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Endophthalmitis Prophylaxis – Implications of the European Society of Cataract and Refractive Surgery Endophthalmitis Study

European Ophthalmic Review, 2007:30-2 DOI: http://doi.org/10.17925/EOR.2007.00.00.30
Received: January 20, 2011 Accepted January 20, 2011 Citation European Ophthalmic Review, 2007:30-2 DOI: http://doi.org/10.17925/EOR.2007.00.00.30

Endophthalmitis is defined by an intraocular inflammation, due mainly to infection. Peri-ocular skin flora from the patient plays a significant role incausing the intraocular infection, and Staphylococcus epidermidis accounts for 81.9% of all cases of endophthalmitis.1

Endophthalmitis infection is an infrequent but devastating consequence of cataract surgery; in fact, cataract surgery is the leading cause of endophthalmitis. Infection after cataract surgery leads to increased health costs2 and also causes devastating clinical consequences, even blindness. This has led to frequent medical lawsuits.3 Despite advances in microsurgical techniques, a recent population-based study reviewingMedicare claims in the US revealed that endophthalmitis following cataract surgery is becoming more prevalent.4 The incidence of endophthalmitis rose from 1.79 cases per 1,000 in 1994 to 2.49 cases per 1,000 in 2001 – an overall increase of 37%.

To date, the best approach to or surgical regimen for cataract surgery to reduce the risk of endophthalmitis remains unclear. The European Society of Cataract and Refractive Surgery (ESCRS) Endophthalmitis Study examined the impact of intracameral cefuroxime and topical levofloxacin on post-operative infection. This article outlines risk factors for endophthalmitis, summarises the ESCRS Endophthalmitis study and discusses the implications of the study results on the future of endophthalmitis prevention within the context of cataract surgery.

Risk Factors Identified Prior to the Study
Risk factors for endophthalmitis are largely the same in both Asian and Western populations.5 Two reports have noted that diabetes mellitus increases the likelihood of developing staphylococci.6,7 Diabetes causes alterations in immunity and consequently leaves sufferers with a higher susceptibility to developing an infection after surgery. In addition, visual prognosis after endophthalmitis treatment is poor in diabetic patients in comparison with non-diabetic patients. Systemic or topical immunosuppressant drugs also alter the immune response, leading to an increased risk of endophthalmitis.6 Patients on antimetabolites or corticosteroids also have a higher incidence of endophthalmitis.

Certain procedures and materials used in cataract surgery have also been found to alter the risk of endophthalmitis.8,9 One study has suggested that the implantation of a heparinised intraocular lens (IOL) and the creation of a tight seal may protect the patient from infection.8 The type of IOL material and the location of the incision were examined in 5,797 small-incision cataract patients at Toyama Medical and Pharmaceutical University Hospital from March 1998 to March 2001.9 The results suggested that temporal corneal incisions may lead to an increased risk of endophthalmitis. Lens material had no effect on risk of endophthalmitis.

Other risk factors identified include infectious respiratory or skin agents from surgeons or other healthcare personnel present in the operating room (OR) coming into contact with the patient’s eye.10 In addition, the cleanliness of the OR air affects the incidence of endophthalmitis.10 Finally, the longer the duration of surgery, the higher the infection rates, most likely due to increased exposure of the eye.11

References:
  1. Bannerman TL, Rhoden DL, McAllister SK, et al., The source of coagulase-negative staphylococci in the Endophthalmitis Vitrectomy Study. A comparison of eyelid and intraocular isolates using pulse-field gel electrophoresis, Archive Ophthalmol, 1997;115:357–61.
  2. Abreu JA, Alilo JL, Cordoves LM, et al., The ESCRS study on antibiotic prophylaxis for endophthalmitis following cataract surgery, Arch Soc Esp Oftalm, 2006;81:627–30.
  3. Alio JL, Muñoz G, Infectious endophthalmitis. In: BenEzra D, Ocular Inflammation: basic and clinical concepts, London: Martin Dunitz, 1999;275–96.
  4. 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;12:1388–94.
  5. Wong TY, Chee SP, Risk factor of acute endophthalmitis after cataract extraction: a case control study in Asian eyes, Br J Ophthalmol, 2004;8:29–31.
  6. Phillips WB, Tasman WS, Postoperative endophthalmitis in association with diabetes mellitus, Ophthalmology, 1994;101: 508–18.
  7. Doft BH, Wisniewski SR, Kelsey SF, et al., Diabetes and postoperative endophthalmitis in the endophthalmitis vitrectomy study, Arch Ophthalmol, 2001;119 (5):650–56.
  8. Montan PG, Koranyi G, Setterquist HE, Endophthalmitis after cataract surgery: risk factors relating to technique and events of the operation and patient history. A retrospective case-control study, Ophthalmology, 1998;105:2171–7.
  9. Nagaki Y, Hayasaka S, Kadoi C, et al., Bacterial endophthalmitis after small-incision cataract surgery. Effect of insicison placement and intraocular lens type, JCRS, 2003;29(1): 20–26.
  10. Ciulla TA, Star MB, Masket S, Bacterial endophthalmitis prophylaxis for cataract surgery: An evidence-based update, Ophthalmol, 2002;109:12–26.
  11. Menikoff JA, Speaker MG, Marmor M, et al., A case-control of risk factors for postoperative endophthalmitis, Ophthalmology, 1991;98(17):61–8.
  12. . Trinavarat A, Atchaneeyasakul L, Nopmaneejumruslers C, Reduction of Endophthalmitis Rate after Cataract Surgery with Preoperative 5% Povidone–Iodine, Dermatology, 2006;212 (Suppl. 1):35–40.
  13. Barry P, Seal DV, Gettinby G, ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study, JCRS, 2006;2:407–10.
  14. Wejde G, Montan PG, Lundstrom M, et al., Endophthalmitis following cataract surgery in Sweden: national prospective survey 1999–2001, Acta Ophthalmol Scand, 2005;83:7–10.
  15. Montan PG, Wejde G, Koranyl G, Rylander M, Prophylactic intracameral cefuroxime: efficacy in preventing endophthalmitis after cataract surgery, J Cataract Refract Surg, 2002;28:977–81.
  16. Marx MA, Fant WK, Cefuroxime axil, Drug Intell Clin Pharm, 1988;22(9):651–8.
  17. Seal DV, Barry P, Gettinby G, et al., ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Case for a European multicenter study, J Cataract Refract Surg, 2006;32:396–406.
  18. ESCRS Endophthalmitis Study Group, Prophylaxis of postoperative endophthalmitis following cataract surgery: Results of the ESCRS multicentre study and identification of risk factors, JCRS, 2007;33(6):978–88.
  19. Lee SY, Chee SP, Group B Streptococcus endogenous endophthalmitis: case reports and review of the literature, Ophthalmology, 2002;109(10):1879–86.
  20. American Society of Ophthalmic Registered Nurses, Interim report identifies several potential sources of recent toxic anterior segment syndrome (TASS) outbreak but no single cause, 21 June 2006. Available at: http://webeye.ophth. uiowa.edu/ASORN/alerts/tass-6-21-2006.htm.