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Retraction notice to: Endophthalmitis Occurring after Cataract Surgery
Endophthalmitis Occurring after Cataract Surgery Outcomes of More Than 480 000 Cataract Surgeries, Epidemiologic Features, and Risk Factors Mahmoud Jabbarvand, MD,1 Hesam Hashemian, MD,1 Mehdi Khodaparast, MD,1 Mohammadkarim Jouhari, MD,1 Ali Tabatabaei, MD,1 Shadi Rezaei, BSC2 Purpose: To report the incidence of endophthalmitis after senile cataract surgery and to describe the epidemiology and main risk factors. Design: Retrospective, single-center, cross-sectional descriptive study. Participants: Patients who underwent cataract surgery in Farabi Eye Hospital from 2006 through 2014. Methods: All patients were evaluated retrospectively to compare risk factors, epidemiologic factors, and prophylaxis methods related to endophthalmitis. Patient records were used to gather the data. Main Outcome Measures: Epidemiologic factors, systemic diseases, other ocular pathologic characteristics, complications during the surgery, technique of cataract surgery, intraocular lens type, method of antibiotic prophylaxis, surgeon experience, vitreous culture, and vision outcome were evaluated in these patients. Results: One hundred twelve endophthalmitis cases among 480 104 operations reported, equaling an incidence of 0.023%. Patients with diabetes mellitus (14.3%) and of older age (mean age, 81 years), perioperative communication with the vitreous (17.9%), extracapsular cataract surgery procedure (11%), and surgery on the left eye (58.9% vs. 41.1% for right eye; P ¼ 0.03) showed a statistically significant association with endophthalmitis. Short-term treatment with topical or systemic preoperative antibiotics or postoperative subconjunctival injection was associated with a 40% to 50% reduced odds of endophthalmitis compared with no prophylaxis (P ¼ 0.2). No cases of endophthalmitis were observed among the 25 920 patients who received intracameral cefuroxime, suggesting that this approach to antibiotic prophylaxis may be far more effective than traditional topical or subconjunctival approaches. Conclusions: The incidence of endophthalmitis after cataract surgery in our center was 0.023%, comparable with that of other previously published international studies. Older rural patients with immune suppressive diseases, such as diabetes mellitus, are particularly more prone to endophthalmitis. Vitreous loss at the time of surgery was associated with a significantly increased risk. Whereas antibiotic prophylaxis overall showed a 40% to 50% reduction in risk, intracameral cefuroxime was 100% effective in preventing endophthalmitis in this series. Ophthalmology 2015;-:1e7 ª 2015 by the American Academy of Ophthalmology.
Cataract surgery is by far the most common ocular surgery performed worldwide. Postoperative endophthalmitis is a raredbut disastrousdcomplication of cataract surgery, with a reported incidence of 0.04% to 0.41%.1 Although it is not prevalent, it presents an important public health problem. The worldwide aging population likely will result in a higher rate of cataract surgeries in the near future. Postoperative endophthalmitis often is associated with serious morbidity and high medical care expenses. Visual outcomes after endophthalmitis often are poor: one third of individuals do not gain vision better than counting fingers, and 50% do not recover vision better than 20/40.2 In some cases, even anatomic distortion of the globe occurs.
2015 by the American Academy of Ophthalmology Published by Elsevier Inc.
In recent years, cataract surgery technique has improved progressively with the use of injectable lenses and topical anesthesia, microincisions, and sutureless surgical wounds. All of these changes may have reduced the rate of postoperative endophthalmitis. So, it is useful to analyze epidemiologic data and the epidemiologic factors associated with surgical infection to prevent its appearance and consequences. The objective of this study was to evaluate the effect of epidemiologic and surgical factors on endophthalmitis occurring after cataract surgery and to assess prophylaxis techniques, treatment methods, and outcomes in a referral center in Iran. One of the advantages of this study in comparison with previous reports is its single-center nature, which may decrease some confounding factors.
http://dx.doi.org/10.1016/j.ophtha.2015.08.023 ISSN 0161-6420/15
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Ophthalmology Volume -, Number -, Month 2015
Methods We retrospectively analyzed the electronic medical records of 480 104 eyes of patients who had undergone senile cataract surgery at Farabi Eye Hospital, Tehran, Iran, from 2006 through 2014. The Farabi Eye Hospital Institutional Review Board approved the study protocol. We identified all cases of endophthalmitis occurring after cataract surgery within this interval. We reexamined the patients who had endophthalmitis and evaluated their risk factors and their final visual results. The diagnosis of endophthalmitis was based on clinical examination indicating an inflammatory reaction out of proportion to the surgical trauma during the normal course of postoperative care, warranting intraocular sampling for bacterial culture. All the patients with a diagnosis code for endophthalmitis using the International Classification of Diseases, Ninth Revision, Clinical Modification codes or similar codes in older records were considered as endophthalmitis: 360.00, purulent endophthalmitis, unspecified; 360.01, acute endophthalmitis; 360.02, panophthalmitis; 360.03, chronic endophthalmitis; and 360.04, vitreous abscess.3 We retrospectively evaluated the following variables between the cases and the entire study population: demographic factors, systemic diseases, prophylactic antibiotic regimen (preoperative, intraoperative, or postoperative antibiotics), bacterial species of infection, management of the endophthalmitis, experience level of the cataract surgeon, patient socioeconomic status, method of surgery, intraoperative complications, and final visual acuity. When endophthalmitis was suspected, a vitreous biopsy was performed immediately and sent to the microbiological laboratory for smear and culture and antibiogram analyses. Endophthalmitis was managed according to the recommendations of the Endophthalmitis Vitrectomy Study.4 According to an antibiotic protocol for cataract surgery in Farabi Eye Hospital, which is followed by all ophthalmologists, all patients received 5% povidoneeiodine for 5 minutes before surgery. At the time of discharge, the patients were prescribed a topical antibioticecorticosteroid solution (betamethasone 0.1% combined with either ciprofloxacin 0.3% or chloramphenicol 0.5%) in tapering dosages during a 45-day postoperative period. Records were excluded if data indicated the eye had undergone previous intraocular surgery. Based on the level of surgeon experience, surgeries were classified as performed by full-time attending or in-training surgeons. Analysis of the latter group’s records was carried out depending on whether the surgeon was a resident or fellow. Fulltime attending physicians performed 72% of surgeries.
Statistical Analysis All statistical analyses were performed using SPSS software (SPSS, Inc., Chicago, IL). Means and standard deviations of quantitative variables and distribution of frequencies of qualitative variables were studied. A Pearson chi-square test and an independent sample test were used for risk factors analysis. P values less than 0.05 were considered statistically significant. Multivariate logistic regression analysis was performed to evaluate diabetes, vitreous loss, and antibiotic prophylaxis as independent risk factors for endophthalmitis.
