Endophthalmitis following cataract surgery in Sweden: national prospective survey 1999-2001

Incidence of postoperative retinal detachment and bacterial endophthalmitis in the Swedish national paediatric cataract register and associated risk factors

PURPOSE

To investigate the incidence and risk factors of retinal detachment (RD) and bacterial endophthalmitis in a cohort of children who underwent cataract surgery before the age of eight.

METHODS

Data was retrieved from the Swedish national paediatric cataract register. All eyes with congenital or infantile cataract that underwent surgery between January 1, 2007, and December 31, 2023 with at least one follow-up were included. Cases associated with trauma, uveitis or RD at surgery were excluded. Parameters that could be important for complications were analysed.

RESULTS

RD was found in seven of 1073 eyes reflecting an incidence of 0.65%. There were no statistically significant differences in age at surgery, presences of intellectual disability or general disease, cataract type, surgical technique, axial length, corneal diameter, previous glaucoma surgery or occurrence of persistent fetal vasculature (PFV), although the frequency of glaucoma surgery and PFV was higher in RD cases; 42.9% versus 13.2% and 57.1% versus 26.0%. Aphakia was significantly more common in RD patients; 71.4% versus 19.3% (p = 0.042), as well secondary glaucoma; 57.1% versus 19.5% (p = 0.032). No cases of endophthalmitis were observed.

CONCLUSION

The incidence of RD was low compared to previous studies and no endophthalmitis was found. This might be a result of centralized paediatric cataract care with few but experienced surgeons. Aphakia and secondary glaucoma were associated with higher RD risk and those cases should be followed carefully. PFV and glaucoma surgery were found at a higher frequency in RD cases prompting comprehensive postoperative care also for these children.

Impact of discontinuation of cephazolin prophylaxis on the incidence of postoperative adverse events in cataract surgery

BACKGROUND

Cataract surgeries are increasing annually, making appropriate medical management essential. The routine use of systemic antimicrobial agents for preventing surgical site infections lacks strong evidence and may increase the risk of drug-resistant bacteria and adverse events. This study examined the impact of discontinuing cefazolin (CEZ) administration during the perioperative period of cataract surgery on the incidence of postoperative adverse events and medical costs.

METHODS

Inpatient cataract surgery patients were divided into two groups: the CEZ-use group (April 2021 to March 2022) and the non-CEZ-use group (April 2022 to March 2023). The primary endpoints were the incidence of adverse events and medical costs, while the secondary endpoint was the incidence of endophthalmitis.

RESULTS

A total of 265 patients were in the CEZ group, and 316 were in the non-CEZ group. Six postoperative adverse events (2.3%, 95% confidence interval: 0.8-4.9) occurred in the CEZ group, with an estimated 230 patients (80-490 from the 95% confidence interval) expected to experience adverse events per 10,000 patients using CEZ. The non-CEZ group had no adverse events and reduced drug costs by approximately 46,000 yen. Insurance claim amounts were also reduced. No cases of early postoperative endophthalmitis were observed in either group.

CONCLUSIONS

Discontinuation of CEZ prophylaxis during the perioperative period of cataract surgery effectively reduced the risk of adverse events. Medical for the period after discontinuing CEZ did not increase.

TRIAL REGISTRATION

Retrospectively registered.

Impact of Patient Characteristics and Surgery-Related Risk Factors on Endophthalmitis after Cataract surgery: A Meta-Analysis

INTRODUCTION

Cataracts are the leading cause of blindness worldwide, with a notably high incidence rate. Endophthalmitis is the most severe complication following cataract surgery, often resulting in profound vision loss. This study evaluates the impact of risk factors such as age, sex, diabetes mellitus (DM), hypertension, posterior capsule rupture (PCR), type of surgery, and use of intraocular lens (IOL) material on the risk of endophthalmitis after cataract surgery.

METHODS

English and Chinese public databases were searched from inception to March 1, 2024. We included studies reporting the number of occurrences of endophthalmitis after cataract surgery on potential risk factors, including age, sex, DM status, hypertension status, intraoperative PCR, type of surgery and use of IOL material. The quality of the included studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 57 studies were included and critically evaluated in the meta-analysis. The results showed that female sex was associated with a lower risk of endophthalmitis (odds ratio [OR]: 0.81; 95% CI: 0.75-0.87; p < 0.001). Individuals with diabetes who underwent cataract surgery were found to have a greater risk of endophthalmitis (I2 = 95%; OR: 4.90; 95% CI: 2.41, 9.95; p < 0.001), but the result may be influenced by publication bias. Individuals with hypertension (OR: 2.88; 95% CI: 1.53, 5.45; p = 0.001) and intraoperative PCR (OR: 9.18; 95% CI: 3.31, 25.43; p < 0.001) were found to have a greater risk of endophthalmitis. Phacoemulsification significantly reduced the risk of endophthalmitis compared with extracapsular cataract extraction (ECCE) (OR: 0.62; 95% CI: 0.45, 0.85) based on network meta-analysis.

CONCLUSION

Male sex, hypertension, intraoperative PCR, and the use of the ECCE surgical approach are associated with a greater risk of postoperative endophthalmitis. Although an age-related trend in elevated risk was observed, this finding should be interpreted cautiously.

Prophylactic antibiotics for postcataract surgery endophthalmitis: a systematic review and network meta-analysis of 6.8 million eyes

To reveal optimal antibiotic prophylactic regimen for postoperative endophthalmitis (POE), we conducted systematic review and network meta-analysis. A total of 51 eligible original articles, including two randomized controlled trials, were identified. In total, 4502 POE cases occurred in 6,809,732 eyes (0.066%). Intracameral injection of vancomycin had the best preventive effect (odds ratio [OR] 0.03, 99.6% confidence interval [CI] 0.00-0.53, corrected P-value = 0.006, P-score = 0.945) followed by intracameral injection of cefazoline (OR 0.09, 99.6% CI 0.02-0.42, corrected P-value < 0.001, P-score = 0.821), cefuroxime (OR 0.18, 99.6% CI 0.09-0.35, corrected P-value < 0.001, P-score = 0.660), and moxifloxacin (OR 0.36, 99.6% CI 0.16-0.79, corrected P-value = 0.003, P-score = 0.455). While one randomized controlled trial supported each of intracameral cefuroxime and moxifloxacin, no randomized controlled trial evaluated vancomycin and cefazoline. Sensitivity analysis focusing on the administration route revealed that only intracameral injection (OR 0.19, 99.4% CI 0.12-0.30, corrected P-value < 0.001, P-score = 0.726) significantly decreased the risk of postoperative endophthalmitis. In conclusion, intracameral injection of either vancomycin, cefazoline, cefuroxime, or moxifloxacin prevented POE.

