The incidence of severe complications in acanthamoeba keratitis: Qualitative and quantitative systematic assessment.

Acanthamoeba keratitis (AK) is a rare, sight-threating corneal infection. The disease is challenging to diagnose and treat, and the amoeba can rapidly encyst, persisting in the tissue and causing recurrences. Medical therapy is conventionally considered the first line treatment, but advanced cases could require more invasive treatments like a "chaud" corneal transplant. We review the incidence of severe complications in patients affected by AK. Of 439 reports screened, 158 met our inclusion criteria. Incidence of severe complications was low, with 2.21 % patients developing perforation, 1 % requiring evisceration/enucleation and less than 1 % developing endophthalmitis. Corneal transplantation was required in 16.68 % of the cases. According to our results, and considering the reported incidences of these complications in other infectious keratitis, AK patients have an overall low risk of developing perforation, endophthalmitis, and enucleation/evisceration. Nevertheless, data available in the literature remain poor, and further randomized control trials are needed to confirm our findings.

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

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

Endophthalmitis rates and risk factors following intraocular surgeries in the medicare population from 2016 to 2019.

AIMS: To determine endophthalmitis rates and risk factors following intraocular surgeries in the Medicare population. METHODS: Retrospective, cross-sectional study from 2016 to 2019 in Medicare fee-for-service and Medicare Advantage beneficiaries. 100% Medicare claims were used to identify eyes that underwent intraocular surgery. Exclusion criteria included eyes that had intraocular surgery 42 days before or after and eyes in patients with a history of endophthalmitis within 12 months. RESULTS: 9 744 400 intraocular surgeries were performed among Medicare beneficiaries from 2016 to 2019. A 42-day postoperative endophthalmitis rate was 0.09%. Endophthalmitis rate by surgery type was 0.43% for corneal transplant, 0.36% for secondary intraocular lens (IOL), 0.24% for retina, 0.16% for glaucoma, 0.11% for cataract combined with other procedures and 0.08% for cataract surgeries alone. On multivariable analysis, the risk of endophthalmitis was increased for all intraocular surgery types when compared with cataract surgeries; adjusted OR (aOR) 5.30 (p<0.01) for corneal transplant, aOR 4.50 (p<0.01) for secondary IOL, aOR 3.00 (p<0.01) for retina, aOR 1.93 (p<0.01) for glaucoma, aOR 1.45 (p<0.01) for combined cataract surgeries. Increased risk of developing endophthalmitis was associated with older age (≥85 vs 65-75 years: aOR 1.36; p<0.01), male sex (aOR 1.20; p<0.001) and greater Charlson Comorbidity Index (≥7 vs 0: aOR 1.79; p<0.01). CONCLUSIONS: Postoperative endophthalmitis rate after intraocular surgeries was 0.09% between 2016 and 2019 for Medicare beneficiaries. Endophthalmitis rates were highest for corneal transplant surgeries followed by secondary IOL surgeries and lowest for cataract surgeries. Older age, male gender and higher comorbidity index were associated with risk of endophthalmitis.

National emergency department trends for endogenous endophthalmitis: an increasing public health challenge.

BACKGROUND/OBJECTIVE: To characterize incidence rates and identify risk factors for admission and mortality in patients with endogenous endophthalmitis (EE) in the United States (US). SUBJECTS/METHODS: Patients with EE were identified using the Nationwide Emergency Department (NEDS) Database from 2006 to 2017 in this cross-sectional study. Subjects were required to have diagnoses of both endophthalmitis and septicaemia using contemporary International Classification of Diseases diagnosis codes. Incidence rates, mortality rates and demographics were evaluated. Risk factors for admission and mortality were identified using weighted logistic regression analysis. RESULTS: A total of 6400 patients with EE were identified. Incidence increased from 0.10 (95% confidence interval [CI]: 0.07-0.12) per 100,000 in the US population in 2006 to 0.25 (95% CI: 0.21-0.30) in 2017 (p < 0.05). Most were female (55.4%), insured with Medicare (53.5%), were in the first income quartile earnings (29.3%) [bottom 25% income bracket], lived in the South (40.5%), and presented to metropolitan teaching hospitals (66.6%). Mortality increased from 8.6% (95% CI: 3.8-18.3%) in 2006 to 13.8% (95% CI: 9.7-19.2%) in 2017 (p = 0.94). Factors predicting admission included older age (odds ratio [OR] 32.59; [95% CI 2.95-359.78]) and intravenous drug use (OR 14.90 [95% CI: 1.67-133.16]). Factors associated with increased mortality included: human immunodeficiency virus infection/immune deficiencies (OR 2.58 [95% CI: 1.26-5.28]), heart failure (OR 2.12 [95% CI: 1.47-3.05]), and hepatic infections/cirrhosis (OR 1.89 [95% CI: 1.28-2.79]). Pneumonia and renal/urinary tract infections (UTI) were associated with both increased hospital admission [(pneumonia OR 9.64 (95% CI: 1.25-74.35, p = 0.030), renal/UTI OR 4.09 (95% CI: 1.77-9.48)] and mortality [(pneumonia OR 1.64 (95% CI: 1.17-2.29, p = 0.030), renal/UTI OR 1.87 (95% CI: 1.18-2.97)]. Patients with diabetes mellitus (DM) had decreased odds ratio for mortality (OR 0.49 [95% CI: 0.33-0.73]). CONCLUSION: EE has increased in incidence throughout US. The two systemic factors that conferred both an increase in mortality and admission were pneumonia, and renal/UTI. Additional exploration of the potential protective association of DM with decreased mortality in this context is needed.