Results Analysis of medical records revealed 112 endophthalmitis cases among 480 104 operations, indicating a postoperative endophthalmitis incidence of 0.023%. The mean agestandard deviation
2
of the entire cataract surgery population was 799.5 years. Endophthalmitis developed in patients with a mean age standard deviation of 817.8 years. Table 1 shows the summary of clinical findings and specifications of patients with endophthalmitis. The average period between surgery and the diagnosis of endophthalmitis was 8 days. One hundred cases (89%) were diagnosed with acute-onset endophthalmitis (within 6 weeks of surgery) and 12 eyes (11%) had late-onset endophthalmitis (>6 weeks from the time of surgery). The cataract surgery technique was reported in all cases. In approximately 98.3% of the entire study population, phacoemulsification surgery was performed with a clear corneal 3.2-mm incision. Endophthalmitis occurred in 100 eyes (89%) after phacoemulsification and in 12 eyes (11%) after extracapsular cataract extraction. Nearly one-fifth of postcataract surgery endophthalmitis cases (17.9%) had experienced posterior capsule rupture and vitreous loss in the initial cataract surgery. Table 2 shows the distribution of cataract surgery techniques performed and the incidence of vitreous loss. A higher incidence of endophthalmitis was present in the extracapsular cataract extraction (P ¼ 0.006), vitreous loss, and diabetic groups. Of all the patients who underwent cataract surgery, 5.4% were diabetic, whereas 16 of 112 endophthalmitis cases (14.3%) occurred in patients with diabetes mellitus (P ¼ 0.004). Multivariate logistic regression analysis demonstrated that diabetes (P ¼ 0.018) and vitreous loss (P < 0.001) were independent risk factors for endophthalmitis. We observed a 7-fold and 3-fold increase in the rate of endophthalmitis among those with vitreous loss and diabetes, respectively (odds ratios, 7.83 and 2.92, respectively, for vitreous loss and diabetes). Among the 112 cases of endophthalmitis, 4 cases (3.6%) were aphakic, 34 of the implanted lenses were hydrophobic (30.4%), and 74 lenses were hydrophilic (66%). Among the entire cataract surgery population, 42.4% had hydrophobic lenses and 57.6% had hydrophilic lenses. A total of 15.3% of patients received preoperative antibiotic eye drops (ciprofloxacin 0.3%). Intracameral cefuroxime was used at the end of cataract surgery in 25 920 patients (5.4%); endophthalmitis did not develop in any of these patients (P ¼ 0.0001). Table 3 shows the single risk factor analysis for prophylaxis antibiotic usage. Single-variable analyses showed that the use of intracameral antibiotics was the decisive prophylactic factor for the development of postoperative endophthalmitis. Among all vitreous samples obtained from endophthalmitis cases, 41 samples (36.6%) showed positive culture results; the
Table 1. Summary of Demographic Data of All Endophthalmitis Cases Gender Male Female Affected eye Right Left Diabetes Lacrimal drainage disease Vitreous loss Location Rural Urban Data are no. (%).
52 (46.4) 60 (53.6) 46 66 16 16 20
(41.1) (58.9) (14.3) (14.3) (17.9)
28 (25) 84 (75)
Jabbarvand et al
Endophthalmitis after Cataract Surgery
Table 2. Rate of Endophthalmitis According to Different Factors
Surgery type Phacoemulsification ECCE Vitreous loss Yes No Diabetes mellitus Yes No IOL type Hydrophobic Hydrophilic
Cases in the Total Population, No. (%)
No. of Endophthalmitis Cases and Rate (%) of Endophthalmitis by Variable
471 840 (98.3) 8160 (1.7)
100 (0.021) 12 (0.14)
12 960 (2.7) 467 040 (97.3)
20 (0.15) 92 (0.019)
25 926 (5.4) 454 178 (94.6)
16 (0.06) 96 (0.02)
202 604 (42.2) 276 540 (57.6)
38 (0.018) 74 (0.026)
Odds Ratio
95% Confidence Interval
0.078
0.0428e0.1420
<0.001
7.83
4.83e12.70
0.004
2.92
1.72e4.96
0.08
0.7
0.47e1.04
P Value 0.006
ECCE ¼ extracapsular cataract extraction; IOL ¼ intraocular lens. The percentage in the third column is the rate of the variable among the entire population (e.g., 98.3% of the entire population underwent phacoemulsification). The percentage in the fourth column is the rate of endophthalmitis in the specific variable group (e.g., 0.021% of the patients who underwent phacoemulsification had endophthalmitis).
Discussion
remaining 71 cases (63.4%) with a clinical diagnosis of endophthalmitis showed negative culture results. Gram-positive species were the main cause, accounting for 33 cases (80%). The final visual acuity was better in patients with negative culture results or coagulase-negative staphylococci. In contrast, eyes with enterococci and Pseudomonas species had worse final vision. Final visual acuity was no light perception in 2 eyes, and 1 of these eyes was eviscerated because of severe corneal melting (Table 4). Patients were categorized into 2 groups based on their location: 38 880 patients (8.1%) were from rural areas and 441 120 patients (91.9%) were from urban areas. Records showed that endophthalmitis had significantly higher occurrence rates among rural patients (0.07%) versus urban patients (0.02%; P ¼ 0.001). Table 5 compares the endophthalmitis rates among different surgeon groups based on their level of experience. The ratio of the cases with endophthalmitis to the number of all patients undergoing cataract surgery was higher among residents compared with surgical fellows and attending surgeons. However, no statistically significant differences were observed in endophthalmitis rates between residents, fellows, and full-time attending physicians when analyzed by linear-by-linear association or the chi-square test. The distribution of endophthalmitis cases according to eye laterality demonstrated a higher incidence of endophthalmitis in the left eye (58.9%); in contrast, a higher number of right eyes underwent cataract surgery (264 000 [55%]), so the endophthalmitis rate was statistically significantly higher in the left eye compared with the right eye (P ¼ 0.03).