Establishing in vitro and in vivo Co-culture Models of Staphylococcus epidermidis and Enterococcus faecalis to Evaluate the Effect of Topical Fluoroquinolone on Ocular Microbes

Purpose: To establish in vitro and in vivo ocular co-culture models of Staphylococcus epidermidis and Enterococcus faecalis and to study how various concentrations of moxifloxacin affect the survival of these two endophthalmitis-causing bacteria. Methods: Standard strains of S. epidermidis and E. faecalis were used. Color detection agar plates were employed to distinguish their colonies. To establish the in vitro and in vivo co-culture models, S. epidermidis and E. faecalis were co-cultivated at different ratios for various periods. For the in vivo model, various volumes and concentrations of either a mono-culture or co-culture were inoculated into the lower conjunctival sac of rabbits. Finally, the newly developed in vitro and in vivo co-culture models were subjected to the moxifloxacin treatment to access its effect on S. epidermidis and E. faecalis. Results: When S. epidermidis and E. faecalis were cultured separately in tryptic soy broth, their growth peaked and plateaued at approximately 16 and 6 h, respectively. When they were co-cultured, the growth peak of S. epidermidis got delayed, whereas the growth peak of E. faecalis did not change. The number of E. faecalis was significantly higher in the co-culture than that in the mono-culture. Treatment with moxifloxacin in the in vitro co-culture model rapidly decreased the number of S. epidermidis cells at doses ≥ 0.125 μg/ml. In contrast, the number of E. faecalis did not change significantly up to 16 μg/ml moxifloxacin. In in vivo co-culture (at 1:1), the S. epidermidis count decreased in a pattern similar to that seen in in vivo mono-culture and was barely detectable at 24 h after inoculation. In contrast, the of E. faecalis count increased up to 16 h and then decreased. When moxifloxacin was applied (zero, one, or two times) to this model, the S. epidermidis count decreased in proportion to the number of treatments. In contrast, the E. faecalis count increased with moxifloxacin treatment. Conclusions: The in vitro and in vivo co-culture models of S. epidermidis and E. faecalis were established to determine the influence of moxifloxacin eye drops on these bacteria. The results clearly show that the moxifloxacin eye drops can make E. faecalis dominant on the ocular surface.

Incremental effect of topical and oral moxifloxacin administration with surgical intracameral prophylaxis

OBJECTIVE

To determine how supplemental perioperative topical or oral moxifloxacin administration impacts anterior chamber (AC) antibiotic concentrations beyond those achieved by intracameral (IC) administration alone for postoperative endophthalmitis (POE) prophylaxis.

DESIGN

Mathematical modeling.

METHODS

The mathematical model developed by Arshinoff, Modabber, and Felfeli was adapted to calculate all reported data. A literature review of pharmacokinetic data for topical and oral moxifloxacin was used to inform the expansion of the model.

RESULTS

Our previously constructed IC model yields a dose of moxifloxacin in the AC sufficient to confer bactericidal coverage against the most common POE pathogen, methicillin-sensitive Staphylococcus aureus (MSSA), for ∼40 hours postoperatively. Topical 0.5% moxifloxacin eye drops alone, administered every 4 or 6 hours, achieve an AC concentration just above or at the mutant prevention concentration (MPC) for MSSA, respectively, whereas 8-hour dosing produces levels generally below the MPC. Combining topical moxifloxacin with IC increases the AC concentration above IC alone only after 20 or more hours and maintains the AC concentration at, or just below, the MPC for MSSA for as long as the drops are continued. Combined perioperative oral moxifloxacin with IC increases AC levels over IC alone only after 16 hours and maintains the AC concentration above the MPC for MSSA for an additional 5 hours, owing to the systemic reservoir.

CONCLUSIONS

The addition of topical or oral moxifloxacin supplemental to IC can extend the duration of bactericidal coverage for the most common, but not the most resistant POE-causing pathogens.

Cefuroxime (Aprokam®) in the Prophylaxis of Postoperative Endophthalmitis After Cataract Surgery Versus Absence of Antibiotic Prophylaxis: A Cost-Effectiveness Analysis in Poland

OBJECTIVE

The analysis aims to assess the cost-effectiveness of cefuroxime (Aprokam®) in the prophylaxis of postoperative endophthalmitis (POE) after cataract surgery compared with the absence of antibiotic prophylaxis from the National Health Fund perspective in Poland.

METHODS

We performed a cost-effectiveness and cost-utility analysis using the decision tree and Markov model, respectively, for patients after cataract surgery. The efficacy of Aprokam was 0.21 (95% confidence interval [CI], 0.08-0.55) and is based on the results of the European Society of Cataract and Refractive Surgery study. According to the epidemiological data from Poland, the risk of POE is 0.377%. The costs associated with the Aprokam administration and POE treatment costs were included. We determined the utilities of the health states in the model depending on visual loss due to POE. To determine the uncertainty of estimates parameters, a one-way deterministic and probabilistic sensitivity analysis were performed.

RESULTS

Using Aprokam allows avoiding 0.003 POEs per patient. The benefit from the intervention is 0.0007 quality-adjusted life years per patient in the lifetime horizon. The total costs of prophylaxis are higher at about €1.70. The cost of avoiding one POE (incremental cost-effectiveness ratio) is about €569.85. The estimated incremental cost-effectiveness utility ratio is equal to €2427.72/quality-adjusted life-years, and it is significantly lower than the cost-effectiveness threshold in Poland in 2019 (about 7.5% of the threshold). In all scenarios of performed one-way sensitivity analyses, Aprokam is cost-effective.

CONCLUSIONS

In Poland, the use of Aprokam is cost-effective, with the estimated incremental cost-utility ratio significantly lower than the cost-effectiveness threshold.

Topical cell-free conditioned media harvested from adipose tissue-derived stem cells promote recovery from corneal epithelial defects caused by chemical burns

Corneal chemical burns can lead to blindness following serious complications. As most of these complications are caused by failure of reepithelization during the acute phase, treatment at this stage is critical. Although there have been some studies on corneal injury recovery using adipose tissue-derived stem cells (ADSCs), none has reported the effect of topical cell-free conditioned culture media (CM) derived from ADSCs on corneal epithelial regeneration. Here, the best conditions for CM were selected and used for in vitro and in vivo experiments. Corneal burn in rats was induced using 100% alcohol. The chosen CM was administered to corneal burn rats (CM-treated [CT] group) four times a day for three days and this group was compared with the normal control and corneal burn (CB) groups. Biomicroscopic fluorescence images and the actual physical corneas were taken over time and used for analysis. mRNA levels of hepatocyte growth factor and epidermal growth factor (EGF) were significantly increased, whereas those of vascular endothelial growth factor, interleukin (IL)-1β, IL-6, IL-10, and matrix metalloproteinase-9 were significantly decreased in the CT group compared with those in the CB group. The numbers of proliferating cell nuclear antigen- and zonular occludens-1-positive cells in the CT group were significantly higher than those in the CB group. The macrophage-infiltrating corneas in the CT group expressed significantly more of the M2 marker arginase than corneas in the CB group. Optimal CM (× 0.5 concentration) treatment significantly accelerated the migration of corneal epithelial cells and induced upregulation of the expression of IL-6, EGF, and C-X-C chemokine receptor type 4 mRNAs. Overall, in this study, topical administration of cell-free CM promoted regeneration of the corneal epithelium after induction of chemical burns.

Intraoperative Cefuroxime Irrigation Prophylaxis for Acute-Onset Endophthalmitis After Phacoemulsification Surgery

Purpose

Acute-onset postoperative endophthalmitis usually compromises the visual function and anatomical integrity of the eye. The aim of this study was to evaluate the efficacy of intraoperative cefuroxime use in irrigating solution on prevention of acute-onset endophthalmitis after phacoemulsification.

Methods

This retrospective, comparative, interventional cohort study included patients who underwent phacoemulsification between January 1, 2012, and December 31, 2019. Under a uniform perioperative protocol, the patients who had surgery from January 1, 2012, to December 31, 2014, received irrigating infusion fluid containing balanced salt solution (BSS) only (group 1), and those from January 1, 2015, to December 31, 2019, received BSS with cefuroxime (1500 μg/mL) during surgery (group 2). All eyes were evaluated postoperatively, and the eyes suspected to have endophthalmitis were assessed and treated by a consultation team. The rates of postoperative endophthalmitis in these two groups were calculated.

