResultsA total of 215 patients (368 eyes) were identified by the search. One-hundred twelve patients (197 eyes) were treated with oral antibiotics postoperatively. One-hundred and three patients (171 eyes) were not treated with oral antibiotics postoperatively. Three cases of endophthalmitis were identified, with one in the antibiotic-treated group and two in the non-antibiotic treated group (P > 0.05, Fisher’s exact test).ConclusionsThe overall incidence of endophthalmitis at the University of Tennessee from 1997–2010 was 0.82%. The rate of post-phacoemulsification endophthalmitis was unaffected by the postoperative administration of oral antibiotics.

Endophthalmitis after pediatric cataract surgery in the United States: report using an insurance claims database.

To describe the characteristics and incidence of children developing endophthalmitis within the first 90 days following pediatric cataract surgery. Deidentified commercial and Medicare Advantage health claims across the United States. Population-based retrospective cohort study. In a retrospective review of approximately 58 million charts in Optum's deidentified Clinformatics Data Mart Database, patients aged <13 years who underwent cataract surgery in one or both eyes with or without primary intraocular lens (IOL) implantation between 2003 and 2017 were identified. Excluded were patients with traumatic cataract, <90 days of continuous insurance coverage, a prior diagnosis of endophthalmitis, and a diagnosis of endophthalmitis occurring after 90 days of cataract surgery. The main outcome measure was the incidence of endophthalmitis occurring within the first 90 days of cataract surgery and the odds ratio for developing endophthalmitis according to demographic and intraoperative factors. Cataract surgery was performed on 789 eyes (52.6% male), with a median age of 4 (interquartile range 1-8) years. The rate of IOL implantation at the time of cataract surgery was 66.8%. Endophthalmitis was diagnosed in 4 of 789 eyes (0.51%). The median time to diagnosis of endophthalmitis was 6.5 days (range: 5-44 days). There was no significant association between endophthalmitis and age, sex, or primary IOL implantation. In this large insurance claims database, the incidence of endophthalmitis following pediatric cataract surgery reported was more than the rate previously reported by any study with patients of a similar age.

Incidence of post-cataract surgery endophthalmitis: a chronological review and intercontinental comparison

Purpose: This review aimed to investigate the global incidence of postoperative endophthalmitis (POE) after cataract surgery over the last three decades, with a particular focus on the use of prophylactic intracameral antibiotics. Study design: Literature review. Methods: A literature search was performed in PubMed and Scopus. Data was collected from included studies and analyzed in IBM SPSS v27. Results: A total of 63 studies from 20 regions were included. The use of prophylactic intracameral antibiotics significantly reduced POE incidence. The baseline POE incidence in studies that involved intracameral prophylaxis tended to be high. A downward linear trend in POE incidence was observed in studies that did not involve intracameral antibiotic prophylaxis. Interestingly, a study in Japan reported the use of intracameral antibiotic prophylaxis in only 10.4% of cataract surgeries with an overall POE incidence of 0.025%, which is comparable to countries that use intracameral prophylaxis routinely. Within studies from Australia, China, Europe, India, Singapore and United States, Australia had the highest POE incidence with and without intracameral prophylaxis, while China had the lowest POE incidences. Conclusion: Intracameral antibiotics are an effective prophylaxis against POE. However, the incidence of POE is decreasing worldwide even without intracameral prophylaxis. The benefits of intracameral antibiotics should be weighed against its risks prior to its implementation as routine prophylaxis protocol for cataract surgery.

Is zero incidence of postoperative endophthalmitis after cataract surgery achievable

Purpose: For over 10 years, there have been zero cases of postoperative endophthalmitis (POE) after cataract surgery at Chatswood Private Hospital (CPH), Sydney, Australia. Study design: We conducted a retrospective audit study to evaluate the reasons for this, as well as the different preferences for route of antibiotic prophylaxis used. Methods: Deidentified data on cataract surgery cases for 2010–2020 were extracted and analyzed descriptively. Results: A total of 28,937 cataract surgery cases were performed at CPH from 2010-2020, for which no cases of POE were identified. The intracameral route for antibiotic prophylaxis was more commonly used compared to subconjunctival or both. Conclusion: Administration of prophylactic antibiotics, regardless of the route of administration, is beneficial and equally effective in preventing POE. Having operating theatres dedicated to ophthalmology helps maintain high standards of sterility of instrumentation and operating environments.