Cost-Effectiveness of Preoperative Topical Antibiotic Prophylaxis for Endophthalmitis Following Cataract Surgery.

PURPOSE: To determine the cost-effectiveness of preoperative topical antibiotic prophylaxis for the prevention of endophthalmitis following cataract surgery. DESIGN: Cost-effectiveness analysis using a decision-analytic microsimulation model. METHODS: Preoperative topical antibiotic prophylaxis vs no-prophylaxis costs and effects were projected over a life-time horizon for a simulated cohort of 500 000 adult patients (≥18 years old) requiring cataract surgery in theoretical surgical centers in the United States. Efficacy and cost (2021 US dollars) values were obtained from the literature and discounted at 3% per year. RESULTS: Based on inputted parameters, the mean incidence of endophthalmitis following cataract surgery for preoperative topical antibiotic prophylaxis vs no-prophylaxis was 0.034% (95% CI 0%-0.2%) and 0.042% (95% CI 0%-0.3%), respectively-an absolute risk reduction of 0.008%. The mean life-time costs for cataract surgery with prophylaxis and no-prophylaxis were $2486.67 (95% CI $2193.61-$2802.44) and $2409.03 (95% CI $2129.94-$2706.69), respectively. The quality-adjusted life-years (QALYs) associated with prophylaxis and no-prophylaxis were 10.33495 (95% CI 7.81629-12.38158) and 10.33498 (95% CI 7.81284-12.38316), respectively. Assuming a cost-effectiveness criterion of ≤$50 000 per QALY gained, the threshold analyses indicated that prophylaxis would be cost-effective if the incidence of endophthalmitis after cataract surgery was greater than 5.5% or if the price of the preoperative topical antibiotic prophylaxis was less than $0.75. CONCLUSIONS: General use of preoperative topical antibiotic prophylaxis is not cost-effective compared with no-prophylaxis for the prevention of endophthalmitis following cataract surgery. Preoperative topical antibiotic prophylaxis, however, would be cost-effective at a higher incidence of endophthalmitis and/or a substantially lower price for prophylaxis.

Incidence and management of acute endophthalmitis after intravitreal injection of bevacizumab.

PURPOSE: To report the incidence, management, and clinical outcomes of cases who developed acute endophthalmitis following the administering of the intravitreal bevacizumab (IVB) injection. METHODS: In this retrospective, non-comparative, single-center, cross-sectional study, the records of patients diagnosed with acute endophthalmitis following IVB injection between March 2013 and October 2019 were reviewed. Immediate injection of intravitreal antibiotics and early pars plana vitrectomy was performed for all cases after clinical diagnosis of acute post IVB endophthalmitis. RESULTS: A total of 28,085 IVB injections were performed during the study period. Nine eyes of nine patients developed acute post IVB endophthalmitis giving an overall incidence of 0.032% (95% CI, 0.01-0.06) (3.2 in 10,000 injections). Three cases (33%) were culture-positive (staphylococcus epidermidis). The mean time between IVB injection and presentation of endophthalmithis was 2.77 ± 1.25 days (Range, 1-6). The mean number of previously received IVB injections before developing of endophthalmitis was 4 ± 1.5 (range 2 to7). The mean best corrected visual acuity (BCVA) before IVB injection, at the presentation of endophthalmithis and three months after the treatment of endophthalmithis were 1.18 ± 0.62, 2.5 ± 0.42, and 1.94 ± 0.88 logMAR, respectively (P = 0.025). One eye developed phthisis bulbi. CONCLUSION: The incidence of acute endophthalmitis following Intravitreal injection of bevacizumab is very low. The time interval between injection and presentation is short. Prompt treatment with immediate intravitreal antibiotics and early pars plana vitrectomy are key in maximizing outcomes. The prognosis of post-IVB endophthalmitis is poor and may result in significantly visual impairment.