This study is one of the largest studies of endophthalmitis occurring after cataract surgery. We designed this study to evaluate the prevalence, the clinical and surgical aspects, and the role of systemic disease and prophylactic antibiotics in endophthalmitis after cataract surgery. This study established rates of endophthalmitis secondary to cataract surgery in the Farabi Eye Hospital, a tertiary care referral hospital in Tehran, Iran. The surgeries were performed by residents engaged in surgical training as well as fellows and full-time attending physicians. Previous reports stated different incidence rates for endophthalmitis occurring after cataract surgery ranging from 1 per 300 cataract procedures to no events over several years.5e8 We found a global endophthalmitis prevalence of 0.023%, comparable with the incidences of 0.029%9 and 0.048%10 in Sweden, and lower than the incidences of 0.06% in China,11 0.09% in the United Kingdom,12 0.14% in Ontario, Canada,13 and 0.15% in Quebec, Canada.14 A systematic review of publications from 1964 through 2003 that included 3 140 650 cataract extractions estimated an endophthalmitis rate of 0.128%.15 The differences among these studies may be the result of differences in prophylactic regimens, differences in sensitivity of the
Table 3. Single Risk Factor Analysis for Prophylactic Antibiotic Use
No antibiotic Preoperative systemic antibiotic Preoperative topical antibiotic Intracameral antibiotic Subconjunctival antibiotic
Total No. of Cases
Proportion of Cases (%)
No. of Endophthalmitis Risk of Cases Endophthalmitis (%)
Odds of Endophthalmitis
Confidence Interval
260 744 47 520
54.6 9.8
84 6
0.032 0.012
1 0.51
0.18e1.44
76 800
15.9
12
0.015
0.62
0.28e1.35
25 920 69 120
5.4 14.3
0 10
0.000 0.014
0 0.58
0.90e0.98 0.25e1.34
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Ophthalmology Volume -, Number -, Month 2015 Table 4. Culture Results and Final Visual Outcomes Species
No. (%)
Negative 71 Coagulase-negative Staphylococci 14 Staphylococcus aureus 6 Enterococci 7 Pseudomonas species 4 Enterobacteriaceae species 2 Other gram-positive bacteria 6 Other gram-negative bacteria 2 Total 112
Mean Corrected Distance Visual Acuity*
(63.4) (12.5) (5.4) (6.3) (3.6) (1.8) (5.4) (1.8) (100)
0.42 0.47 0.55 0.9 1.12 0.65 0.5 0.4 0.5
(20/52) (20/59) (20/70) (20/158)y (20/260)y (20/89) (20/63) (20/50) (20/63)
*Logarithm of the minimum angle of resolution (Snellen equivalent). y Two patients had no light perception vision. Pseudomonas aeruginosa was found in one culture and Enterococci was found in the other.
definition of endophthalmitis, and finally racial and socioeconomic differences. One of the main advantages of this study over previous endophthalmitis studies is that we enrolled patients who underwent cataract surgery at a single eye hospital with the same operating rooms, surgical instruments, and protocols of sterilization so we could eliminate the confounding factors that may affect the result. An unavoidable drawback directly related to the retrospective nature of studies of endophthalmitis is missing cases (e.g., if a patient who underwent cataract surgery in our center goes to another center after endophthalmitis occurs). The primary assumption for all of these studies is that all patients who underwent surgery would return to the same center in case of any complications. We believe that because of the position of Farabi Eye Hospital in Iran, this bias is very unlikely to happen. Farabi Eye Hospital is by far the largest referral center in Iran, and most of the referrals across the country are made to it. The relationship between Farabi Eye Hospital and ophthalmologists nationwide makes it extremely unlikely that patients who undergo surgery at Farabi Eye Hospital receive treatment for postoperative complications elsewhere. All ophthalmologists who perform surgery in Farabi Eye Hospital visit postoperative patients there. We identified a 7-fold increase in the odds of endophthalmitis associated with intraoperative vitreous loss, and this complication was identified in association with 18% of endophthalmitis cases in this study. The role of vitreous loss in promoting endophthalmitis was first identified by Javitt
et al16 in 1991 and has been confirmed in numerous subsequent reports.5,9,17,18 Nearly 20% of our patients with endophthalmitis had diabetes mellitus, which is much higher than the rate of total cataract surgery (4.3%). Diabetes increased the odds of endophthalmitis approximately 3-fold. Other previous reports also have mentioned diabetes as an independent risk factor of endophthalmitis.17e19 Because the source of most of the bacterial causes of postoperative endophthalmitis is the patient’s fornix, eyelid, and conjunctiva,20,21 preoperative disinfection of periocular surfaces is very effective for endophthalmitis prophylaxis. As the accepted protocol in Farabi Eye Hospital, all surgeons perform periorbital disinfection using gauze soaked with povidoneeiodine for 5 minutes. Povidoneeiodine is applied in the conjunctival sac at least 1 minute before surgery. This may help to reduce the endophthalmitis rate in Farabi Eye Hospital compared with previously mentioned studies. Ciulla et al,22 in a literature review, concluded that preoperative povidoneeiodine is the single most effective means for reducing the risk for postoperative endophthalmitis. The role of antibiotics in surgical prophylaxis continues to be controversial. No cases of endophthalmitis were observed among the 25 920 patients who received intracameral cefuroxime, suggesting that this approach to antibiotic prophylaxis may be far more effective than traditional topical or subconjunctival approaches. This finding is in accordance with previous prospective and retrospective studies.9,10,17,23e25 Recently, a study from Portugal reported a decrease in the endophthalmitis rate from 0.26% to 0% after use of intracameral cefuroxime.26 A 5-fold risk reduction also was reported in the randomized, multicenter European Society of Cataract and Refractive Surgeons study.5,23 A Spanish study27 reported a reduction in the risk of endophthalmitis, from 0.59% to 0.043%, after cefuroxime. However, some studies28 reported lower rates of endophthalmitis with no use of intracameral antibiotics compared with the European Society of Cataract and Refractive Surgeons (ESCRS) cefuroxime group (0.07%). In this study, we observed a lower total rate of endophthalmitis also. An appropriate antibiotic for intracameral use should be safe for intracameral use, have broad antimicrobial coverage, and be prepared easily. Cefuroxime is a broadspectrum drug, and although intracameral use is off label,
Table 5. Distribution of Endophthalmitis According to Surgeon Experience and Eye Laterality Surgeon Skill Resident in training <5 mos* >5 mosy Fellow in training Full-time attending physician
No. (%) of Patients (n [ 480 104) 90 740 34 567 8641 346 155
No. (%) of Endophthalmitis Cases (n [ 112)
(18.9) (7.2) (1.8) (72.1)
*Residents with fewer than 5 months of experience in cataract surgery. y Residents with more than 5 months of experience in cataract surgery.