Postoperative Endophthalmitis in Immediate Sequential Bilateral Cataract Surgery: A Nationwide Registry Study

To report the incidence of postoperative endophthalmitis (PE) after immediate sequential bilateral cataract surgery (ISBCS) in Sweden. Retrospective cohort registry study. Patient data from 1 457 172 cataract extractions, including 1 364 934 unilateral surgeries and 92 238 ISBCSs. Endophthalmitis cases reported to the Swedish National Cataract Register (NCR) during a 16-year period (2002-2017) were analyzed in comparison to all control cases with regard to patient characteristics, surgical technique, and capsule complication. Incidence and determinants for PE in ISBCS compared with unilateral surgeries. A total of 422 cases of PE were identified in 1 457 172 cataract extractions, yielding an overall incidence of 0.029% (95% confidence interval [CI], 0.0262-0.0317). For unilateral procedures, the rate was 0.0299% (95% CI, 0.0270-0.0328) or 408 cases in 1 364 934 operations, whereas that for ISBCS was 0.0152% (95% CI, 0.0072-0.0231) or 14 incidents in 92 238 operations (P= 0.01). In a logistic regression model including all cataract procedures, nonuse of intracameral (IC) antibiotics (ABs), capsule complication, age 85 years or more, male gender, and ocular comorbidity were found to be independent risk factors for PE. All these parameters were less frequent in ISBCS. Notwithstanding, in the same multivariate analysis, ISBCS in itself was associated with asignificantly lower risk for PE. At follow-up, 5 of the 14 PE cases in the ISBCS cohort had a visual acuity (VA) of 20/200 or worse. Of these, one 93-year-old ISBCS patient developed bilateral infection. After ISBCS in Sweden, PE occurred once in 6600 surgeries. The risk of sustaining a final VA of 20/200 or less was 1 incident in 18 000 operated eyes. When counseling potential ISBCS patients about the risk of PE, it seems reasonable to state that the reported risk in the literature is lower than that with unilateral surgery but not negligible. Precautions remain necessary.

Postoperative endophthalmitis with and without intracameral moxifloxacin prophylaxis in a high volume surgery setting

ObjectiveThis study was conducted to understand the effects of intracameral moxifloxacin in decreasing the incidence of postoperative endophthalmitis after cataract surgery in an eye hospital with a high volume surgical...

The ocular surface bacterial contamination and its management in the prophylaxis of post cataract surgery endophthalmitis.

Objective: To investigate the recent pieces of evidence regarding the bacterial ocular surface contamination and its treatment in the prophylaxis of post-cataract surgery endophthalmitis.Methods: We conducted a literature research on the topic of interest and selected the most relevant data.Results: The studies reported a relatively high rate of positive conjunctival culture and the most frequently isolated organism was Coagulase negative Staphylococcus, which is also the most common etiological agent of the postoperative endophthalmitis. The bacterial ocular surface load is influenced by age, climate, associated diseases, topical and systemic medication. The use of povidone-iodine alone or in association with levofloxacin eyedrops as prophylactic method is effective in reducing the conjunctival bacterial contamination and consequently decreases the incidence of postoperative endophthalmitis.Conclusions: Based on the current pieces of evidence, adequate treatment of the bacterial ocular surface contamination prior to cataract surgery seems to be effective in preventing endophthalmitis after cataract surgery.Abbreviations: EU = European Union, Spp. = Species, HIV = Human Immunodeficiency Virus

This issue of Acta Feb 2021

This issue of Acta Feb 2021

Safety of intracameral cefuroxime in pars plana vitrectomy.