Results

A total of 61,299 eyes were included over the eight years. Among these eyes, 11 in group 1 (0.07% of 15,948 eyes) and 5 in group 2 (0.01% of 45,351 eyes) developed endophthalmitis, and the difference was significant (P < 0.01). Five among 16 patients (31.25%) with endophthalmitis were positive in bacterial culture. The positive rate of bacterial culture was not significantly different between group 1 (4/11) and group 2 (1/5) (P > 0.05). No adverse events related to the irrigation of cefuroxime were found.

Conclusion

Intraoperative cefuroxime irrigation (1500 μg/mL) could decrease the rate of postoperative endophthalmitis after phacoemulsification by 7-fold. This study provides evidence that intraoperative irrigation with cefuroxime is effective as an antibiotic prophylaxis for endophthalmitis.

Commonly used intracameral antibiotics for endophthalmitis prophylaxis: A literature review

Endophthalmitis is a serious complication of cataract surgery that occurs in thousands of patients each year. To decrease the incidence of postoperative endophthalmitis, many surgeons inject intracameral antibiotics (cefuroxime, moxifloxacin, and vancomycin) routinely at the end of surgery. A large number of recently published retrospective studies and large database analyses have reported decreased endophthalmitis rates with routine antibiotic use, and the only prospective, multicenter, randomized trial performed by the European Society of Cataract and Refractive Surgery demonstrated that intracameral cefuroxime decreases the incidence of postoperative endophthalmitis. Routine cefuroxime use has become common in many European countries, whereas moxifloxacin is the most commonly used drug in India, and vancomycin use predominates in Australia. The decision regarding whether or not to use intracameral prophylaxis and the drug that is selected varies considerably throughout the world because of antibiotic availability and cost, and the spectrum of causative organisms. Adverse events due to intracameral antibiotics are infrequent, but complications such as hemorrhagic occlusive retinal vasculitis have been reported. Because additional prospective, comparative trials have not been performed, a consensus regarding best practices to prevent postoperative endophthalmitis has not been reached. Additionally, many surgeons do not routinely use intracameral antibiotics because they believe them unnecessary with modern aseptic techniques, small incision surgery, and shorter operating times. We discuss the most commonly used intracameral antibiotics, present the risks and potential benefits of this approach, and highlight challenges with drug compounding and safety.

Behcet's Disease Presenting With Bilateral Hypopyon Masquerading Post Cataract Surgery Endophthalmitis

PURPOSE

To report a case of Behcet's disease presented with bilateral hypopyon after sequential cataract surgery masquerading delayed onset post-operative endophthalmitis.

METHODS

A 53-year-old man with a history of sequential uneventful cataract surgeries came to our clinic with decreased vision (0.3 LogMAR) since 2 days ago and bilateral hypopyon in his both eyes. The primary diagnosis was chronic late-onset endophthalmitis.

RESULTS

There was no lid edema or chemosis on the external examination. On slit-lamp examination, the cornea was clear, the pupil was well reactive with no posterior synechia, the intraocular lens was centered with good red reflex, however, bilateral hypopyon was detected in his both eyes which was more prominent in the left eye. The eyes were fairly calm and absence of vitreous reaction on slit-lamp examination, there was no pain and photophobia. Further, on physical examination, oral mucosal ulcerations were detected. His systemic workup revealed Behcet's disease with HLA-B5 positive serology.

CONCLUSION

In cases with delayed onset hypopyon following cataract surgery, inflammatory diseases such as Behcet's disease should be considered. Appropriate history taking and physical examinations in the context of serologic laboratory investigations may lead to the proper diagnosis.

Swedish Quality Registry for Caries and Periodontal Diseases - a framework for quality development in dentistry

ObjectivesL There is a need for monitoring dental health and healthcare, as support for quality development, allocation of resources and long-term planning of dental care. The aim of this paper is to describe the concept and implementation of the Swedish Quality Registry for Caries and Periodontal Diseases (SKaPa). Materials and methods: The SKaPa receives information by automatic transfer of data daily from electronic patient dental records via secure connections from affiliated dental care organisations (DCOs). The registry stores information about DCOs, dental professionals and patients. Information on a patient level includes personal identifier, gender, age, living area, dental status, risk assessments for caries and periodontitis, and dental care provided. In addition, data generated from a global question on patient-perceived oral health are uploaded. In total, more than 400 variables are transferred to the registry and updated daily. Results: In 2018, all of the 21 public DCOs and the largest private DCO in Sweden were affiliated to SKaPa, representing a total of 1,089 public and 234 private dental clinics. The accumulated amount of information on dental healthcare covers 6.9 million individuals out of the total Swedish population of 10 million. SKaPa produces reports on de-identified data, both cross-sectional and longitudinal. Conclusion: As a nationwide registry based on automatic retrieval of data directly from patient records, SKaPa offers the basis for a new era of systematic evaluation of oral health and quality of dental care. The registry supports clinical and epidemiological research, data mining and external validation of results from randomised controlled trials

Management and Microbiological Characteristics of Membrane Formation on a Hydrophilic Acrylic Intraocular Lens: A Clinical Case Series and Material Comparative Study of Different IOLs

Background/Aims. To report a case series of membrane formation on intraocular lenses (IOLs) after uneventful phacoemulsification and to evaluate the material characteristics and biofilm formation on different IOLs. Methods. Ten eyes implanted with the same type of IOLs were found to have membranes on their IOLs after uneventful phacoemulsification from May 2015 to May 2016. No other patients were found with the same phenomenon among 11236 patients who underwent cataract surgeries during this period. To further investigate the reasons for their formation, we assessed seven types of IOLs used in our hospital, including their material characteristics and the presence of microbes (Staphylococcus epidermidis) on the IOL surface by scanning electron microscopy (SEM). All IOLs were incubated under in vitro flow conditions (BioFlux 1000Z). After 36 h, the IOLs were taken from the system, and both the bound bacteria and biofilm formation were observed. Results. Five eyes underwent intravitreal injections of ceftazidime and norvancomycin with one positive culture obtained from the anterior chamber fluid. The other five eyes only received topical treatment of gatifloxacin/levofloxacin and tobramycin. At the last follow-up, all patients had best-corrected visual acuity (BCVA) of 20/50 or better. In the biofilm study on the IOL surface, Staphylococcus epidermidis biofilms formed more readily on hydrophilic acrylic IOLs than on hydrophobic acrylic IOLs. Conclusions. Bacterial adhesion and biofilm tend to develop on certain types of IOLs because of the characteristics of the biomaterial.

The Routine Use of Intracameral Antibiotics to Prevent Endophthalmitis After Cataract Surgery: How Good is the Evidence?

Post-operative endophthalmitis (POE) following cataract surgery is an uncommon, vision-threatening complication that has been reported to occur at rates of between approximately 0.03% and 0.2%. Prompt diagnosis and treatment of endophthalmitis is critical for minimizing vision loss, but most recent efforts have focused on the prophylactic administration of antibiotics to prevent the development of endophthalmitis. Surgeons from around the world have different topical and intracameral antibiotic usage patterns to prevent endophthalmitis, and to date no general consensus regarding best practice has emerged. Several studies have reported on the routine use of intracameral cefuroxime, moxifloxacin, and vancomycin, including a single randomized clinical trial by the European Society of Cataract and Refractive Surgery (ESCRS) in 2007. These studies have notable shortcomings, but many authors suggest that intracameral cefuroxime together with topical antibiotics probably decreases the risk of endophthalmitis. However, the deleterious effects of routine prophylactic antibiotics, which include toxicity, cost, and increasing antimicrobial resistance, among others, are noteworthy. In contrast, aseptic technique with pre-operative instillation of povidone-iodine remains the only technique supported by level I evidence to reduce the incidence of endophthalmitis. Although the routine use of intracameral antibiotics continues to increase throughout the world, data from multicenter, randomized, prospective trials is needed to provide better guidance regarding the prophylactic use of antibiotics.