4
30 14 1 67
(26.7) (12.5) (0.9) (59.8)
Endophthalmitis Rate (%)
P Value
0.03 0.04 0.01 0.01
0.46
Jabbarvand et al
Endophthalmitis after Cataract Surgery
it has been proven to be safe.29,30 A review of the preferred practice in European countries reported that intracameral cefuroxime still is not used widely by European ophthalmologists.31 The main drawback of its use is the risk of miscalculation of dosage or contamination during preparation because it is not available in many countries, including Iran, as a commercial preparation for intracameral use. Although there were no reports of side effects in Farabi Eye Hospital, there are some reports of adverse effects resulting from overdoses of the drug in the literature.30,32 Fortunately, a specific commercial preparation with the necessary concentration (0.1 mg/ml) for intracameral use, called Aprokam (Laboratoires Théa, Clermont-Ferrand, France),33 has been available in Europe since 2012. The other drawback of this drug is its insufficient antibacterial coverage over highly virulent enterococci and some gram-negative bacteria.9 We believe that because of the proven effect of intracameral cefuroxime, it should be used at least in patients with a higher risk of endophthalmitis (i.e., those with diabetes or whose cataract surgery was complicated). This study showed that short-term pretreatment with topical or systemic antibiotics or postoperative subconjunctival injection of antibiotics can reduce postoperative endophthalmitis, but the difference was not statistically significant (P ¼ 0.2). These prophylaxis roots were associated with a 40% to 50% reduced odds of endophthalmitis compared with no prophylaxis. It should be recognized that our study was retrospective and observational, and therefore, we could not change the antibiotic types or dosage. There is no consensus in the literature for the effect of prophylactic antibiotics to prevent endophthalmitis. Shortterm pretreatment of topical antibiotics reduced the conjunctival microbial burden in several reports.34e37 However, another study38 reported that using postoperative antibiotic adds no benefit for reducing the rate of endophthalmitis after intracameral usage of cefuroxime. Intracameral cefuroxime has been reported to be 3 times more effective for endophthalmitis prophylaxis than subconjunctival cefuroxime.24 However, we believe that a prospective clinical trial is required to evaluate completely the effectiveness of different kinds and routes of prophylactic antibiotics on cases of postsurgical endophthalmitis. Older age was a risk factor for endophthalmitis in this study, which is consistent with previous reports.10,14,39,40 Two possible causes would explain this finding. First, with aging, a cataract hardens and zonules weaken, so the operation will be more prone to complication, and endophthalmitis is more prevalent in complicated cataract surgery. Second, more bacteria are present in the conjunctiva of older patients compared with that of younger patients.41,42 Isolating the organism is the mainstay of the antibacterial therapy of endophthalmitis. Only 41 of 112 vitreous culture results were positive. Previous studies reported grampositive bacteria as the most common isolated bacteria.43 In this study, coagulase-negative Staphylococcus was the most prevalent isolated bacteria, which is consistent with previous reports.43
This study also demonstrated a higher rate of endophthalmitis in the left eye. It may be the result of the incision site being placed in the left eye by a right-handed surgeon: the main incision is near the upper lid margin, but in the right eye, the stab incision is near upper lid and the main incision is in the palpebral fissure. Considering lid margin flora as the main cause of endophthalmitis, it may justify the difference of the infection rate between the 2 eyes. Previous studies3,44,45 reported that longer surgical experience and a higher annual volume of surgery decreased the risk of postoperative endophthalmitis, but they did not involve surgeons still in training. We found a higher rate of endophthalmitis patients treated by residents, but the difference was not significant. This is comparable with the previous report by Ravindran et al.46 The effect of intraocular lens materials is controversial. Baillif et al47 found greater bacterial adherence to hydrophobic lenses compared with hydrophilic lenses. In our study, the endophthalmitis rate was higher in the hydrophilic group (0.026% vs. 0.018%), but the difference was not significant (P ¼ 0.08). In this report, the incidence of endophthalmitis among patients who underwent phacoemulsification was only 0.021%. This is comparable with reported rates after phacoemulsification from the United States and other countries.1,9,10,48 The endophthalmitis rate was significantly higher in patients who underwent extracapsular cataract extraction for cataract extraction (0.14%). Norregaard et al49 reported a comparable rate of 0.18% in a study of extracapsular cataract surgery performed in Denmark. Because phacoemulsification is the preferred cataract surgery technique in Farabi Eye Hospital, extracapsular cataract surgery is performed primarily either in mature cataracts or in cases with higher rates of complications (e.g., zonulysis), or secondarily in cases of failed phacoemulsification. So the higher rate of endophthalmitis associated with the extracapsular technique may be the result of different patient specifications and not of a higher risk associated with the technique. In conclusion, older age, intraoperative vitreous communication, systemic diseases such as diabetic mellitus, and rural residence are associated with a higher risk of postoperative endophthalmitis. Whereas antibiotic prophylaxis overall showed a 40% to 50% reduction in risk, intracameral cefuroxime was 100% effective in preventing endophthalmitis in this series.
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37.
38.
endophthalmitis. Ophthalmology 1991;98:639–49. discussion 650. Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based update. Ophthalmology 2002;109:13–24. Barry P, Seal DV, Gettinby G, et al; Group EES. ESCRS 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: 407–10. Yu-Wai-Man P, Morgan SJ, Hildreth AJ, et al. Efficacy of intracameral and subconjunctival cefuroxime in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg 2008;34:447–51. Wejde G, Montan P, Lundstrom M, et al. Endophthalmitis following cataract surgery in Sweden: national prospective survey 1999e2001. Acta Ophthalmol Scand 2005;83: 7–10. Beselga D, Campos A, Castro M, et al. Postcataract surgery endophthalmitis after introduction of the ESCRS protocol: a 5year study. Eur J Ophthalmol 2014;24:516–9. Garcia-Saenz MC, Arias-Puente A, Rodriguez-Caravaca G, Banuelos JB. Effectiveness of intracameral cefuroxime in preventing endophthalmitis after cataract surgery: ten-year comparative study. J Cataract Refract Surg 2010;36:203–7. Lloyd JC, Braga-Mele R. Incidence of postoperative endophthalmitis in a high-volume cataract surgicentre in Canada. Can J Ophthalmol 2009;44:288–92. Yoeruek E, Spitzer MS, 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;34:2139–45. Delyfer MN, Rougier MB, Leoni S, et al. Ocular toxicity after intracameral injection of very high doses of cefuroxime during cataract surgery. J Cataract Refract Surg 2011;37:271–8. Behndig A, Cochener B, Guell JL, et al. Endophthalmitis prophylaxis in cataract surgery: overview of current practice patterns in 9 European countries. J Cataract Refract Surg 2013;39:1421–31. Lockington D, Flowers H, Young D, Yorston D. Assessing the accuracy of intracameral antibiotic preparation for use in cataract surgery. J Cataract Refract Surg 2010;36:286–9. Keating GM. Intracameral cefuroxime: prophylaxis of postoperative endophthalmitis after cataract surgery. Drugs 2013;73:179–86. Isenberg SJ, Apt L, Yoshimori R, Khwarg S. Chemical preparation of the eye in ophthalmic surgery. IV. Comparison of povidone-iodine on the conjunctiva with a prophylactic antibiotic. Arch Ophthalmol 1985;103:1340–2. Ta CN, Sinnar S, He L, et al. Prospective randomized comparison of 1-day versus 3-day application of topical levofloxacin in eliminating conjunctival flora. Eur J Ophthalmol 2007;17:689–95. Mino de Kaspar H, Kreutzer TC, Aguirre-Romo I, et al. A prospective randomized study to determine the efficacy of preoperative topical levofloxacin in reducing conjunctival bacterial flora. Am J Ophthalmol 2008;145:136–42. He L, Ta CN, Hu N, et al. Prospective randomized comparison of 1-day and 3-day application of topical 0.5% moxifloxacin in eliminating preoperative conjunctival bacteria. J Ocul Pharmacol Ther 2009;25:373–8. Raen M, Sandvik GF, Drolsum L. Endophthalmitis following cataract surgery: the role of prophylactic postoperative chloramphenicol eye drops. Acta Ophthalmol 2013;91:118–22.