Endophthalmitis Rates among Medicare Beneficiaries Undergoing Cataract Surgery between 2011 and 2019.

PURPOSE: To determine national incidence and risk factors associated with developing endophthalmitis after cataract surgery in the United States. DESIGN: Retrospective, cross-sectional analysis. PARTICIPANTS: Medicare beneficiaries aged ≥65 years undergoing cataract surgery between 2011 and 2019. METHODS: Medicare claims were used to identify all patients who underwent ≥1 cataract surgery between 2011 and 2019. Endophthalmitis cases within 90 days of the cataract surgery were identified using diagnostic codes. Patients with a history of endophthalmitis 12 months before their cataract surgery procedure were excluded. Annual and aggregate 9-year incidences were determined for all cataract surgeries and for stand-alone cataract procedures. A stepwise multivariable logistic regression model using generalized estimating equations was used to evaluate factors associated with occurrence of postoperative endophthalmitis. MAIN OUTCOME MEASURES: The 90-day postoperative endophthalmitis rate and patient risk factors associated with onset of endophthalmitis after cataract surgery. RESULTS: A total of 14 396 438 cataract surgeries were performed among Medicare beneficiaries between 2011 and 2019. The overall 90-day postoperative endophthalmitis rate was 1.36 per 1000 cataract surgeries for all cataract procedures and 1.30 per 1000 cataract surgeries for stand-alone cataract procedures. A decreasing trend was noted for postoperative endophthalmitis rates during the 9-year study period. On multivariable analysis, the risk of endophthalmitis after cataract surgery was increased for cases performed among those aged ≥75 years versus those aged <75 years (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.11-1.18), Blacks (OR, 1.13; 95% CI, 1.07-1.20), Native Americans (OR, 1.43; 95% CI, 1.19-1.73), and eyes with any history of invasive glaucoma surgery (OR, 1.40; 95% CI, 1.18-1.65). Cataract cases combined with retinal surgery (OR, 2.60; 95% CI, 2.15-3.16) and those performed when the Charlson Comorbidity Index (CCI) was greater than 0 also had an increased likelihood of developing endophthalmitis. The risk of endophthalmitis was lower for cases performed on women versus men (OR, 0.89; 95% CI, 0.86-0.92). CONCLUSIONS: The overall 90-day postoperative endophthalmitis rate after cataract surgery was 1.36 per 1000 cataract surgeries between 2011 and 2019. Patient age, gender, race, and CCI were associated with risk of endophthalmitis.

Trends, Factors, and Outcomes Associated with Immediate Sequential Bilateral Cataract Surgery among Medicare Beneficiaries.

