Risk Factor For Postoperative Endophthalmitis Research Articles

Decade-long analysis of postoperative endophthalmitis in Sweden: Insights from insurance and national quality registers

PurposeTo analyse clinical characteristics and risk factors for post-operative endophthalmitis (POE) in a Swedish patient insurance database and compare prevalence of POE with two national quality registers. MethodsWe analysed 218 medical records of patients who claimed compensation for POE following ocular surgery from 2010 to 2020. The data were cross-referenced with national quality registers. ResultsIn total, 189 of 218 patients presented with severe ocular inflammation with no visibility into the posterior fundus and 160 of 218 had hypopyon. After treatment, the best corrected visual acuity improved from 2.4 to 1.8 LogMAR in mean (p < 0.01). Poorer visual outcome was associated with POE caused by Staphylococcus aureus, Enterococcus faecalis, and Streptococcus infections, as compared to coagulase-negative staphylococci (p < 0.01). Retinal detachment was linked to worse visual prognosis (p = 0.01). Eighteen patients required enucleation or evisceration, three of these had initially undergone vitrectomy, compared with 124 of 200 where the eyes were preserved. Peripheral vitrectomy showed better outcome compared to central vitrectomy (p = 0.02). Financial compensation was granted for 92 % of patients. However, a discrepancy was noted when comparing the number of patients with insurance claims to those reported by the national quality registers, indicating underreporting in both. ConclusionThis study highlights the impact of bacterial type on visual recovery in POE. Peripheral vitrectomy showed better outcomes than central vitrectomy. Most patients needing enucleation or evisceration were not treated with vitrectomy. Significant discrepancies were found between POE prevalence in quality registers and insurance reports, indicating the need for better reporting, though the exact magnitude of underreporting remains unclear.

Commentary: Rule out lacrimal duct obstruction before every intraocular procedure.

The age of presentation often overlaps for a person with acquired cataracts and acquired nasolacrimal duct obstruction (NLDO). Hence, there is more probability of having an asymptomatic NLDO and a cataract in the same person. Ipsilateral NLDO is considered an important risk factor for postoperative endophthalmitis in an intraocular procedure. Therefore, it becomes mandatory to rule out ipsilateral NLDO in all patients planned for cataract surgery.[1] Overall, the reported incidence of NLDO is 3–6.6%, with a mean age range of 48–59.5 years.[12] The ophthalmic evaluation of cataract surgery focuses on the factors affecting the visual acuity outcomes, like the health of tear-film, cornea, and anterior and posterior segments. Similarly, the ocular investigations are also targeted mainly at calculating and computing the refractive indices directly involved in the outcome of cataract surgery. Regurgitation on pressing lacrimal sac (ROPLaS) and lacrimal irrigation are generally not included in the routine examination of most ophthalmic cases. Hence, an asymptomatic lacrimal patient with a cataract tends to get his/her NLDO missed. ROPLaS and/or lacrimal irrigation must be included in the preoperative workup of a cataract patient to avoid the chance of postoperative endophthalmitis.[3] Lacrimal irrigation is an invasive diagnostic procedure requiring the desired skill-set to avoid any iatrogenic injury to the delicate lacrimal drainage system and interpret the results. Moreover, the patient and examiner must be in specific positions for lacrimal irrigation rather than sitting on an examination chair and slit lamp. Each step requires patient co-operation, like topical anesthesia, gaze positioning of the patient, punctum dilatation (preferably superior), lacrimal cannula insertion in horizontal canaliculus, and perception of gently forced injection of fluid in nose or throat. A significant part of lacrimal irrigation is dependent on the patient’s co-operation and systemic condition. ROPLaS, on the other hand, is a simple test that can be easily performed in the sitting position (any position) of the patient without consuming much time in the workup period. All those beneficial parameters are vital in high-volume centers and screening camps in remote areas. The examiner desires no special instrumentation or patient co-operation. In a survey involving members of the Oculoplastics Association of India, ROPLaS (59.6%) was opted as the preferred modality compared to lacrimal irrigation/syringing (32.6%), for checking NLDO before cataract surgery.[3] The sensitivity and specificity of ROPLaS have been reported to be 93.2% and 99.3%, respectively.[1] They recommended preoperative lacrimal irrigation to be unnecessary in case of a negative ROPLaS test. A recent retrospective, single-center study from India, including a large sample size (87,144 eyes), compared postcataract surgery endophthalmitis rates among eyes undergoing syringing (48,071 eyes) or ROPLAS (39,073 eyes) test before cataract surgery.[4] They found that the rates of post-cataract endophthalmitis (PCE) were comparable among the eyes undergoing either syringing test or ROPLAS before cataract surgery. This study was performed to avoid lacrimal irrigation, an aerosol-generating procedure, during COVID-19 times. However, when the safety of a vision-restoring surgical procedure (elective cataract surgery) is in question, more details in the ophthalmic examination will add to the safety value. As per the current study by Kim et al.,[5] the ROPLaS and lacrimal irrigation are both recommended to be performed in the preoperative workup of a cataract patient.[5] In their study, the ROPLaS was performed by an ophthalmologist, while a trained ophthalmic technician performed the lacrimal irrigation. We want to emphasize that ophthalmologists should first train the technician adequately before performing an invasive procedure (lacrimal irrigation) on a patient. This would ensure the desired outcomes from the lacrimal irrigation procedure without iatrogenic trauma to the lacrimal punctum and canaliculus. Additionally, a history of significant epiphora ± discharge goes a long way in suspecting lacrimal obstructions. Slit-lamp examination of the tear film and inferior conjunctival fornix is a must to rule out any debris/discharge. The fluorescein dye staining provides basic information about the health of corneal epithelium, and the simultaneous observation of the fluorescein dye disappearance test can provide an additional dimension in ruling out lacrimal duct obstruction. We believe that if a patient has a positive ROPLaS test, lacrimal irrigation is not necessary. However, in a patient with negative ROPLaS, lacrimal irrigation should be performed before any intraocular procedure to avoid the most-dreaded complication of endophthalmitis due to a treatable cause - NLDO.