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39. Li J, Morlet N, Ng JQ, et al. Significant nonsurgical risk factors for endophthalmitis after cataract surgery: EPSWA fourth report. Invest Ophthalmol Vis Sci 2004;45:1321–8. 40. West ES, Behrens A, McDonnell PJ, et al. The incidence of endophthalmitis after cataract surgery among the U.S. Medicare population increased between 1994 and 2001. Ophthalmology 2005;112:1388–94. 41. Rubio EF. Influence of age on conjunctival bacteria of patients undergoing cataract surgery. Eye 2006;20:447–54. 42. Mino De Kaspar H, Ta CN, Froehlich SJ, et al. Prospective study of risk factors for conjunctival bacterial contamination in patients undergoing intraocular surgery. Eur J Ophthalmol 2009;19:717–22. 43. Pijl BJ, Theelen T, Tilanus MA, et al. Acute endophthalmitis after cataract surgery: 250 consecutive cases treated at a tertiary referral center in the Netherlands. Am J Ophthalmol 2010;149:482–7. e481e2. 44. Fang YT, Chien LN, Ng YY, et al. Association of hospital and surgeon operation volume with the incidence of postoperative endophthalmitis: Taiwan experience. Eye 2006;20:900–7.
45. Bell CM, Hatch WV, Cernat G, Urbach DR. Surgeon volumes and selected patient outcomes in cataract surgery: a population-based analysis. Ophthalmology 2007;114:405–10. 46. Ravindran RD, Venkatesh R, Chang DF, et al. Incidence of post-cataract endophthalmitis at Aravind Eye Hospital: outcomes of more than 42,000 consecutive cases using standardized sterilization and prophylaxis protocols. J Cataract Refract Surg 2009;35:629–36. 47. Baillif S, Ecochard R, Hartmann D, et al. [Intraocular lens and cataract surgery: comparison between bacterial adhesion and risk of postoperative endophthalmitis according to intraocular lens biomaterial]. J Franc Ophtalmol 2009;32:515–28. 48. Moshirfar M, Feiz V, Vitale AT, et al. Endophthalmitis after uncomplicated cataract surgery with the use of fourthgeneration fluoroquinolones: a retrospective observational case series. Ophthalmology 2007;114:686–91. 49. Norregaard JC, Thoning H, Bernth-Petersen P, et al. Risk of endophthalmitis after cataract extraction: results from the International Cataract Surgery Outcomes study. Br J Ophthalmol 1997;81:102–6.
Footnotes and Financial Disclosures Originally received: March 20, 2015. Final revision: August 13, 2015. Accepted: August 15, 2015. Available online: ---.
Author Contributions:
Manuscript no. 2015-467.
1
Department of Ophthalmology, Ophthalmology Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran.
2
Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran. Presented at: American Society of Cataract and Refractive Surgery Annual Meeting, April 2015, San Diego, California. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. No funding was received.
Conception and design: Jabbarvand, Hashemian, Khodaparast, Tabatabaei Analysis and interpretation: Jabbarvand, Hashemian, Khodaparast, Tabatabaei, Jouhari, Rezaei Data collection: Hashemian, Khodaparast, Rezaei, Jouhari Obtained funding: Jabbarvand Overall responsibility: Hashemian Abbreviations and Acronyms: ECCE ¼ extracapsular cataract extraction; ESCRS ¼ European Society of Cataract & Refractive Surgeons; IOL ¼ intraocular lens. Correspondence: Hesam Hashemian, MD, Farabi Eye Hospital, Qazvin Square, Tehran, Iran. E-mail: [email protected].
7
Cataract surgery is by far the most common ocular surgery performed worldwide. Postoperative endophthalmitis is a raredbut disastrousdcomplication of cataract surgery, with a reported incidence of 0.04% to 0.41%.1 Although it is not prevalent, it presents an important public health problem. The worldwide aging population likely will result in a higher rate of cataract surgeries in the near future. Postoperative endophthalmitis often is associated with serious morbidity and high medical care expenses. Visual outcomes after endophthalmitis often are poor: one third of individuals do not gain vision better than counting fingers, and 50% do not recover vision better than 20/40.2 In some cases, even anatomic distortion of the globe occurs.
2015 by the American Academy of Ophthalmology Published by Elsevier Inc.
In recent years, cataract surgery technique has improved progressively with the use of injectable lenses and topical anesthesia, microincisions, and sutureless surgical wounds. All of these changes may have reduced the rate of postoperative endophthalmitis. So, it is useful to analyze epidemiologic data and the epidemiologic factors associated with surgical infection to prevent its appearance and consequences. The objective of this study was to evaluate the effect of epidemiologic and surgical factors on endophthalmitis occurring after cataract surgery and to assess prophylaxis techniques, treatment methods, and outcomes in a referral center in Iran. One of the advantages of this study in comparison with previous reports is its single-center nature, which may decrease some confounding factors.
http://dx.doi.org/10.1016/j.ophtha.2015.08.023 ISSN 0161-6420/15
1
Ophthalmology Volume -, Number -, Month 2015
Methods We retrospectively analyzed the electronic medical records of 480 104 eyes of patients who had undergone senile cataract surgery at Farabi Eye Hospital, Tehran, Iran, from 2006 through 2014. The Farabi Eye Hospital Institutional Review Board approved the study protocol. We identified all cases of endophthalmitis occurring after cataract surgery within this interval. We reexamined the patients who had endophthalmitis and evaluated their risk factors and their final visual results. The diagnosis of endophthalmitis was based on clinical examination indicating an inflammatory reaction out of proportion to the surgical trauma during the normal course of postoperative care, warranting intraocular sampling for bacterial culture. All the patients with a diagnosis code for endophthalmitis using the International Classification of Diseases, Ninth Revision, Clinical Modification codes or similar codes in older records were considered as endophthalmitis: 360.00, purulent endophthalmitis, unspecified; 360.01, acute endophthalmitis; 360.02, panophthalmitis; 360.03, chronic endophthalmitis; and 360.04, vitreous abscess.3 We retrospectively evaluated the following variables between the cases and the entire study population: demographic factors, systemic diseases, prophylactic antibiotic regimen (preoperative, intraoperative, or postoperative antibiotics), bacterial species of infection, management of the endophthalmitis, experience level of the cataract surgeon, patient socioeconomic status, method of surgery, intraoperative complications, and final visual acuity. When endophthalmitis was suspected, a vitreous biopsy was performed immediately and sent to the microbiological laboratory for smear and culture and antibiogram analyses. Endophthalmitis was managed according to the recommendations of the Endophthalmitis Vitrectomy Study.4 According to an antibiotic protocol for cataract surgery in Farabi Eye Hospital, which is followed by all ophthalmologists, all patients received 5% povidoneeiodine for 5 minutes before surgery. At the time of discharge, the patients were prescribed a topical antibioticecorticosteroid solution (betamethasone 0.1% combined with either ciprofloxacin 0.3% or chloramphenicol 0.5%) in tapering dosages during a 45-day postoperative period. Records were excluded if data indicated the eye had undergone previous intraocular surgery. Based on the level of surgeon experience, surgeries were classified as performed by full-time attending or in-training surgeons. Analysis of the latter group’s records was carried out depending on whether the surgeon was a resident or fellow. Fulltime attending physicians performed 72% of surgeries.