PURPOSE: To report the incidence of immediate sequential bilateral cataract surgery (ISBCS) and delayed sequential bilateral cataract surgery (DSBCS) and to identify factors associated with undergoing ISBCS. DESIGN: Retrospective cohort study. PARTICIPANTS: Medicare beneficiaries aged ≥ 65 who underwent ISBCS and DSBCS from 2011 through 2019. METHODS: Population-based analysis of the 100% Medicare fee-for-service carrier claims data. Logistic regression models were performed to evaluate factors associated with ISBCS. MAIN OUTCOME MEASURES: Incidence of ISBCS and DSBCS; demographic, ocular, and medical characteristics associated with receipt of ISBCS; and rates of endophthalmitis and cystoid macular edema (CME) after ISBCS or DSBCS. RESULTS: A total of 4014 (0.2%) ISBCS and 1 940 965 (99.8%) DSBCS patients were identified. Black (odds ratio [OR], 2.31; 95% confidence interval [CI], 2.06-2.59), Asian (OR, 1.82; 95% CI, 1.51-2.19), and Native American (OR, 2.42; 95% CI, 1.81-3.23) patients were more likely to receive ISBCS than White patients. Patients residing in rural areas showed a higher likelihood of ISBCS (OR, 1.26; 95% CI, 1.17-1.35) than patients in metropolitan areas. Patients undergoing surgery at a hospital, compared with an ambulatory setting (OR, 2.71; 95% CI, 2.53-2.89), were more likely to receive ISBCS. Patients with bilateral complex versus noncomplex cataract (OR, 3.23; 95% CI, 2.95-3.53) were more likely to receive ISBCS. Patients with a Charlson comorbidity index (CCI) of 1 to 2 (OR, 1.45; 95% CI, 1.29-1.62), 3 to 4 (OR, 1.70; 95% CI, 1.47-1.97), 5 to 6 (OR, 1.97; 95% CI, 1.62-2.39), and CCI ≥ 7 (OR, 1.97; 95% CI, 1.55-2.50) were more likely to receive ISBCS than those with a CCI of 0. In contrast, patients with glaucoma (OR, 0.82; 95% CI, 0.76-0.89), macular degeneration (OR, 0.75; 95% CI, 0.68-0.82), and macular hole or epiretinal membrane (OR, 0.55; 95% CI, 0.48-0.65) were less likely to undergo ISBCS than those without. Cumulatively, no significant difference was found in endophthalmitis rates within 42 days between ISBCS (1.74 per 1000 ISBCS procedures) and DSBCS (1.01 per 1000 DSBCS procedures; P = 0.15). Similarly, there was no significant cumulative difference between CME rates (P = 0.45) in ISBCS (1.79 per 100 ISBCS procedures) and DSBCS (1.96 per 100 DSBCS procedures). CONCLUSIONS: Overall use of ISBCS among Medicare beneficiaries remained low over the past decade, although rates of endophthalmitis and CME were comparable to DSBCS. Race, geography, and systemic and ocular comorbidities were associated with receiving ISBCS. ISBCS represents a potential opportunity to improve access to cataract surgery.

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

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

Comparison of post-cataract surgery endophthalmitis rates using syringing or regurgitation on pressure over the lacrimal sac as a preoperative screening tool for nasolacrimal duct obstruction: An impact assessment of protocol alteration due to the COVID-19 pandemic.

Purpose: To compare the post-cataract endophthalmitis (PCE) rates among eyes undergoing syringing or regurgitation on pressure over the lacrimal sac (ROPLAS) test prior to cataract surgery. Methods: We performed a single-center, retrospective, comparative analysis of eyes developing PCE who underwent syringing prior to cataract surgery (group A) in the pre-COVID-19 era between November 1 2019 and January 31, 2020 and the eyes that underwent ROPLAS test prior to cataract surgery (group B) in the COVID-19 era between November 1, 2020 and January 31, 2021. Results: A total of 87,144 eyes underwent cataract surgery during the two time periods of the study. Syringing was performed in 48,071 eyes, whereas ROPLAS was performed in 39,073 eyes. In group A, 19 eyes (0.039%) developed PCE, whereas 20 eyes (0.051%) developed PCE in group B (P = 0.517). Between the two groups, the grade of anterior chamber cellular reaction (P = 0.675), hypopyon (P = 0.738), and vitreous haze (P = 0.664) were comparable. Gram-positive organisms were detected in 4 eyes in group A and 6 eyes in group B; 2 eyes in group A had gram-negative bacilli. The presenting visual acuity (Group A: LogMAR 1.42 and Group B: LogMAR 1.30) and final visual acuity (Group A: LogMAR 0.52 and Group B: LogMAR 0.5) were comparable between the two groups. (P = 0.544 and 0.384, respectively). Conclusion: The rates of PCE were comparable among the eyes undergoing either syringing test or ROPLAS prior to cataract surgery.

Endophthalmitis Post Pars Plana Vitrectomy Surgery: Incidence, Organisms' Profile, and Management Outcome in a Tertiary Eye Hospital in Saudi Arabia.