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.

Does cataract surgery in patients with concurrent lower lid malposition increase the risk of postoperative endophthalmitis?

ObjectiveTo evaluate the safety of performing cataract surgery prior to eyelid (entropion/ectropion) surgery in patients with concurrent cataract and lower eyelid malposition. DesignRetrospective case series. Participants and MethodsPatients with concurrent lower eyelid malposition and cataract undergoing cataract surgery before lower eyelid repair from 2013 to 2020 were identified from two ophthalmologists (M.L.W., G.R.). Both surgeries were performed by the same ophthalmologist, with eyelid repair completed at least 1 month following cataract extraction. Data analysis was performed with two-parameter estimations. The primary outcome was the postoperative endophthalmitis rate in this cohort. Results129 cases in 90 patients were found (86 involutional entropion and 43 involutional ectropion). No cases of endophthalmitis were encountered. Statistical analysis using the 95% Jeffreys interval for one-sample binomial proportion revealed an upper limit of 1.9%. The Agresti-Caffo interval of the proportional difference between the study procedure and historical incidence data of postoperative endophthalmitis following cataract surgery alone yielded an estimate of 0.8% with an upper confidence limit of 2.2%. ConclusionWe present preliminary evidence on the endophthalmitis risk in patients with concurrent lower eyelid malposition and cataract who undergo cataract surgery prior to eyelid repair. We propose that this strategy may be a viable option to expedite vision restoration and reduce the risk of recurrent lower eyelid malposition in select patients. More data are required to reach statistically significant noninferiority and show that a malpositioned lower eyelid is not a risk factor for postoperative endophthalmitis following cataract surgery.

Postoperative Endophthalmitis and Toxic Anterior Segment Syndrome Prophylaxis: 2020 Update.

Improved surgical techniques have led to an increase in the number of outpatient ophthalmic procedures. In spite of decreased surgical times and overall improved outcomes, endophthalmitis remains one of the most severe complications of ophthalmic surgery. Although there are well known risk factors for postoperative endophthalmitis, some prophylaxis strategies remain controversial. A category of noninfectious postoperative inflammation, known as toxic anterior segment syndrome (TASS), is a rare but important complication of cataract surgery. While several worldwide outbreaks of TASS have occurred, it is challenging to identify an etiology in order to reduce the risk of further cases. Endophthalmitis and TASS cannot be prevented completely, but their rates may be decreased through risk reduction strategies supported by peer-reviewed evidence. This review highlights the current evidence in the prevention strategies for postoperative endophthalmitis and TASS.