Toxic Anterior Segment Syndrome after Uncomplicated Cataract Surgery

Purpose

To evaluate the anterior segment examination findings and the response to medical therapy of patients who had toxic anterior segment syndrome (TASS) after uncomplicated cataract surgery.

Methods

Fourteen eyes of 14 patients were enrolled in the study. Visual acuity, biomicroscopic anterior segment examination, intraocular pressure measurement, and fundus examination were performed to assess TASS occurring during postoperative 12–48 hours after uncomplicated phaco surgery. The visual impairment, corneal edema, tyndallization, fibrin formation, hypopyon, vitritis, and response to steroid therapy were evaluated prospectively.

Results

After topical steroid therapy lasting for 1 week, visual acuity improved in 11 eyes. No significant visual improvement occurred in 3 eyes. Significant corneal edema was found in 4 and mild corneal edema was observed in the other 10 eyes. Fibrin reaction occurred in 5 and tyndallization in various degrees was positive in all eyes. There was a 1-mm hypopyon in 1 patient. There was no sign of vitritis and steroid therapy was effective in all of the patients. In addition to topical treatment with steroid and antibiotic drops; systemic and subconjunctival steroids were used in 3 patients who had fibrin formation and in one patient who had hypopyon.

Conclusions

After uncomplicated cataract surgery, toxic anterior segment may occur in the early postoperative period, which is treated successfully with steroids. More studies are needed to understand the multifactorial risk factors affecting the etiopathogenesis of this syndrome.

Endophthalmitis Following Pediatric Cataract Surgery: An International Pediatric Ophthalmology and Strabismus Council Global Perspective

PURPOSE

To compile international data on the risk factors, diagnosis, and treatment of endophthalmitis following pediatric cataract surgery.

METHODS

An e-mail containing a link to an online survey was sent to all members of the American Association for Pediatric Ophthalmology and Strabismus. The questionnaire examined the incidence, risk factors, treatment, outcomes, and prophylaxis of endophthalmitis following pediatric cataract surgery around the world.

RESULTS

Two hundred thirty-seven ophthalmologists answered the questionnaire. Eight ophthalmologists (3.4%) encountered 22 cases of endophthalmitis following pediatric cataract surgery during their practice. Most patients with endophthalmitis following pediatric cataract surgery were 2 to 4 years of age (36.4%). An intraocular lens was implanted in 59.1% of cases, most of which were acrylic intraocular lenses (53.8%). The main presenting symptoms were photophobia (50%) and pain (40.9%). The most common signs were conjunctival injection (36.4%) and hypopyon (31.8%). The final visual acuity was counting fingers or worse in 86% of cases. The most common cultured organism was Staphylococcus aureus (31.8%). The most common management of endophthalmitis following pediatric cataract surgery was a combination of intravitreal, systemic, and topical antibiotics (36.4%). Most ophthalmologists (68.2%) administered prophylactic intracameral antibiotic treatment during surgery and 50% used vancomycin.

CONCLUSIONS

Endophthalmitis following pediatric cataract surgery is an uncommon, multifactorial complication with poor visual prognosis. Efforts directed at minimizing its risk, such as treating potential predisposing systemic conditions, improving sterilization techniques, optimizing operative conditions to reduce complications and surgery duration, and using subconjunctival and intracameral antibiotics, decrease its incidence. Early postoperative evaluation, subsequent follow-up visits, and keeping a high index of suspicion should facilitate the recognition of endophthalmitis following pediatric cataract surgery to avoid delaying treatment. [J Pediatr Ophthalmol Strabismus. 2018;55(1):23-29.].

Effectiveness of meibomian gland massage combined with topical levofloxacin against ocular surface flora in patients before penetrating ocular surgery

OBJECTIVE

To investigate the bacterial profile in the conjunctiva and meibomian glands in patients before penetrating ocular surgeries, and to compare the anti-bacterial efficacy of 0.5% levofloxacin and its combination with meibomian gland massage.

DESIGN

Hospital-based, case-control study.

PARTICIPANTS

Two hundred and twenty-six eyes from 226 patients with non-infective ocular diseases and scheduled for penetrating ocular surgeries.

METHODS

Tested eyes were administered topical 0.5% levofloxacin (4 times daily) for 2 days. Among them, 91 eyes received meibomian gland massage before levofloxacin application. Samples from the conjunctival sac and meibomian glands were collected for aerobic and anaerobic cultures.

MAIN OUTCOME MEASURES

Culture-positivity and bacterial strains.

RESULTS

Before treatment, aerobes and anaerobes were cultured from 38.5% and 11.0% of the conjunctival samples respectively, compared with 38.5% and 8.8% in the meibomian secretions respectively. Staphylococcus epidermidis and Propionibacterium acnes were the commonest isolated aerobe and anaerobe. Two-day application of levofloxacin reduced aerobic growth to 29.6% in the conjunctiva and 19.3% in the meibomian glands. It had no effect on the anaerobes in these regions (13.3% in the conjunctiva and 10.4% in the meibomian glands). Combined levofloxacin with meibomian gland massage further reduced aerobic growth to 19.8% in the conjunctiva and 11.0% in the meibomian glands. It also drastically decreased anaerobic growth in the meibomian glands (1.1%).

CONCLUSIONS

Meibomian glands carrying considerable bacteria should be considered as a potential source of contamination in ocular surgery. Meibomian gland massage shows additional anti-bacterial effects to topical levofloxacin and could be recommended as a complementary preoperative prophylaxis.

Endophthalmitis Prophylaxis for Cataract Surgery

Endophthalmitis after cataract surgery is a rare but potentially devastating complication. There is great variability in endophthalmitis prophylaxis practice patterns worldwide. Treatment varies globally and is based on the microbiological profile and availability of formulations. Periocular povidone-iodine antisepsis is universally adopted and considered the standard of care in most practices. Perioperative topical antibiotics are also very popular despite the lack of level 1 evidence confirming efficacy. Based on growing observational evidence, routine intracameral antibiotic prophylaxis is increasing, especially where approved commercial intraocular preparations are available. This review updates recent trends and evidence regarding endophthalmitis prophylaxis and the preferred choice of intracameral antibiotics.

Do evidence-based guidelines change clinical practice patterns?

In 2013, the Danish Health and Medicines Authorities published a National Clinical Guideline on the treatment of age-related cataracts. The guideline provided evidence-based recommendations on the indication for cataract surgery, cataract surgery in patients with age-related macular degeneration, on the use of toric intraocular lenses (IOLs) to correct preoperative corneal astigmatism, the use of intracameral and topical antibiotics to prevent endophthalmitis, choice of anti-inflammatory medication to control postoperative inflammation and prevent cystoid macular oedema, the use of immediate sequential bilateral cataract surgery and on the postoperative check-up of patients. A questionnaire was sent to all members of the Danish Ophthalmological Society before and after publication of the guideline. The responses showed that the guideline had changed practice patterns so that surgeons were more likely to prescribe non-steroidal anti-inflammatory eye drops and to not prescribe topical antibiotic eye drops after the guideline was published. Other parameters, most notably the use of toric IOLs and use of postoperative examinations were more guided by reimbursement standards than by evidence-based medicine. Thus, evidence-based guidelines do change practice patterns unless they are counteracted by the reimbursement system.

Post-cataract surgery endophthalmitis: Brief literature review

PURPOSE

To investigate recent evidence in prophylaxis and management of post-cataract surgery endophthalmitis.