Statistical Analysis All statistical analyses were performed using SPSS software (SPSS, Inc., Chicago, IL). Means and standard deviations of quantitative variables and distribution of frequencies of qualitative variables were studied. A Pearson chi-square test and an independent sample test were used for risk factors analysis. P values less than 0.05 were considered statistically significant. Multivariate logistic regression analysis was performed to evaluate diabetes, vitreous loss, and antibiotic prophylaxis as independent risk factors for endophthalmitis.
Results Analysis of medical records revealed 112 endophthalmitis cases among 480 104 operations, indicating a postoperative endophthalmitis incidence of 0.023%. The mean agestandard deviation
2
of the entire cataract surgery population was 799.5 years. Endophthalmitis developed in patients with a mean age standard deviation of 817.8 years. Table 1 shows the summary of clinical findings and specifications of patients with endophthalmitis. The average period between surgery and the diagnosis of endophthalmitis was 8 days. One hundred cases (89%) were diagnosed with acute-onset endophthalmitis (within 6 weeks of surgery) and 12 eyes (11%) had late-onset endophthalmitis (>6 weeks from the time of surgery). The cataract surgery technique was reported in all cases. In approximately 98.3% of the entire study population, phacoemulsification surgery was performed with a clear corneal 3.2-mm incision. Endophthalmitis occurred in 100 eyes (89%) after phacoemulsification and in 12 eyes (11%) after extracapsular cataract extraction. Nearly one-fifth of postcataract surgery endophthalmitis cases (17.9%) had experienced posterior capsule rupture and vitreous loss in the initial cataract surgery. Table 2 shows the distribution of cataract surgery techniques performed and the incidence of vitreous loss. A higher incidence of endophthalmitis was present in the extracapsular cataract extraction (P ¼ 0.006), vitreous loss, and diabetic groups. Of all the patients who underwent cataract surgery, 5.4% were diabetic, whereas 16 of 112 endophthalmitis cases (14.3%) occurred in patients with diabetes mellitus (P ¼ 0.004). Multivariate logistic regression analysis demonstrated that diabetes (P ¼ 0.018) and vitreous loss (P < 0.001) were independent risk factors for endophthalmitis. We observed a 7-fold and 3-fold increase in the rate of endophthalmitis among those with vitreous loss and diabetes, respectively (odds ratios, 7.83 and 2.92, respectively, for vitreous loss and diabetes). Among the 112 cases of endophthalmitis, 4 cases (3.6%) were aphakic, 34 of the implanted lenses were hydrophobic (30.4%), and 74 lenses were hydrophilic (66%). Among the entire cataract surgery population, 42.4% had hydrophobic lenses and 57.6% had hydrophilic lenses. A total of 15.3% of patients received preoperative antibiotic eye drops (ciprofloxacin 0.3%). Intracameral cefuroxime was used at the end of cataract surgery in 25 920 patients (5.4%); endophthalmitis did not develop in any of these patients (P ¼ 0.0001). Table 3 shows the single risk factor analysis for prophylaxis antibiotic usage. Single-variable analyses showed that the use of intracameral antibiotics was the decisive prophylactic factor for the development of postoperative endophthalmitis. Among all vitreous samples obtained from endophthalmitis cases, 41 samples (36.6%) showed positive culture results; the
Table 1. Summary of Demographic Data of All Endophthalmitis Cases Gender Male Female Affected eye Right Left Diabetes Lacrimal drainage disease Vitreous loss Location Rural Urban Data are no. (%).
52 (46.4) 60 (53.6) 46 66 16 16 20
(41.1) (58.9) (14.3) (14.3) (17.9)
28 (25) 84 (75)
Jabbarvand et al
Endophthalmitis after Cataract Surgery
Table 2. Rate of Endophthalmitis According to Different Factors
Surgery type Phacoemulsification ECCE Vitreous loss Yes No Diabetes mellitus Yes No IOL type Hydrophobic Hydrophilic
Cases in the Total Population, No. (%)
No. of Endophthalmitis Cases and Rate (%) of Endophthalmitis by Variable
471 840 (98.3) 8160 (1.7)
100 (0.021) 12 (0.14)
12 960 (2.7) 467 040 (97.3)
20 (0.15) 92 (0.019)
25 926 (5.4) 454 178 (94.6)
16 (0.06) 96 (0.02)
202 604 (42.2) 276 540 (57.6)
38 (0.018) 74 (0.026)
Odds Ratio
95% Confidence Interval
0.078
0.0428e0.1420
<0.001
7.83
4.83e12.70
0.004
2.92
1.72e4.96
0.08
0.7
0.47e1.04
P Value 0.006
ECCE ¼ extracapsular cataract extraction; IOL ¼ intraocular lens. The percentage in the third column is the rate of the variable among the entire population (e.g., 98.3% of the entire population underwent phacoemulsification). The percentage in the fourth column is the rate of endophthalmitis in the specific variable group (e.g., 0.021% of the patients who underwent phacoemulsification had endophthalmitis).
Discussion
remaining 71 cases (63.4%) with a clinical diagnosis of endophthalmitis showed negative culture results. Gram-positive species were the main cause, accounting for 33 cases (80%). The final visual acuity was better in patients with negative culture results or coagulase-negative staphylococci. In contrast, eyes with enterococci and Pseudomonas species had worse final vision. Final visual acuity was no light perception in 2 eyes, and 1 of these eyes was eviscerated because of severe corneal melting (Table 4). Patients were categorized into 2 groups based on their location: 38 880 patients (8.1%) were from rural areas and 441 120 patients (91.9%) were from urban areas. Records showed that endophthalmitis had significantly higher occurrence rates among rural patients (0.07%) versus urban patients (0.02%; P ¼ 0.001). Table 5 compares the endophthalmitis rates among different surgeon groups based on their level of experience. The ratio of the cases with endophthalmitis to the number of all patients undergoing cataract surgery was higher among residents compared with surgical fellows and attending surgeons. However, no statistically significant differences were observed in endophthalmitis rates between residents, fellows, and full-time attending physicians when analyzed by linear-by-linear association or the chi-square test. The distribution of endophthalmitis cases according to eye laterality demonstrated a higher incidence of endophthalmitis in the left eye (58.9%); in contrast, a higher number of right eyes underwent cataract surgery (264 000 [55%]), so the endophthalmitis rate was statistically significantly higher in the left eye compared with the right eye (P ¼ 0.03).