Relationship between anesthesia and postoperative endophthalmitis

Previous study showed that patients under general anesthesia (GA) had nasopharyngeal secretions on the face at the end of ocular surgery, especially in propofol-based total intravenous anesthesia (TIVA), it might induce postoperative endophthalmitis. Therefore, we conducted a retrospective study to compare the incidence of endophthalmitis after ocular surgery under topical, inhalation anesthesia, and propofol-based TIVA in our medical center from 2011 to 2015.A total of 21,032 patients were included, and we evaluated epidemiologic factors, systemic diseases, other ocular pathologic characteristics, complications during the surgery, technique of ocular surgery, method of antibiotic prophylaxis, vitreous culture, and vision outcome in these patients.Fifteen endophthalmitis cases among 21,032 operations reported, equaling an incidence of 0.071%. The incidence rates under topical, inhalation anesthesia, and propofol-based TIVA were 0.083%, 0.039%, and 0%, respectively (P = 0.39). Moreover, the risk of endophthalmitis under GA (0.024%) was significantly lower than topical anesthesia (0.083%) (P < 0.001). We also found that elder was the risk factor for endophthalmitis following ocular surgery.In conclusion, propofol-based TIVA or inhalation anesthesia did not increase the risk of endophthalmitis after ocular surgery. Thus, GA was not a risk factor for postoperative endophthalmitis. By contrast, elder was the risk factor for postoperative endophthalmitis.

Nasolacrimal duct screening to minimize post‐cataract surgery endophthalmitis

AbstractBackgroundTo examine unrecognized nasolacrimal duct obstruction as a risk factor for developing endophthalmitis post‐cataract surgery in order to assess the value of preoperative lacrimal system screening.DesignProspective case‐control study.ParticipantsA random sample of patients undergoing phacoemulsification cataract surgery (control group) and a consecutive series of patients admitted to our hospital with post‐cataract surgery endophthalmitis.MethodsWe compared the rate of nasolacrimal duct obstruction in the control group versus the endophthalmitis series. Both groups underwent nasolacrimal duct syringing with normal saline on the ipsilateral side to the surgery. A standard macro‐dacryocystogram was performed to confirm for obstruction detected on syringing.Main Outcome MeasuresNasolacrimal duct obstruction rate.ResultsForty‐four eyes from 39 patients were included in this study: 34 eyes from 29 patients formed the control group and 10 eyes from 10 patients formed the endophthalmitis group.A higher rate of nasolacrimal duct obstruction was found among patients who developed endophthalmitis post‐cataract in comparison with the control group, on both nasolacrimal duct syringing (50.0% vs. 11.8%; P = 0.018) and macro‐dacryocystogram (20.0% vs. 2.9%, P = 0.125). Two out of the three patients with radiologically confirmed nasolacrimal duct obstruction reported a long history of epiphora.ConclusionThe higher rates of obstruction on nasolacrimal duct syringing and macro‐dacryocystogram among patients who developed endophthalmitis suggest that nasolacrimal duct obstruction is a significant risk factor for postoperative endophthalmitis. We recommend routine screening for symptoms and examination of the lacrimal system prior to cataract surgery.

Risk factors for postoperative endophthalmitis caused by Pseudomonas aeruginosa: Possible role of environment

This article describes an investigation to identify risk factors for postoperative endophthalmitis caused by Pseudomonas aeruginosa. A retrospective case-control study, including 8 cases and 24 controls operated from 2005 to 2009, was undertaken. The risk factors associated with P aeruginosa infection were a particular operating room (P = .003) and longer phacoemulsification duration (P = .001), suggesting that infection was not associated with patient characteristics but rather with the surgical environment and phacoemulsification duration.

Epidemiology of postoperative endophthalmitis in an Asian population: 11-year incidence and effect of intracameral antibiotic agents

To describe the incidence of postoperative endophthalmitis after cataract surgery in a multiethnic Asian population over an 11-year period, compare the endophthalmitis rates before and after the use of intracameral antibiotic agents, and identify potential risk factors for endophthalmitis. Department of Ophthalmology, Tan Tock Seng Hospital, Singapore. Cohort study. The incidence and risk factors for postoperative endophthalmitis in patients who had cataract surgery over 11 years were reviewed. Subconjunctival antibiotic agents only were administered over 7 years; in the subsequent 4 years, intracameral cefazolin (1.0 mg/0.1 mL) was used. The overall incidence of postoperative endophthalmitis in 50,177 was 0.042%. Over the 7 years without intracameral antibiotics, the endophthalmitis rate was 0.064% (19/29,539). With the use of intracameral cefazolin, the incidence decreased to 0.01% (2/20,638) (multivariate odds ratio [OR], 13.6; 95% confidence interval [CI], 3.15-58.58; P<.001). The independent risk factors for endophthalmitis were age (OR, 1.05; 95% CI, 1.01-1.09; P=.025) and male sex (0.06% versus 0.02%; OR, 2.96; 95% CI; 1.15-7.65; P=.025). There was a significant reduction in the rate of postoperative endophthalmitis in a multiethnic Asian population with the use of intracameral cefazolin. Men and older patients were at a higher risk for endophthalmitis. No author has a financial or proprietary interest in any material or method mentioned.