METHODS

We conducted a literature search using Pubmed database for post cataract surgery endophthalmitis, and relevant articles were selected from original English papers published since 2015.

RESULTS

Forty-nine articles were published regarding post-cataract surgery endophthalmitis from January 2015 to February 2016. A low incidence of post-cataract surgery endophthalmitis has been reported. A growing number of articles are focusing on preventing endophthalmitis using intracameral antibiotics.

CONCLUSION

Based on the current evidence, intracameral antibiotics seems to be effective in preventing endophthalmitis after cataract surgery.

Evaluation of lid speculum with a drape (LiDrape(®)) for preventing surgical-field contamination

Purpose

To compare the degree of surgical-field contamination in cataract surgeries between a new draping method using a lid speculum with a drape (LiDrape^®) and a conventional draping method.

Methods

Cataract surgery was performed on 21 eyes using LiDrape^® (LiDrape^® group) and on 22 eyes using a conventional draping method (conventional group). Contamination was evaluated by bacterial culture of conjunctival sac scrapings and ocular surface irrigation fluid. Conjunctival sac scrapings were collected before and after application of preoperative antibiotics. Ocular surface irrigation fluid was collected before incision placement and during surgery. Bacterial detection rate and types of organisms isolated at these four time points were examined.

Results

Bacterial detection rates were significantly decreased in the LiDrape^® group at all time points after the application of antibiotics compared with preapplication. Regarding between-group comparisons, the bacterial detection rate in the LiDrape^® group was only significantly lower than that in the conventional group in the intraoperative sample. Propionibacterium acnes was the most common organism isolated from ocular surface irrigation fluid. The number of P. acnes in the intraoperative sample was significantly lower in the LiDrape^® group compared with the conventional group. There were no significant differences in detection rates for other bacteria between the groups.

Conclusion

LiDrape^® was as effective as conventional draping for preventing surgical-field contamination. The number of P. acnes during surgery was significantly lower in the LiDrape^® group compared with the conventional group, suggesting that LiDrape^® may contribute to the prevention of postoperative infection.

Antibiotic prevention of postcataract endophthalmitis: a systematic review and meta-analysis

Endophthalmitis is one of the most feared complications after cataract surgery. The aim of this systematic review was to evaluate the effect of intracameral and topical antibiotics on the prevention of endophthalmitis after cataract surgery. A systematic literature review in the MEDLINE, CINAHL, Cochrane Library and EMBASE databases revealed one randomized trial and 17 observational studies concerning the prophylactic effect of intracameral antibiotic administration on the rate of endophthalmitis after cataract surgery. The effect of topical antibiotics on endophthalmitis rate was reported by one randomized trial and one observational study. The quality and design of the included studies were analysed using the Cochrane risk of bias tool. The quality of the evidence was evaluated using the GRADE approach. We found high-to-moderate quality evidence for a marked reduction in the risk of endophthalmitis with the use of intracameral antibiotic administration of cefazolin, cefuroxime and moxifloxacin, whereas no effect was found with the use of topical antibiotics or intracameral vancomycin. Endophthalmitis occurred on average in one of 2855 surgeries when intracameral antibiotics were used compared to one of 485 surgeries when intracameral antibiotics were not used. The relative risk (95% CI) of endophthalmitis was reduced to 0.12 (0.08; 0.18) when intracameral antibiotics were used. The difference was highly significant (p < 0.00001). Intracameral antibiotic therapy is the best choice for preventing endophthalmitis after cataract surgery. We did not find evidence to conclude that topical antibiotic therapy prevents endophthalmitis.

[Ocular toxicity of intracamerally injected antibacterial and antifungal drugs (experimental and morphological study)]

OBJECTIVE

To study anterior eye segment toxicity of variously diluted brand name and generic antibiotic and antifungal drugs, including domestically produced generics (Moxifloxacin, asketin cefuroxime, amikacin, gentamicin, Diflucan, and amphotericin B), experimentally injected into the anterior chamber.

MATERIAL AND METHODS

A total of 13 Chinchilla rabbits were included in the experiment. Group 1 (6 rabbits) received sterile intracameral injections of 0.2 ml antibiotics and antifungals in concentrations suitable for intravenous administration (Moxifloxacin 1.6 mg/ml, Diflucan 2 mg/ml, and the following generics: asketin cefuroxime 125 mg/ml, amikacin 50 mg/ml, gentamicin 40 mg/ml, amphotericin B 50 mg/m). BSS was injected into the fellow eye for control. Group 2 (7 rabbits) also received sterile intracameral injections of 0.2 ml antibiotics and antifungals, which were the same as for group 1 but highly diluted (Moxifloxacin 150 μg/ml and 500 μg/ml, Diflucan 10 μg/ml, asketin cefuroxime 1 mg/ml, gentamicin 200 μg/ml, amikacin 400 μg/ml, amphotericin B 10 μg/ml).

RESULTS

There were no toxic effects in group 1 after BSS and Moxifloxacin 1.6 mg/ml injections into the anterior chamber. However, high concentrations of other antibiotic and antifungal drugs were associated with changes in the corneal endothelium of various severity (from cytoplasmic swelling of the endothelial cells to their complete desquamation), as well as fibrin exudation in the posterior chamber. In group 2 neither of injected drugs caused toxic, allergic, or inflammatory reactions according to histopathological examination.

CONCLUSION

The experiment proved safety of the intracameral route of administration for highly diluted medications from the list and also demonstrated the absence of toxic reaction after intracameral injection of Moxifloxacin 1.6 mg/ml.

An 8-year retrospective study of cataract surgery and postoperative endophthalmitis: injectable intraocular lenses may reduce the incidence of postoperative endophthalmitis

BACKGROUND/AIMS

Postoperative endophthalmitis (POE) is a rare but potentially devastating complication of modern cataract surgery. We examine whether the use of injectable intraocular lenses (IOLs) is associated with a lower rate of POE after cataract surgery compared with forceps-inserted foldable IOLs.

METHODS

A single-centre retrospective cohort study of 25 410 cataract operations was performed over an 8-year period when standard practice in cataract surgery changed from the use of forceps-inserted foldable IOLs to injectable IOLs. Cases of POE were identified and the rates compared between the two groups.

RESULTS

Twelve cases of POE were identified in the study period. The rate of POE was significantly lower in the injectable IOL group compared with the forceps-inserted foldable IOL group (0.008% vs 0.081%, p=0.008). This difference remained significant when controlling for posterior capsular rupture and lens material.

CONCLUSIONS

This study, the largest of its kind to date, supports the use of injectable IOLs over forceps-inserted foldable IOLs as a significant measure in reducing the risk of POE.