This study is one of the largest studies of endophthalmitis occurring after cataract surgery. We designed this study to evaluate the prevalence, the clinical and surgical aspects, and the role of systemic disease and prophylactic antibiotics in endophthalmitis after cataract surgery. This study established rates of endophthalmitis secondary to cataract surgery in the Farabi Eye Hospital, a tertiary care referral hospital in Tehran, Iran. The surgeries were performed by residents engaged in surgical training as well as fellows and full-time attending physicians. Previous reports stated different incidence rates for endophthalmitis occurring after cataract surgery ranging from 1 per 300 cataract procedures to no events over several years.5e8 We found a global endophthalmitis prevalence of 0.023%, comparable with the incidences of 0.029%9 and 0.048%10 in Sweden, and lower than the incidences of 0.06% in China,11 0.09% in the United Kingdom,12 0.14% in Ontario, Canada,13 and 0.15% in Quebec, Canada.14 A systematic review of publications from 1964 through 2003 that included 3 140 650 cataract extractions estimated an endophthalmitis rate of 0.128%.15 The differences among these studies may be the result of differences in prophylactic regimens, differences in sensitivity of the
Table 3. Single Risk Factor Analysis for Prophylactic Antibiotic Use
No antibiotic Preoperative systemic antibiotic Preoperative topical antibiotic Intracameral antibiotic Subconjunctival antibiotic
Total No. of Cases
Proportion of Cases (%)
No. of Endophthalmitis Risk of Cases Endophthalmitis (%)
Odds of Endophthalmitis
Confidence Interval
260 744 47 520
54.6 9.8
84 6
0.032 0.012
1 0.51
0.18e1.44
76 800
15.9
12
0.015
0.62
0.28e1.35
25 920 69 120
5.4 14.3
0 10
0.000 0.014
0 0.58
0.90e0.98 0.25e1.34
3
Ophthalmology Volume -, Number -, Month 2015 Table 4. Culture Results and Final Visual Outcomes Species
No. (%)
Negative 71 Coagulase-negative Staphylococci 14 Staphylococcus aureus 6 Enterococci 7 Pseudomonas species 4 Enterobacteriaceae species 2 Other gram-positive bacteria 6 Other gram-negative bacteria 2 Total 112
Mean Corrected Distance Visual Acuity*
(63.4) (12.5) (5.4) (6.3) (3.6) (1.8) (5.4) (1.8) (100)
0.42 0.47 0.55 0.9 1.12 0.65 0.5 0.4 0.5
(20/52) (20/59) (20/70) (20/158)y (20/260)y (20/89) (20/63) (20/50) (20/63)
*Logarithm of the minimum angle of resolution (Snellen equivalent). y Two patients had no light perception vision. Pseudomonas aeruginosa was found in one culture and Enterococci was found in the other.
definition of endophthalmitis, and finally racial and socioeconomic differences. One of the main advantages of this study over previous endophthalmitis studies is that we enrolled patients who underwent cataract surgery at a single eye hospital with the same operating rooms, surgical instruments, and protocols of sterilization so we could eliminate the confounding factors that may affect the result. An unavoidable drawback directly related to the retrospective nature of studies of endophthalmitis is missing cases (e.g., if a patient who underwent cataract surgery in our center goes to another center after endophthalmitis occurs). The primary assumption for all of these studies is that all patients who underwent surgery would return to the same center in case of any complications. We believe that because of the position of Farabi Eye Hospital in Iran, this bias is very unlikely to happen. Farabi Eye Hospital is by far the largest referral center in Iran, and most of the referrals across the country are made to it. The relationship between Farabi Eye Hospital and ophthalmologists nationwide makes it extremely unlikely that patients who undergo surgery at Farabi Eye Hospital receive treatment for postoperative complications elsewhere. All ophthalmologists who perform surgery in Farabi Eye Hospital visit postoperative patients there. We identified a 7-fold increase in the odds of endophthalmitis associated with intraoperative vitreous loss, and this complication was identified in association with 18% of endophthalmitis cases in this study. The role of vitreous loss in promoting endophthalmitis was first identified by Javitt
et al16 in 1991 and has been confirmed in numerous subsequent reports.5,9,17,18 Nearly 20% of our patients with endophthalmitis had diabetes mellitus, which is much higher than the rate of total cataract surgery (4.3%). Diabetes increased the odds of endophthalmitis approximately 3-fold. Other previous reports also have mentioned diabetes as an independent risk factor of endophthalmitis.17e19 Because the source of most of the bacterial causes of postoperative endophthalmitis is the patient’s fornix, eyelid, and conjunctiva,20,21 preoperative disinfection of periocular surfaces is very effective for endophthalmitis prophylaxis. As the accepted protocol in Farabi Eye Hospital, all surgeons perform periorbital disinfection using gauze soaked with povidoneeiodine for 5 minutes. Povidoneeiodine is applied in the conjunctival sac at least 1 minute before surgery. This may help to reduce the endophthalmitis rate in Farabi Eye Hospital compared with previously mentioned studies. Ciulla et al,22 in a literature review, concluded that preoperative povidoneeiodine is the single most effective means for reducing the risk for postoperative endophthalmitis. The role of antibiotics in surgical prophylaxis continues to be controversial. No cases of endophthalmitis were observed among the 25 920 patients who received intracameral cefuroxime, suggesting that this approach to antibiotic prophylaxis may be far more effective than traditional topical or subconjunctival approaches. This finding is in accordance with previous prospective and retrospective studies.9,10,17,23e25 Recently, a study from Portugal reported a decrease in the endophthalmitis rate from 0.26% to 0% after use of intracameral cefuroxime.26 A 5-fold risk reduction also was reported in the randomized, multicenter European Society of Cataract and Refractive Surgeons study.5,23 A Spanish study27 reported a reduction in the risk of endophthalmitis, from 0.59% to 0.043%, after cefuroxime. However, some studies28 reported lower rates of endophthalmitis with no use of intracameral antibiotics compared with the European Society of Cataract and Refractive Surgeons (ESCRS) cefuroxime group (0.07%). In this study, we observed a lower total rate of endophthalmitis also. An appropriate antibiotic for intracameral use should be safe for intracameral use, have broad antimicrobial coverage, and be prepared easily. Cefuroxime is a broadspectrum drug, and although intracameral use is off label,
Table 5. Distribution of Endophthalmitis According to Surgeon Experience and Eye Laterality Surgeon Skill Resident in training <5 mos* >5 mosy Fellow in training Full-time attending physician
No. (%) of Patients (n [ 480 104) 90 740 34 567 8641 346 155
No. (%) of Endophthalmitis Cases (n [ 112)
(18.9) (7.2) (1.8) (72.1)
*Residents with fewer than 5 months of experience in cataract surgery. y Residents with more than 5 months of experience in cataract surgery.