Postoperative endophthalmitis is a rare, but serious complication of pars plana vitrectomy (PPV). Subconjunctival cefuroxime injection has been the traditional choice for post vitrectomy endophthalmitis prophylaxis. Its effectiveness and safety in this context are however poorly understood and cases of retinal toxicity have been reported. The traditional standard subconjunctival antibiotic prophylaxis has been superceded in cataract surgery by intracameral antibiotic prophylaxis. The primary aim of this three centre non-randomised retrospective database cohort study of 7,532 PPV procedures was to identify the rate of endophthalmitis in cohorts of patients treated with intracameral or subconjunctival cefuroxime. A secondary aim was to estimate the achieved intraocular antibiotic concentrations of cefuroxime in eyes with intracameral versus subconjunctival administration using mathematical modelling. The overall incidence of postoperative endophthalmitis was 0.07% (5/7532). There were no cases of endophthalmitis in eyes receiving intracameral cefuroxime alone or in combination with subconjunctival cefuroxime (0/5586). Patients receiving subconjunctival cefuroxime alone had a higher incidence of endophthalmitis (0.22%, 4/1835), and there was one case of endophthalmitis in eyes not receiving any perioperative antibiotics (0.9%, 1/111). No cases of cefuroxime toxicity were identified. With subconjunctival cefuroxime, in the presence of a sclerotomy leak, we estimated the vitreous drug concentration to be higher than that for intracameral cefuroxime and potentially toxic. Intracameral cefuroxime appears to be a safe and efficient choice for prophylaxis against endophthalmitis after PPV. Small eyes with intraocular tamponade seem to be at particular risk of drug toxicity if cefuroxime is administered via the subconjunctival route.

ENDOPHTHALMITIS AFTER TRANSCONJUNCTIVAL PARS PLANA VITRECTOMY: A 6-year Experience Without Prophylactic Intraoperative Subconjunctival Antibiotics.

This study aimed to investigate the incidence and risk factors of endophthalmitis after transconjunctival pars plana vitrectomy (PPV) without intraoperative subconjunctival antibiotics. Retrospective, consecutive case series at a single institution. Consecutive cases of transconjunctival 25-gauge PPV without intraoperative subconjunctival antibiotics performed by three retina surgeons at a single surgical site at the Dean McGee Eye Institute from 2012 to 2018 were reviewed. Of 4,263 cases of PPV without intraoperative subconjunctival antibiotics, five cases (0.117%, 5/4,263) of post-PPV endophthalmitis were identified. Of these five cases, four cases (80%, 4/5) received combined cataract extraction or secondary intraocular lens implantation at the time of PPV. The incidence of endophthalmitis in isolated PPV was 0.027% (1/3,606 cases), whereas the incidence in combined PPV with anterior segment procedures was 0.608% (4/657 cases). Risk factors for endophthalmitis included diabetes mellitus, which was present in 80% of patients with endophthalmitis (4/5 cases). Causative organisms were identified in four of the five cases (80%), including Staphylococcus epidermidis (N = 3) and Propionibacterium acnes (N = 1). Performing transconjunctival PPV alone with standard preparation using povidone-iodine and postoperative topical antibiotics for 1 week without intraoperative subconjunctival antibiotics did not lead to an increase in incidence of postoperative endophthalmitis (1 per 3,606 cases).

Twenty years of endophthalmitis: Incidence, aetiology and clinical outcome.

To review the incidence, aetiology and outcomes of endophthalmitis during a 20-year period in a Norwegian university hospital. Single-centre retrospective review. Medical records of all patients admitted to Stavanger University Hospital with suspected endophthalmitis between January 1999 and December 2018 were reviewed. We identified 84 eyes of 81 patients. Postoperative endophthalmitis (PE) was seen in 64 eyes (76%), endogenous endophthalmitis in thirteen eyes (15%), trauma in four eyes (5%) and three eyes (4%) had keratitis-associated endophthalmitis. Administration of intravitreal injections (IVI) was the most common cause (30%), followed by cataract surgery (CS) (21%). Of 40238 IVI, 23 PE cases were identified (incidence, 0.057%; 95% confidence interval [CI] 0.036-0.086%). Of 39697 CS, 12 PE cases were identified (incidence, 0.030%; 95%CI 0.016-0.053%). After introduction of intracameral cefuroxime PE incidence after CS decreased from 0.10% in 1999-2003 to 0.015% in 2004-2018 (p=0.003). Eighty-four per cent of organisms were Gram-positive. Coagulase-negative staphylococci accounted for 54% of culture-proven cases, and 89% of post-IVI culture-proven cases. Thirty eyes (36%) either regained their previous vision or lost ≤1 Early Treatment Diabetic Retinopathy Study line. One third of endophthalmitis cases had a favourable visual outcome of logMAR 0.2 or better. PE after IVI occurred in 1 in 1750 procedures, and was the most common cause of PE. The incidence of PE after CS has decreased >sixfold since 2003, to 1 in 6700 surgeries. A high proportion of low-virulence bacterial species may have contributed to the favourable visual outcome.