Quality assessment of cataract surgery in Denmark - risk of retinal detachment and postoperative endophthalmitis

The main purpose of this thesis was to examine whether the Danish National Patient Registry (NPR) could be used to monitor and assess the quality of cataract surgery in Denmark by studying the risks of two serious postoperative complications following cataract surgery - retinal detachment (RD) and postoperative endophthalmitis (PE). The thesis consists of four retrospective studies. In the first study (paper I), we used data from the NPR in the calendar period 2000-2010 to investigate the risk of pseudophakic retinal detachment (PRD) using the fellow non-operated eyes of the patients as reference. The study showed that over a 10-year study period, the risk of PRD was increased by a factor of 4.2 irrespective of sex and age. The risk of PRD was highest in the first part of the postoperative period and then gradually decreased but remained statistically significantly higher than the risk of RD in non-operated fellow eyes up to 10 years after cataract surgery. The epidemiology of RD in the non-operated fellow eyes was different from the epidemiology of RD in the background population as young men had the highest risk of RD in the non-operated fellow eyes. This means that the absolute risk of PRD was highest for young men because they had a higher risk of RD before they underwent cataract surgery. In the second study (paper II), we used data from the NPR and reviewed patient charts to assess the risk of PE after cataract surgery performed in public eye departments and private hospitals/clinics in the study period 2002-2010. The overall risk of PE among the seven public eye departments was 0.36 per 1000 registered cataract operations, and the PE risk among the departments was homogeneous. The overall risk of PE among the 28 private hospitals/clinics was 0.73 per 1000 registered cataract operations, and the risk among the private hospitals/clinics was heterogeneous. Most private hospitals/clinics had a risk of PE that was lower than or similar to the risk of PE after registered cataract surgery in public eye departments, but six private hospitals/clinics had a statistically significantly higher risk of PE compared to the public eye departments. We used PE as a proxy measure of the registration of cataract surgery and found that 98% of the cataract operations performed in public eye departments were registered in the NPR while only 38% of the cataract operations performed in private hospitals/clinics were registered in the NPR. In general, the coding of the PE cases was not uniform and the lack of registration by the private hospitals/clinics meant that the NPR could not be used to monitor the true risk of PE. NPR data were also used in the third study (paper III) to examine whether patients who had surgical intervention for PE following cataract surgery with either a pars plana vitrectomy (PPV) or a vitreous tap (VT) had a higher risk of subsequent surgical complications. There was no statistically significant difference in the overall risk of complications among the two groups, but the risk of surgery for vitreous opacities was statistically significantly higher for patients who underwent a VT. A surgical complication occurred in 27.3% of the patients and 9.9% of the patients developed more than one surgical complication. Ninety-seven per cent of the primary surgical complications occurred within the first 5 months. The risk of surgical complications in this study was similar to or higher than the risk of complications in the landmark Endophthalmitis Vitrectomy Study from the early 1990s. In the fourth study (paper IV), we used data from all three Danish cataract registries to describe the epidemiology of cataract operations performed in public hospitals and private hospitals/clinics in the study period 2004-2012. Again, PE was used as a proxy measure of the registration of cataract surgery. There were several noticeable differences in the epidemiology of the cataract operations performed in public hospitals and private hospitals/clinics. Patients who had cataract surgery in public hospitals had a statistically significantly higher mortality compared to patients who had cataract surgery in private hospitals/clinics during the entire period. The decrease in the mean age at first eye cataract surgery in private hospitals/clinics was statistically significantly greater compared to public hospitals during the study period. There was a statistically significantly shorter median time interval between first and second eye cataract surgery at private hospitals/clinics compared to public hospitals during the entire study period. The study showed that only 54% of the cataract operations performed in private hospitals/clinics that led to PE were registered. The lack of registration of cataract surgery is the main reason why the NPR has limitations when used as a tool to monitor and assess the quality of cataract surgery in Denmark.

Intracameral cefuroxime and moxifloxacin used as endophthalmitis prophylaxis after cataract surgery: systematic review of effectiveness and cost-effectiveness

Postoperative endophthalmitis is one of the most serious potential complications of ocular lens surgery. Its incidence can be reduced by means of antibiotic prophylaxis. Although the prophylactic use of intracameral cefuroxime has been extended, other drugs, such as moxifloxacin, have arisen as alternatives. We performed a systematic literature review on the effectiveness and efficiency of intracameral cefuroxime and moxifloxacin for the prophylaxis of postoperative endophthalmitis after cataract surgery. Several bibliographic databases were searched up to October 2010 and were updated up to January 2013. Outcomes were the onset of endophthalmitis after surgery and the cost-effectiveness ratio of using both antibiotic prophylaxis alternatives. The following were included: a clinical trial reported in two papers, six observational studies, and an economic evaluation. All studies assessed cefuroxime compared with another antibiotic prophylaxis or no prophylaxis. The only randomized controlled trial performed by the European Society of Cataract and Refractive Surgery found that intracameral cefuroxime is significantly more effective than not using prophylaxis or the use of a topical antibiotic. The observational studies support these results. The economic evaluation compared different prophylaxis regimens and concluded that intracameral cefuroxime showed the best cost-effectiveness ratio. Both the observational studies and the economic evaluation have methodological limits that reduce their validity. This review confirmed that cefuroxime can prevent endophthalmitis after cataract surgery. Further randomized controlled trials, with large sample sizes, are required to compare different antibiotic prophylaxis regimens.

Cohort study of intracameral moxifloxacin in postoperative endophthalmitis prophylaxis

We conducted a cohort study to evaluate post-cataract surgery endophthalmitis rates in relation to prophylactic intracameral moxifloxacin administration. A total of 2332 patients (2674 eyes) who underwent phacoemulsification by a single surgeon from January 2007 through December 2012 were included in the study. A total of 1056 eyes did not receive intracameral prophylactic moxifloxacin and the antibiotic was injected in 1618 eyes. The incidence of presumed postoperative endophthalmitis in the 2 groups was calculated. The rate of presumed infectious endophthalmitis after cataract surgery between January 2007 and June 2009 (without intracameral moxifloxacin) was 0.094%. The rate in the second period, from July 2009 to December 2012 (with prophylactic intracameral moxifloxacin), was 0%. In our patients, a decline in the incidence of presumed infectious postoperative endophthalmitis appeared to be associated with the application of intracameral moxifloxacin.

Outsourced cataract surgery and postoperative endophthalmitis

PURPOSE

To compare the risk of postoperative endophthalmitis (PE) after cataract surgery at eye departments in public hospitals and private hospitals/eye clinics and to evaluate if the Danish National Patient Registry (NPR) is a reliable database to monitor the PE risk.

METHODS

Postoperative endophthalmitis cases were retrospectively identified via the NPR and chart review in order to confirm PE cases that had cataract surgery in the calendar period 2002-2010.

RESULTS

We identified 39 cases of PE after 107 701 registered public cataract operations; PE risk = 0.36 [corrected] per 1000 operations and 27 cases of PE after 36 760 registered private operations; PE risk = 0.73 [corrected] per 1000 operations. There was homogeneity in the PE risk among the eye departments in public hospitals (p = 0.6), but heterogeneity in the PE risk among the private hospitals/eye clinics (p = 0.0001). Six private hospitals/eye clinics had a statistically significantly higher PE risk compared with the eye departments in public hospitals. In all, 98% of public cataract surgery was registered in the NPR compared with 38% of private cataract surgery. The private hospitals/eye clinics with the highest PE risk after registered cataract surgery had many cases of PE where the causative cataract operation was not registered with the NPR.

CONCLUSION

A few private hospitals/eye clinics had a statistically significantly higher PE risk than the PE risk at the eye departments in public hospitals. The lack of registration with the NPR by the private hospitals/eye clinics suggests that better monitoring of cataract surgery is needed in Denmark to reduce risk and to improve quality.

[Spectrum and susceptibility of preoperative conjunctival bacteria]

PURPOSE

To describe the conjunctival bacterial spectrum of our patients undergoing intraocular surgery and their antibiotic sensitivity during the study period.

METHODS

A retrospective study of preoperative conjunctival culture of patients consecutively scheduled for intraocular surgery from 21 February 2011 to 1 April 2013. Specimens were directly seeded onto blood-agar and MacConkey-agar (aerobiosis incubation, 2 days), and on chocolate-agar (6% CO2 incubation, 7 days). The identified bacteria were divided into 3 groups according to their origin; the bacteria susceptibility tests were performed on those more pathogenic and on some of the less pathogenic when more than 5 colonies were isolated. The sensitivity of the exigent growing bacteria was obtained with disk diffusion technique, and for of the non-exigent bacteria by determining their minimum inhibitory concentration. The Epidat 3.1 program was used for statistical calculations.