PURPOSE: To determine the incidence of endophthalmitis after pars plana vitrectomy (PPV), organisms' profile, and management outcomes at a tertiary eye hospital in a Middle East country. METHODS: In this single-arm cohort study conducted in 2020, medical records of patients who underwent PPV not accompanied by any other intraocular surgery were reviewed; those with a diagnosis of acute endophthalmitis in the immediate postoperative period (within 6 weeks) during the past 6 years were analyzed. RESULTS: A total of 8153 records of PPV surgeries were reviewed. Five cases had endophthalmitis post-PPV with an incidence of 0.061%. Three (0.037%) had positive cultures, all of them for Staphylococcus epidermidis. The interval between PPV and diagnosis of endophthalmitis ranged from 3 to 25 days (mean, 15.8 days). Final vision after treatment ranged from 20/400 to no light perception, and one eye was eviscerated. CONCLUSION: The incidence of endophthalmitis post PPV is low. Despite prompt diagnosis and standard management, visual prognosis seems to be poor. The infective agents for endophthalmitis were commensals from the ocular surface.

Mortality risk associated with endophthalmitis in West Virginia.

PURPOSE: To explore how endophthalmitis presented from 2009 to 2019 in a West Virginia population particularly affected by the national opioid crisis. The analysis explores the relationship between the type of endophthalmitis and mortality, accounting for factors including age, gender, type of organism, and intravenous drug use (IVDU). METHODS: The electronic health record of West Virginia University (WVU) Medicine was queried for all patients managed for endophthalmitis from October 2009 to October 2019. For each of the included subjects, age, gender, history of IVDU, culture results, concomitant endocarditis, type of endophthalmitis, and the date of diagnosis were extracted. Mortality data were obtained from WVU's electronic medical record, the Social Security Death Index, and public obituaries. Mortality results were represented by a Kaplan-Meier Survival curve following each patient for one year from the date of diagnosis. Results were analyzed using unadjusted and adjusted Cox Proportional Hazard models. RESULTS: One-year mortality was 14 out of 113 endogenous cases (12.4%) compared to 6 out of 173 exogenous cases (3.5%). Endogenous endophthalmitis cases had significantly higher mortality than exogenous ones within one year of diagnosis (p = 0.0034). The unadjusted Cox proportional hazards model revealed that the type of endophthalmitis (endogenous vs. exogenous) was the only variable with a significant impact on 1-year mortality with a hazard ratio of 3.78 (p = 0.01). However, the hazard ratio for endogenous infections rose to 10.91 (CI 3.544-33.595) when the other variables of age, gender, organism, and IVDU were controlled (p < 0.01). The Cox proportional hazard ratios for age group, gender, organism type, and history of IVDU were not significantly different when adjusted for all other variables. CONCLUSION: Endogenous cases, which were significantly overrepresented in West Virginia, were associated with a significantly higher 1-year mortality rate than the exogenous ones. Age, gender, organism type, and history of IVDU have less, if any, modifying effect on mortality.

Cataract Surgery Complexity and Surgical Complication Rates Among Medicare Beneficiaries With and Without Dementia.

PURPOSE: To evaluate cataract surgery complexity and complications among US Medicare beneficiaries with and without dementia. DESIGN: Retrospective claims-based cohort study. PARTICIPANTS: A 20% representative sample of Medicare beneficiaries, 2006-2015. METHODS: Dementia was identified from diagnosis codes on or prior to each beneficiary's first-eye cataract surgery. For each surgery, we identified setting, routine vs complex coding, anesthesia provider type, duration, and any postoperative hospitalization. We evaluated 30- and 90-day complication rates-return to operating room, endophthalmitis, suprachoroidal hemorrhage, retinal detachment, retinal tear, macular edema, glaucoma, or choroidal detachment-and used adjusted regression models to evaluate likelihood of surgical characteristics and complications. Complication analyses were stratified by second-eye cataract surgery within 90 days postoperatively. RESULTS: We identified 457,128 beneficiaries undergoing first-eye cataract surgery, 23,332 (5.1%) with dementia. None of the evaluated surgical complications were more likely in dementia-diagnosed beneficiaries. There was also no difference in likelihood of nonambulatory surgery center setting, anesthesiologist provider, or postoperative hospitalization. Dementia-diagnosed beneficiaries were more likely to have surgeries coded as complex (15.6% of cases vs 8.8%, P < .0001), and surgeries exceeding 30 minutes (OR = 1.21, 95% CI = 1.17-1.25). CONCLUSIONS: Among US Medicare beneficiaries undergoing cataract surgery, those with dementia are more likely to have "complex" surgery" lasting more than 30 minutes. However, they do not have greater likelihood of surgical complications, higher-acuity setting, advanced anesthesia care, or postoperative hospitalization. This may be influenced by case selection and may suggest missed opportunities to improve vision. Future research is needed to identify dementia patients likely to benefit from cataract surgery.