Prophylaxe der postoperativen infektiösen Endophthalmitis durch intrakamerale Cefuroximgabe – auf dem Weg zum Therapiestandard?

Several studies investigating the antibiotic prophylaxis of acute postoperative endophthalmitis provide very different results concerning the incidence and prophylaxis of this very severe complication of cataract surgery. For a long time the preoperative use of povidione-iodine had been the only procedure with overall acceptance and proven benefit. Following findings in Sweden that supported the advantages of the use of intracameral cefuroxime, the European Society of Cataract and Refractive Surgeons (ESCRS) performed a study to confirm the Swedish results and to lead to a revision of ESCRS guidelines. In a randomised, partially masked and placebo-controlled study 16,211 patients undergoing phacoemulsification cataract surgery were included. 25 ophthalmological units in 9 European countries took part in this study. The study consists of a 2 x 2 factorial design, dividing patients into 4 treatment groups. Two out of the 4 groups were treated with 1 mg intracameral cefuroxime (in 0.1 mL isotonic NaCl solution). In parallel, two groups (one treated with cefuroxime, one untreated) received topical levofloxacin 0.5% in a standard regimen. If clinical signs like pain or loss of vision indicated a postoperative endophthalmitis, suspicious results were confirmed by culture, Gram stain and PCR. In a follow-on study, Sundelin (Sweden) and colleagues included 30 patients who received topically-applied levofloxacin 0.5% following the ESCRS dosing scheme, in addition to intracameral administration of cefuroxime. Aqueous humour samples were taken at the end of surgery and at a second time point postoperatively. The levofloxacin concentration was measured by HPLC. The median maximal concentration (Cmax) was compared with the MIC90-values of relevant bacterial isolates. 29 patients developed a postoperative endophthalmitis, of whom 20 were classified as having a proven infectious cause. The absence of a prophylactic intracameral cefuroxime administration at 1 mg in 0.1 mL isotonic NaCl was associated with a 4.92-fold increase in the risk of postoperative endophthalmitis (95% CI 1.87-12.9). A clear corneal incision (CCI) or the use of silicon based IOL optic material accounted as additional risk factors for postoperative endophthalmitis. While the use of CCI was associated with a 5.88-fold higher risk of infection compared to STI (scleral tunnel incision), the implantation of silicon based IOL was associated with a 3.13-fold higher risk. Intraoperative complications were also associated with a higher risk of postoperative endophthalmitis (4.95-fold higher risk). Intracameral injection of cefuroxime reduces the risk of postoperative infectious endophthalmitis following phacoemulsification cataract surgery. Additional risk factors are the use of CCI and silicon based IOL implants.

Outbreak of Postoperative Endophthalmitis in a Thai Tertiary Care Center

We performed a study with a 1:3 ratio of case patients (n = 11) to control patients (n = 33) to evaluate risk factors for postoperative endophthalmitis in a Thai tertiary care center. Multivariate analysis revealed that diabetes mellitus and surgeon A were associated risk factors. Preoperative diabetes mellitus control and the improvement of infection control practices led to the termination of the outbreak.

Endophthalmitis after Cataract Surgery: A Nationwide Prospective Study Evaluating Incidence in Relation to Incision Type and Location

To 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.Prospective, multicenter, comparative, nonrandomized, observational study.All cataract surgeries in Sweden performed from January 2002 through December 2004 and all endophthalmitis cases in the same period that were reported to the Swedish National Cataract Register (NCR).Through a standard reporting form sent to the NCR, patient and operation technique data were recorded. In addition, PE cases with a traceable number to the main register were collected. Various parameters with a possible impact on endophthalmitis development were evaluated. Univariate analyses and logistic regression were statistical methods.The rate and etiology of PE; possible risk factors pertaining to patient history and operation technique, with a special emphasis on incision type and location; use of injector for the intraocular lens implantation; kind of prophylaxis; and presence of peroperative communication between the anterior chamber and vitreous.The overall rate of PE was 0.048% (109 cases in 225 471 CEs). Incidences of PE were 0.053% with clear corneal incisions and 0.036% with sclerocorneal incisions (P = 0.14, logistic regression analysis). The corresponding results were 0.040% for superior incisions and 0.055% for temporal incisions (P = 0.14). Communication between the anterior segment and vitreous was found to be a highly significant independent risk factor for PE (P<0.001), as were patient age > or = 85 years (P<0.001) and the nonuse of intracameral cefuroxime (P<0.001).The overall rate of PE after cataract surgery is low in Sweden, which may be a consequence of the widespread use of prophylactic intracameral cefuroxime. Only a trend for an increased risk of PE was detected for clear corneal and temporal wounds. The present data indicate that the use of clear corneal and/or temporal approaches will result in 1 additional PE case in approximately 5500 procedures on top of the PE rate after sclerocorneal or superior incisions, which was approximately 1 case in 2400 operations.