RESULTS

A total of 13,203 bacteria were identified in 6,051 cultures, with 88.7% being typical colonizers of conjunctiva (group 1), 8.8% typical of airways (group 2), and the remaining 2.5% of undetermined origin (group 3). 530 cultures (8.8%) were sterile. The sensitivity of group 1 was: 99% vancomycin, 95% rifampicin, 87% chloramphenicol, 76% tetracycline. Levels of co-trimoxazole, aminoglycosides, quinolones, β-lactams and macrolides decreased since 2007. The group 2 was very sensitive to chloramphenicol, cefuroxime, rifampicin, ciprofloxacin and amoxicillin/clavulanate. In group 3, to levofloxacin 93%, ciprofloxacin 89%, tobramycin 76%, but ceftazidime 53% and cefuroxime 29% decreased.

CONCLUSIONS

None of the tested antibiotics could eradicate all possible conjunctival bacteria. Bacteria living permanently on the conjunctiva (group 1) have achieved higher resistance than the eventual colonizers.

Risk factors for acute endophthalmitis following cataract surgery: a systematic review and meta-analysis

Background

Acute endophthalmitis is one of the most serious complications of cataract surgery and often results in severe visual impairment. Several risk factors for acute postoperative endophthalmitis (POE) following cataract surgery have been reported but the level of evidence and strength of association is varied. The purpose of this study was to critically appraise published reports on and to summarize clinical risk factors associated with acute POE which could be easily assessed by ophthalmologists for the introduction and implementation of preventive measure.

Methods

A systematic review and meta-analysis of observational studies was performed. Six databases were searched with no limits on the year or language of publication. Study-specific odds ratios (Ors) or relative risk (RR) of each risk factor were pooled using a random effect model.

Results

A total of 6 686 169 participants with 8 963 endophthalmitis in 42 studies were analyzed. Of the nine risk factors identified in our systematic review and meta-analysis, extra- or intracapsular cataract extraction, a clear corneal incision, without intracameral cefazolin (1 mg in 0.1 ml solution), without intracameral cefuroxime (1 mg in 0.1 ml solution), post capsular rupture, silicone intraocular lenses and intraoperative complications were found strongly associated with acute endophthalmitis. Other significant factors with a lower strength of association (risk estimates generally 1.5 or less) were male gender and old age (85 years and older).

Conclusions

Our study provides summary data on the risk factors for acute POE. Identifying patients at high risk of this sight-threatening eye disease is important from both the public health and clinical perspectives as this would facilitate detection of disease before the onset of irreversible visual loss enabling earlier intervention.

Intracameral cefuroxime: prophylaxis of postoperative endophthalmitis after cataract surgery

Results of the landmark European Society of Cataract and Refractive Surgeons trial and additional prospective and retrospective studies support the use of intracameral cefuroxime in the prophylaxis of endophthalmitis following cataract surgery. Prophylaxis with intracameral cefuroxime at the recommended dose appears to be well tolerated in patients undergoing cataract surgery. However, off-label use of intracameral cefuroxime usually requires a two-step dilution process with the potential for dilution errors, and there are also concerns regarding the risk of contamination. Aprokam® (intracameral cefuroxime) has been approved in the EU for the prophylaxis of postoperative endophthalmitis after cataract surgery. After reconstitution of Aprokam®, no further dilution is required and each vial is only indicated for single-patient use; this has the potential to reduce the risk of both dilution errors and contamination.

Endophthalmitis following cataract surgery: the role of prophylactic postoperative chloramphenicol eye drops

PURPOSE

The main aim of the study was to assess whether omitting prophylactic postoperative topical antibiotics (chloramphenicol) influenced the risk of developing endophthalmitis after cataract surgery.

METHODS

We conducted a retrospective study including all patients who had cataract surgery at our outpatient cataract unit between 2004 and 2011. Postoperative topical antibiotics (chloramphenicol) were omitted from 2007 onwards, as was the first postoperative day review. Patients with a diagnosis of endophthalmitis after cataract surgery were extracted, and the rate of postoperative endophthalmitis (PE) before and after changing these routines was compared. The diagnosis of PE was defined as severe intraocular inflammation requiring prompt vitreous sampling for culture.

RESULTS

Seven thousand one hundred and twenty-three and 8131 cataract surgeries were performed in the following periods: January 2004 through December 2006 (period 1) and January 2007 through December 2010 (period 2), respectively. Five cases of PE were identified in period 1 (0.070%) and four patients in period 2 (0.049%). The median time between cataract surgery and onset of symptoms was 6 days in period 1 and 4.5 days in period 2. Median time for intervention was 7 and 5 days postsurgery, respectively.

CONCLUSION

We found no difference in the frequency of PE following cataract surgery when changing the postoperative topical medication from a mixture of corticosteroids and antibiotics to only corticosteroids.

Topical azithromycin or ofloxacin for endophthalmitis prophylaxis after intravitreal injection

BACKGROUND

The number of patients who have undergone intravitreal injections has increased enormously in recent years, but a consensus is still lacking on prophylaxis for endophthalmitis. The aim of this prospective, observational study was to evaluate the prophylactic effect of azithromycin eye drops versus ofloxacin eye drops.

METHODS

The study was conducted in five hospitals in Spain and included all patients undergoing intravitreal injections of triamcinolone, bevacizumab, ranibizumab, or pegaptanib over one year. Patients received azithromycin 15 mg/g eye drops (twice daily on the day prior to injection and for another 2 days) or ofloxacin 3 mg/g eye drops (every 6 hours on the day prior to injection and for another 7 days).

RESULTS

In the azithromycin group, there were 4045 injections in 972 eyes of 701 patients. In the ofloxacin group, there were 4151 injections in 944 eyes of 682 patients. There were two cases of endophthalmitis (0.049%) in the azithromycin group and five (0.12%) in the ofloxacin group. The odds ratio of presenting with endophthalmitis in the ofloxacin group compared with the azithromycin group was 2.37 (95% confidence interval [CI] 1.32-3.72, P < 0.001). There were two cases of noninfectious uveitis after triamcinolone injection in the azithromycin group (0.049%) and two (0.048%) in the ofloxacin group; no significant differences were observed (odds ratio 0.902, 95% CI 0.622-1.407, P = 0.407). Conjunctival hyperemia was observed in 12 cases in the azithromycin group and none in the ofloxacin group.

CONCLUSION

The risk of endophthalmitis was significantly greater with ofloxacin than with azithromycin. These findings provide a valuable addition to the ever-increasing pool of information on endophthalmitis prophylaxis after intravitreal injection, although further large-scale studies are required to provide definitive conclusions.

Outcome of endophthalmitis treatment in a tertiary referral center in southern iran

Purpose:

The purpose of this study was to investigate the causative organisms, the clinical characteristics, visual outcomes, and the incidence of acute endophthalmitis after cataract surgery.