Incidence of Drug Use-Related Endogenous Endophthalmitis Hospitalizations in the United States, 2003 to 2016.

Importance: Complications arising from the nationwide opioid epidemic led to an increase in health care use. Few studies have investigated whether this is reflected in hospital admissions for endogenous endophthalmitis. Objective: To report changing trends in epidemiology, risk factors, hospital course, and costs associated with drug use-related endogenous endophthalmitis hospitalizations in the United States from 2003 to 2016. Design, Setting, and Participants: Nationwide, retrospective cross-sectional study using the National Inpatient Sample. A total of 56 839 patients admitted with a diagnosis of endogenous endophthalmitis were included. Data were analyzed between 2003 and 2016. Exposures: Inpatient admission for endogenous endophthalmitis during the years 2003 to 2016. Main Outcomes and Measures: The Nationwide Inpatient Sample was queried to identify all inpatient admissions with a diagnosis of endogenous endophthalmitis in the United States between the years 2003 and 2016. Analyses were performed to identify national and regional trends in incidence and prevalence of associated infectious and noninfectious comorbidities in patients with or without a history of drug dependence or use. Median and cumulative inflation-adjusted costs for admissions were calculated. Results: Of all patients, 55.6% were White, 13.6% were Black, and 10.6% were Hispanic. There were an estimated 56 839 endogenous endophthalmitis-related hospitalizations; 13.7% of these patients (n = 7783) had a history of drug dependence or use. The drug-using population was significantly younger (49.6 vs 57.5 years; difference, 7.9; 95% CI, 6.93-8.88; P < .001) and more likely to be male (61.8% [n = 35 127] vs 49.0% [n = 21 712]; difference, 12.8%; 95% CI, 11.6%-14.0%; P < .001). The incidence of endogenous endophthalmitis associated with drug dependence or use increased from 0.08 per 100 000 in 2003 to 0.32 per 100 000 population in 2016 across all 4 US geographic regions. Conclusions and Relevance: A 4-fold increase in drug use-related endogenous endophthalmitis hospitalizations was observed in the United States from 2003 to 2016, resulting in substantial health care use burden. These findings support the hypothesis that clinicians should maintain a high index of suspicion for endophthalmitis when evaluating patients with intraocular inflammation in the setting of drug dependence or use.

Postoperative Complications in Medicare Beneficiaries Following Endothelial Keratoplasty Surgery.

PURPOSE: To determine national-level incidence rates of major postoperative complications following endothelial keratoplasty (EK) procedures and to stratify these rates based on EK indications over an 8-year period using Medicare claims data. DESIGN: Retrospective, cohort study. METHODS: Setting: population-based; study population: Medicare beneficiaries aged ≥65 years who underwent EK procedures; main outcome measurements: 1) occurrence of major postoperative complications (i.e., endophthalmitis, choroidal hemorrhage, infectious keratitis, cystoid macular edema [CME], retinal detachment [RD], or RD surgery) following EK surgery; 2) time-to-event analysis for glaucoma surgery; and 3) occurrence of graft complications. RESULTS: A total of 94,829 EK procedures (n = 71,040 unique patients) were included in the analysis. Of the total, 29% of patients had pre-existing glaucoma. The overall 90-day cumulative incidence of postoperative endophthalmitis and choroidal hemorrhage following EK was 0.03% and 0.05%, respectively. The overall 1-year cumulative rates of RD or RD surgery, infectious keratitis, and CME were 1.0%, 0.8%, and 4.1%, respectively. Approximately 7.6%, 12.2%, and 13.8% of all eyes in this study needed glaucoma surgery at 1-, 5-, and 8-years of follow-up, respectively. The probability of glaucoma surgery among patients with pre-existing glaucoma was 29% vs. 8% among those without pre-existing glaucoma at 8 years. The cumulative probabilities of developing any graft complications were 13%, 23.2%, and 27.1% at 1, 5, and 8 years, respectively, of follow-up. On average, patients undergoing EK procedures for a prior failed graft had the highest rate of complications, whereas those with Fuchs' corneal endothelial dystrophy had the lowest. CONCLUSIONS: The incidence of major postoperative complications including endophthalmitis, retinal detachment, and choroidal hemorrhage following EK procedures is low. A high proportion of eyes undergoing EK eventually require glaucoma surgery and experience graft-related complications. Postoperative outcomes are typically worse for patients undergoing EK for prior failed grafts than for those undergoing EK for Fuchs' corneal endothelial dystrophy.