Postoperative Morganella morganii endophthalmitis associated with subclinical urinary tract infection

We report a case of Morganella morganii acute endophthalmitis following clear corneal phacoemulsification cataract surgery in which a coincident asymptomatic chronic urinary tract infection was detected postoperatively. Morganella morganii is a gram-negative bacillus that inhabits the gastrointestinal tract and is part of the normal fecal flora. It is an opportunistic pathogen usually encountered in postoperative and nosocomial settings, causing urinary tract and wound infections. Chronic urinary tract infection may be a risk factor for postoperative endophthalmitis. A dipstick urinalysis before elective cataract surgery in elderly patients with a history of recurrent urinary tract infections may be considered.

Endophthalmitis following cataract surgery in Sweden. The 1998 national prospective survey.

To investigate the morbidity of postoperative endophthalmitis (POE) following cataract surgery in Sweden in 1998. Clinically presumed cases of POE were reported in a prospective survey in which all Swedish ophthalmic surgical units except one had agreed to participate. Data on intraocular cultures and visual outcomes at 3 months after infection were supplied. Surgical cases that became infected were identified in the Swedish National Cataract Register, thereby enabling screening for various putative risk factors. The nationwide incidence of POE amounted to 58 cases out of 54 666 cataract operations, or 0.1% of surgical cases. The predominant aetiology was gram-positive bacteria, which comprised 57% of the material. Acrylic intraocular lenses were found to decrease the risk of POE significantly in comparison to hydrogel and polymethylmethacrylate lenses. The incidence of POE after cataract surgery in Sweden is similar to that currently reported elsewhere in the developed world. We hope that continued registration of cases of POE in Sweden will shed light on the possible influences of various prophylactic measures and different intraocular lens materials on the development of postoperative infection.

Endophthalmitis following pediatric intraocular surgery for congenital cataracts and congenital glaucoma.

The incidence of endophthalmitis following pediatric anterior segment surgery is currently unknown. The paucity of reports of this entity has led some observers to recommend simultaneous bilateral surgery for congenital cataracts or glaucoma. In this study, we surveyed over 500 pediatric ophthalmologists and glaucoma specialists concerning their knowledge of, or involvement with, endophthalmitis following pediatric intraocular surgery. Seventeen cases of endophthalmitis were documented to occur out of 24,000 reported surgical cases. This results in an incidence estimate of 0.071%, or 7 cases per 10,000, which is similar to that recently reported following adult extracapsular cataract extraction. The presence of infection was diagnosed by the 3rd postoperative day in 82% of cases. An organism was documented by culture in 65% of cases. The organism was gram positive in all cases. Visual outcome was generally poor with 65% having no light perception. The presence of possible concurrent risk factors for postoperative endophthalmitis, including nasolacrimal duct obstruction and upper respiratory infection, was noted in 8 of the 17 cases.

A Case-control Study of Risk Factors for Postoperative Endophthalmitis

The authors conducted a case-control study to identify risk factors for postoperative endophthalmitis. Fifty-four cases of patients who developed endophthalmitis after intraocular surgery at the New York Eye and Ear Infirmary during the period from January 1988 through October 1990 were identified. A control group of 228 patients was randomly selected from the 24,105 patients who underwent intraocular surgery during this same period. Logistic regression analysis identified significant independent risks associated with intraoperative communication with the vitreous cavity (risk ratio 13.7, P < 0.001) and use of an intraocular lens with haptics made of polypropylene (risk ratio 4.5, P = 0.007). The study predicts that there would be approximately 700 fewer cases of postoperative endophthalmitis annually in the United States (approximately a 50% decrease in incidence) if intraocular lenses with haptics made of polymethylmethacrylate, rather than polypropylene, were used exclusively.