Materials and Methods:

In this retrospective study, a chart review was performed for patients treated in a tertiary referral center for acute endophthalmitis after cataract surgery from January 2005 to December 2009. During the study period, 62 additional patients with acute postoperative endophthalmitis were referred to and treated in this center. Therefore the cohort comprised 70 patients (8 of whom underwent cataract surgery at our center, and 62 who were referred). Demographic, clinical, and laboratory data were analyzed. The primary outcome measure was final visual acuity. P<0.05 indicated statistical significance

Results:

During the study period, 7737 cataract surgeries were performed in this center. Eight (0.10%) of 7737 eyes developed acute postoperative endophthalmitis. Subgroup analysis indicated that extracapsular cataract extraction was associated with a fourfold higher risk of endophthalmitis compared with phacoemulsification. We found better initial visual acuity (VA) (≥ hand motion) (P<0.001) and negative cultures (P=0.021) were independently associated with a more favorable visual outcome. Patients with relative afferent papillary defect (RAPD) were associated with lower initial VA (P<0.001) and worse visual outcome (P=0.001). Positive microbial cultures were found for 33 (42.9%) cases. Staphylococcus aureus was the most common organism isolated. Positive cultures were more frequently found in patients with RAPD. The “gram-positive coagulase-negative” and “no growth” groups had the best visual outcome. Associated keratitis and avoiding intraocular steroids were associated with the risk of evisceration.

Conclusion:

The visual outcome after endophthalmitis was generally poor and only one eighth of the eyes achieved a final corrected visual acuity of ≥20/200. Therefore, better treatment strategies are warranted. Immediate treatment is essential and the role of primary vitrectomy requires further investigation. In addition, RAPD, as an objective test, may complement VA for predicting the prognosis and planning the course of treatment.

Bacterial endophthalmitis in the age of outpatient intravitreal therapies and cataract surgeries: host-microbe interactions in intraocular infection

Bacterial endophthalmitis is a sight threatening infection of the interior structures of the eye. Incidence in the US has increased in recent years, which appears to be related to procedures being performed on an aging population. The advent of outpatient intravitreal therapy for management of age-related macular degeneration raises yet additional risks. Compounding the problem is the continuing progression of antibiotic resistance. Visual prognosis for endophthalmitis depends on the virulence of the causative organism, the severity of intraocular inflammation, and the timeliness of effective therapy. We review the current understanding of the pathogenesis of bacterial endophthalmitis, highlighting opportunities for the development of improved therapeutics and preventive strategies.

Endophthalmitis: A review of recent trends

Endophthalmitis is a feared complication of trauma, surgical procedures and septicemia. Although uncommon, its potential for significant visual loss is well recognized. Especially over the past decade, complicated surgeries and medical techniques have increased and seriously ill patients are being sustained in ever increasing numbers. New pathogens are being recognized and known ones reclassified thanks to advances in molecular analysis. Continuously evolving PCR methodologies also add a new dimension to the diagnosis of infectious endophthalmitis. As well, medical literature is now truly international, encompassing studies from around the world that expand our understanding of ocular infectious disease. This report reviews some of these changes as they relate to endophthalmitis and particularly to the spectrum of organisms involved.

Postcataract surgery endophthalmitis in the United States: analysis of the complete 2003 to 2004 Medicare database of cataract surgeries

OBJECTIVE

To estimate endophthalmitis incidence after cataract surgery nationally and at the state level in 2003 and 2004 and to explore risk factors.

DESIGN

Analysis of Medicare beneficiary claims data.

PARTICIPANTS

We evaluated billed claims for cataract surgery and endophthalmitis diagnosis and treatment for all Medicare fee-for-service beneficiaries in 2003-2004.

METHODS

Cataract surgeries were identified by procedure codes and merged with demographic information. Cataract annual surgical volume was calculated for all surgeons. Presumed postoperative endophthalmitis cases were identified by International Classification of Diseases-9 Clinical Modification Codes on claims within 42 days after surgery. Endophthalmitis rates and 95% confidence intervals (CI) were calculated at state and national levels. Logistic regression was used to investigate the association between developing endophthalmitis and surgery location and surgeon factors.

MAIN OUTCOME MEASURES

Endophthalmitis incidence and risk factors.

RESULTS

We included 4006 cases of presumed endophthalmitis, which occurred after 3 280 966 cataract surgeries. The national rate in 2003 was 1.33 per 1000 surgeries (95% CI, 1.27-1.38) and decreased to 1.11 per 1000 (95% CI, 1.06-1.16) in 2004. Males (relative risk [RR], 1.23; 95% CI, 1.15-1.31), older individuals (RR, 1.53; 95% CI, 1.38-1.69; ≥85 compared with 65-74 years), blacks (RR, 1.17; 95% CI, 1.03-1.33), and Native Americans (RR, 1.72; 95% CI, 1.07-2.77) had increased risk of disease. After adjustment, surgeries by surgeons with low annual volume (RR, 3.80; 95% CI, 3.13-4.61 for 1-50 compared with ≥1001 annual surgeries) and less experience (RR, 1.41; 95% CI, 1.25-1.59 for 1-10 compared with ≥30 years), and surgeries performed in 2003 (RR, 1.20; 95% CI, 1.13-1.28) had increased endophthalmitis risk.

CONCLUSIONS

Endophthalmitis rates are lower than previous yearly US estimates, but remain higher than rates reported from a series of studies from Sweden; patient factors or methodologic differences may contribute to differences across countries. Patient age, gender, and race, and surgeon volume and years of experience are important risk factors.

Results at seven years after the use of intracamerular cefazolin as an endophthalmitis prophylaxis in cataract surgery

Background

To evaluate results after seven years using prophylactic intracameral cefazolin for the prevention of endophthalmitis in cataract surgery.

Methods

A prospective, observational study of all patients submitted to cataract surgery over the period January 1996 to December 2009. All cases of postoperative endophthalmitis over that period were reviewed. The patients were classified in two groups: Group 1 (11,696 patients) operated on between January 1996 and December 2002, Group 2 (13,305 patients) between January 2003 and December 2009 (in whom a 1 mg/0.1 bolus of intracameral cefazolin was instilled).

Results

During the study period, 76 cases of endophthalmitis were observed in Group 1, and seven in Group 2. The rate of postoperative endophthalmitis reduced from 0.63% to 0.05% with a cefazolin injection. The relative risk (RR) for endophthalmitis in Group 1 against group 2 was 11.45 [95% CI 5.72-22.84, p < 0.001].

Conclusions

An intracameral bolus injection of cefazolin (1 mg in 0.1 ml solution) at the conclusion of the cataract surgery significantly reduced the rate of postoperative endophthalmitis.

A European perspective on topical ophthalmic antibiotics: current and evolving options

BACKGROUND

Eye infections can be vision-threatening and must be treated effectively by appropriate and safe use of topical ophthalmic anti-infectives. This review will essentially consider the current and evolving treatment options for the various types of bacterial eye infections. Ocular surface bacterial infections affect subjects of all ages with a high frequency in newborns and children.

METHODS

This article presents a review of the peer-reviewed published scientific literature in order to define the well-established uses of anti-infective eye drops in the field of ocular infections. A comprehensive search of the recent published literature including topical ophthalmic anti-infectives effective in bacterial ocular infections was performed. Clinical studies provide relevant data concerning the characteristics and clinical efficacy of antibacterial eye drops in ocular anterior segment infections or for perioperative prophylaxis. Publications were included to cover the current options of antibacterial eye drops available in Europe.

RESULTS

Several recent publications identified effective topical ocular antibacterials requiring a reduced dose regimen and a short treatment course. Additional literature reviewed included data on novel perioperative prophylaxis, indications for topical fortified antibiotics and innovative research including the risk of resistance.

CONCLUSIONS

Safe and effective topical antibiotic eye drops for the treatment and prevention of ocular infections must be adapted to the type of bacteria suspected. Usual topical antimicrobials should be replaced by more recent and more effective treatments. The use of highly effective fluoroquinolones should be reserved for the most severe cases to avoid resistance. Short treatment courses, such as azithromycin, can be easily used in children, thereby improving quality of life.