Treatment regimens for administration of anti-vascular endothelial growth factor agents for neovascular age-related macular degeneration.

BACKGROUND: Age-related macular degeneration (AMD) is one of the leading causes of permanent blindness worldwide. The current mainstay of treatment for neovascular AMD (nAMD) is intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents: aflibercept, ranibizumab, and off-label bevacizumab. Injections can be given monthly, every two or three months ('extended-fixed'), or as needed (pro re nata (PRN)). A variant of PRN is 'treat-and-extend' whereby injections are resumed if recurrence is detected and then delivered with increasing intervals. Currently, injection frequency varies among practitioners, which underscores the need to characterize an optimized approach to nAMD management. OBJECTIVES: To investigate the effects of monthly versus non-monthly intravitreous injection of an anti-VEGF agent in people with newly diagnosed nAMD. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, LILACS, and three trials registers from 2004 to October 2019; checked references; handsearched conference abstracts; and contacted pharmaceutical companies to identify additional studies. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared different treatment regimens for anti-VEGF agents in people with newly diagnosed nAMD. We considered standard doses only (ranibizumab 0.5 mg, bevacizumab 1.25 mg, aflibercept 2.0 mg, or a combination of these). DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods for trial selection, data extraction, and analysis. MAIN RESULTS: We included 15 RCTs. The total number of participants was 7732, ranging from 37 to 2457 in each trial. The trials were conducted worldwide. Of these, six trials exclusively took place in the US, and three included centers from more than one country. Eight trials were at high risk of bias for at least one domain and all trials had at least one domain at unclear risk of bias. Seven trials (3525 participants) compared a PRN regimen with a monthly injection regimen, of which five trials delivered four to eight injections using standard PRN and three delivered nine or 10 injections using a treat-and-extend regimen in the first year. The overall mean change in best-corrected visual acuity (BCVA) at one year was +8.8 letters in the monthly injection group. Compared to the monthly injection, there was moderate-certainty evidence that the mean difference (MD) in BCVA change at one year for the standard PRN subgroup was -1.7 letters (95% confidence interval (CI) -2.8 to -0.6; 4 trials, 2299 participants), favoring monthly injections. There was low-certainty evidence of a similar BCVA change with the treat-and-extend subgroup (0.5 letters, 95% CI -3.1 to 4.2; 3 trials, 1226 participants). Compared to monthly injection, there was low-certainty evidence that fewer participants gained 15 or more lines of vision with standard PRN treatment at one year (risk ratio (RR) 0.87, 95% CI 0.76 to 0.99; 4 trials, 2299 participants) and low-certainty evidence of a similar gain with treat-and-extend versus monthly regimens (RR 1.11, 95% CI 0.91 to 1.36; 3 trials, 1169 participants). The mean change in central retinal thickness was a decrease of -166 µm in the monthly injection group; the MD compared with standard PRN was 21 µm (95% CI 6 to 32; 4 trials, 2215 participants; moderate-certainty evidence) and with treat-and extend was 22 µm (95% CI 37 to -81 µm; 2 trials, 635 participants; low-certainty evidence), in favor of monthly injection. Only one trial (498 participants) measured quality of life and reported no evidence of a difference between regimens, but data could not be extracted (low-certainty evidence). Both PRN regimens (standard and 'treat-and-extend') used fewer injections than monthly regimens (standard PRN: MD -4.6 injections, 95% CI -5.4 to -3.8; 4 trials, 2336 participants; treat-and-extend: -2.4 injections, 95% CI -2.7 to -2.1 injections; moderate-certainty evidence for both comparisons). Two trials provided cost data (1105 participants, trials conducted in the US and the UK). They found that cost differences between regimens were reduced if bevacizumab rather than aflibercept or ranibizumab were used, since bevacizumab was less costly (low-certainty evidence). PRN regimens were associated with a reduced risk of endophthalmitis compared with monthly injections (Peto odds ratio (OR) 0.13, 95% CI 0.04 to 0.46; 6 RCTs, 3175 participants; moderate-certainty evidence). Using data from all trials included in this review, we estimated the risk of endophthalmitis with monthly injections to be 8 in every 1000 people per year. The corresponding risk for people receiving PRN regimens was 1 in every 1000 people per year (95% CI 0 to 4). Three trials (1439 participants) compared an extended-fixed regimen (number of injections reported in only one large trial: 7.5 in one year) with monthly injections. There was moderate-certainty evidence that BCVA at one year was similar for extended-fixed and monthly injections (MD in BCVA change compared to extended-fixed group: -1.3 letters, 95% CI -3.9 to 1.3; RR of gaining 15 letters or more: 0.94, 95% CI 0.80 to 1.10). The change in central retinal thickness was a decrease of 137 µm in the monthly group; the MD with the extended-fixed group was 8 µm (95% CI -11 to 27; low-certainty evidence). The frequency of endophthalmitis was lower in the extended-fixed regimen compared to the monthly group, but this estimate was imprecise (RR 0.19, 95% CI 0.03 to 1.11; low-certainty evidence). If we assumed a risk of 8 cases of endophthalmitis in 1000 people receiving monthly injections over one year, then the corresponding risk with extended-fixed regimen was 2 in 1000 people (95% CI 0 to 9). Other evidence comparing different extended-fixed or PRN regimens yielded inconclusive results. AUTHORS' CONCLUSIONS: We found that, at one year, monthly regimens are probably more effective than PRN regimens using seven or eight injections in the first year, but the difference is small and clinically insignificant. Endophthalmitis is probably more common with monthly injections and differences in costs between regimens are higher if aflibercept or ranibizumab are used compared to bevacizumab. This evidence only applies to settings in which regimens are implemented as described in the trials, whereas undertreatment is likely to be common in real-world settings. There are no data from RCTs on long-term effects of different treatment regimens.