4
30 14 1 67
(26.7) (12.5) (0.9) (59.8)
Endophthalmitis Rate (%)
P Value
0.03 0.04 0.01 0.01
0.46
Jabbarvand et al
Endophthalmitis after Cataract Surgery
it has been proven to be safe.29,30 A review of the preferred practice in European countries reported that intracameral cefuroxime still is not used widely by European ophthalmologists.31 The main drawback of its use is the risk of miscalculation of dosage or contamination during preparation because it is not available in many countries, including Iran, as a commercial preparation for intracameral use. Although there were no reports of side effects in Farabi Eye Hospital, there are some reports of adverse effects resulting from overdoses of the drug in the literature.30,32 Fortunately, a specific commercial preparation with the necessary concentration (0.1 mg/ml) for intracameral use, called Aprokam (Laboratoires Théa, Clermont-Ferrand, France),33 has been available in Europe since 2012. The other drawback of this drug is its insufficient antibacterial coverage over highly virulent enterococci and some gram-negative bacteria.9 We believe that because of the proven effect of intracameral cefuroxime, it should be used at least in patients with a higher risk of endophthalmitis (i.e., those with diabetes or whose cataract surgery was complicated). This study showed that short-term pretreatment with topical or systemic antibiotics or postoperative subconjunctival injection of antibiotics can reduce postoperative endophthalmitis, but the difference was not statistically significant (P ¼ 0.2). These prophylaxis roots were associated with a 40% to 50% reduced odds of endophthalmitis compared with no prophylaxis. It should be recognized that our study was retrospective and observational, and therefore, we could not change the antibiotic types or dosage. There is no consensus in the literature for the effect of prophylactic antibiotics to prevent endophthalmitis. Shortterm pretreatment of topical antibiotics reduced the conjunctival microbial burden in several reports.34e37 However, another study38 reported that using postoperative antibiotic adds no benefit for reducing the rate of endophthalmitis after intracameral usage of cefuroxime. Intracameral cefuroxime has been reported to be 3 times more effective for endophthalmitis prophylaxis than subconjunctival cefuroxime.24 However, we believe that a prospective clinical trial is required to evaluate completely the effectiveness of different kinds and routes of prophylactic antibiotics on cases of postsurgical endophthalmitis. Older age was a risk factor for endophthalmitis in this study, which is consistent with previous reports.10,14,39,40 Two possible causes would explain this finding. First, with aging, a cataract hardens and zonules weaken, so the operation will be more prone to complication, and endophthalmitis is more prevalent in complicated cataract surgery. Second, more bacteria are present in the conjunctiva of older patients compared with that of younger patients.41,42 Isolating the organism is the mainstay of the antibacterial therapy of endophthalmitis. Only 41 of 112 vitreous culture results were positive. Previous studies reported grampositive bacteria as the most common isolated bacteria.43 In this study, coagulase-negative Staphylococcus was the most prevalent isolated bacteria, which is consistent with previous reports.43
This study also demonstrated a higher rate of endophthalmitis in the left eye. It may be the result of the incision site being placed in the left eye by a right-handed surgeon: the main incision is near the upper lid margin, but in the right eye, the stab incision is near upper lid and the main incision is in the palpebral fissure. Considering lid margin flora as the main cause of endophthalmitis, it may justify the difference of the infection rate between the 2 eyes. Previous studies3,44,45 reported that longer surgical experience and a higher annual volume of surgery decreased the risk of postoperative endophthalmitis, but they did not involve surgeons still in training. We found a higher rate of endophthalmitis patients treated by residents, but the difference was not significant. This is comparable with the previous report by Ravindran et al.46 The effect of intraocular lens materials is controversial. Baillif et al47 found greater bacterial adherence to hydrophobic lenses compared with hydrophilic lenses. In our study, the endophthalmitis rate was higher in the hydrophilic group (0.026% vs. 0.018%), but the difference was not significant (P ¼ 0.08). In this report, the incidence of endophthalmitis among patients who underwent phacoemulsification was only 0.021%. This is comparable with reported rates after phacoemulsification from the United States and other countries.1,9,10,48 The endophthalmitis rate was significantly higher in patients who underwent extracapsular cataract extraction for cataract extraction (0.14%). Norregaard et al49 reported a comparable rate of 0.18% in a study of extracapsular cataract surgery performed in Denmark. Because phacoemulsification is the preferred cataract surgery technique in Farabi Eye Hospital, extracapsular cataract surgery is performed primarily either in mature cataracts or in cases with higher rates of complications (e.g., zonulysis), or secondarily in cases of failed phacoemulsification. So the higher rate of endophthalmitis associated with the extracapsular technique may be the result of different patient specifications and not of a higher risk associated with the technique. In conclusion, older age, intraoperative vitreous communication, systemic diseases such as diabetic mellitus, and rural residence are associated with a higher risk of postoperative endophthalmitis. Whereas antibiotic prophylaxis overall showed a 40% to 50% reduction in risk, intracameral cefuroxime was 100% effective in preventing endophthalmitis in this series.
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Footnotes and Financial Disclosures Originally received: March 20, 2015. Final revision: August 13, 2015. Accepted: August 15, 2015. Available online: ---.
Author Contributions:
Manuscript no. 2015-467.
1
Department of Ophthalmology, Ophthalmology Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran.
2
Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran. Presented at: American Society of Cataract and Refractive Surgery Annual Meeting, April 2015, San Diego, California. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. No funding was received.
Conception and design: Jabbarvand, Hashemian, Khodaparast, Tabatabaei Analysis and interpretation: Jabbarvand, Hashemian, Khodaparast, Tabatabaei, Jouhari, Rezaei Data collection: Hashemian, Khodaparast, Rezaei, Jouhari Obtained funding: Jabbarvand Overall responsibility: Hashemian Abbreviations and Acronyms: ECCE ¼ extracapsular cataract extraction; ESCRS ¼ European Society of Cataract & Refractive Surgeons; IOL ¼ intraocular lens. Correspondence: Hesam Hashemian, MD, Farabi Eye Hospital, Qazvin Square, Tehran, Iran. E-mail: [email protected].
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