Eye-Related Emergency Department Visits and The Opioid Epidemic: a 10-Year Analysis.

PURPOSE: To describe the epidemiology of Emergency Department (ED) visits related to opioid abuse with primary ophthalmic diagnoses in the United States (US). METHODS: This retrospective cross-sectional study used National ED Sample (NEDS) (2006-2015), a representative sample of all US EDs, to analyze and compare the epidemiology of primary ophthalmic diagnoses in opioid abusers and a control group of non-opioid users. National incidence and descriptive statistics were calculated for demographics and prevalent diagnoses. Multivariable logistic regression was used to compare outcomes between primary ophthalmic diagnoses in opioid and non-opioid abusers. RESULTS: An estimated 10,617 visits had a primary ophthalmic diagnosis and an accompanying opioid abuse diagnosis, and the incidence increased from 0.2 in 2006 to 0.6 per 100,000 US population in 2015. Opioid abuse group had more adults (6,747:63.5%) and middle-aged (3,361:31.7%) patients, while in controls adults (7,905,003:40.4%) and children (4,068,534:20.8%) were affected more. Leading etiologies were similar: traumatic and infectious etiologies were most common; however, opioid abuse patients had more severe ophthalmic diagnoses such as orbital fractures (8.4%), orbital cellulitis (7.4%), globe injury (3.4%) and endophthalmitis (3.2%) compared to controls. Patients in the opioid abuse group were also more likely to be admitted (adjusted Odds Ratio [aOR], 28.38 [95% CI, 24.50-32.87]). CONCLUSIONS: In the era of opioid crisis, an increase in ED visits with ophthalmic complaints is seen, with increasing direct and indirect costs on the healthcare system. More research is needed to establish causality and devise strategies to lower this burden.

Posttraumatic Endophthalmitis in children: Epidemiology, Diagnosis, Management, and Prognosis.

Pediatric posttraumatic endophthalmitis presents with great complexities and challenges arising due to delayed presentation, difficulty in eliciting an accurate history, or trauma with unusual and highly contaminated objects. The possibility of initial misdiagnosis as panuveitis, metastatic endophthalmitis, and masquerade syndrome is also very high, which results not only in several unwarranted investigations being performed, but also a delay in the initiation of treatment. The standard treatment remains primary repair of the wound, intravitreal therapy with broad spectrum antibiotics, and parsplana vitrectomy. Despite appropriate intervention, visual outcome in children with posttraumatic endophthalmitis is dampened by additional factors like poor compliance with postoperative instructions and high risk of amblyopia. Hence, it is important to recognize that posttraumatic endophthalmitis in children differs from that in adults in several ways. We made a very tailored effort to review the published literature pertaining to posttraumatic endophthalmitis in children and herein present the results of our search.