Anesthesia techniques and the risk of complications as reflected in the European Registry of Quality Outcomes for Cataract and Refractive Surgery.

PURPOSE: To determine the trends in anesthesia techniques for cataract surgery over the past decade and their relationship to surgical complications. SETTING: Clinics affiliated with the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO). DESIGN: Retrospective cross-sectional register-based study. METHODS: Variables include patient demographics, visual acuity, ocular comorbidities, surgery characteristics, intraoperative complications, and postoperative complications for the study period from January 2008, to December 2018. The anesthesia methods registered in the EUREQUO and included in the study are topical, combined topical and intracameral, sub-Tenon, regional, and general anesthesia. Multivariate logistic regression models for each complication were constructed to estimate the adjusted odds ratio (OR) and 95% CIs. RESULTS: Complete data were available of 1 354 036 cataract surgeries. Topical anesthesia increased significantly over time (from 30% to 76%, P < .001). Sub-Tenon and regional anesthesia decreased (from 27% and 38% to 16% and 6%, respectively, P < .001), and general and combined topical and intracameral anesthesia remained stable (around 2%). Sub-Tenon (OR, 0.80; 95% CI, 0.71-0.91, P < .001), regional (0.74; 95% CI, 0.71-0.78, P < .001), general (0.53; 95% CI, 0.50-0.56, P < .001), and intracameral anesthesia (0.76; 95% CI, 0.64-0.90, P = .001) carried a significantly decreased risk of posterior capsule rupture (PCR), with and without dropped nucleus, compared with topical anesthesia. The risk of endophthalmitis was significantly lower with regional anesthesia compared with topical anesthesia (OR, 0.60; 95% CI, 0.44-0.82, P = .001). CONCLUSIONS: The use of topical anesthesia for cataract surgery increased over time. Topical anesthesia is associated with an increased risk of PCR with and without dropped nucleus, and endophthalmitis.

Characterization and distribution of viridans group streptococci isolated from infectious endophthalmitis and keratitis / Caracterização e distribuição de estreptococos do grupo viridans isolados de endoftalmite infecciosa e ceratite

ABSTRACT Purpose: The aims of this study were to characterize alpha-hemolytic streptococci among isolates from cases of infectious endophthalmitis and keratitis and to determine their distributions. Methods: The sample included 27 and 35 nonduplicated isolates of alpha-hemolytic streptococci recovered from patients with infectious endophthalmitis (2002-2013) and keratitis (2008-2013), respectively. Isolates were identified by the optochin susceptibility and bile solubility tests, using a biochemical identification system. The minimum inhibitory concentration was determined by the broth microdilution method. Molecular identification was performed by analyses of three constitutive genes and the complementary multilocus sequence. The molecular epidemiology of Streptococcus pneumoniae was investigated using multilocus sequence typing, and the presence of the capsular polysaccharide-encoding gene was assessed using conventional polymerase chain reaction. Outcomes were evaluated using the patients' medical records. Results: Phenotypic tests differentiated S. pneumoniae from other alpha-hemolytic streptococci, consistent with later molecular identifications. Streptococcus oralis was significantly prevalent among the endophthalmitis isolates, as was S. pneumoniae in the keratitis isolates. High levels of susceptibility to antibiotics were observed, including vancomycin, cephalosporins, and fluoroquinolones. High genetic variability was detected among the 19 S. pneumoniae strains, with 15 predicted to be encapsulated. The medical records of patients with infectious endophthalmitis were reviewed (n=15/27; 56%), and final visual acuity was assessed in 12 cases (44%). Many patients progressed to a final visual acuity state of "no light perception" (6/12; 50%), "light perception" (3/12; 25%), or "hand motion" (1/12; 8%). The medical records of patients with infectious keratitis were also reviewed (n=24/35; 69%), and final visual acuity was assessed in 18 cases (51%). Similarly, most patients progressed to a final visual acuity state of "no light perception" (6/18; 33%), "light perception" (1/18; 6%), or "hand motion" (6/18; 33%). Overall, the majority of patients progressed to a final visual acuity state of "no light perception" (12/30), "light perception" (4/30), or "hand motion" (7/30). Conclusions: The distribution of alpha-hemolytic streptococci in ocular infections suggested the presence of a species-specific tissue tropism. The prognoses of patients with ocular streptococcal infections were highly unfavorable, and antibiotic resistance did not contribute to the unfavorable clinical progressions and poor outcomes.

RESUMO Objetivo: O objetivo deste estudo foi caracterizar os estreptococos alfa-hemolíticos isolados de endoftalmite infecciosa e ceratite e determinar sua distribuição. Métodos: A amostra incluiu 27 e 35 isolados não-duplicados de estreptococos alfa-hemolíticos recuperados de pacientes com endoftalmite infecciosa (2002-2013) e ceratite (2008-2013), respectivamente. Os isolados foram identificados pelos testes de suscetibilidade à optoquina e bile solubilidade, utilizando um sistema de identificação bioquímica. A concentração inibitória mínima foi determinada pelo método de microdiluição em caldo. A identificação molecular foi realizada pela análise de três genes constitutivos e análise complementar de sequências multilocus. A epidemiologia molecular do Streptococcus pneumoniae foi investigada por tipagem de sequência multilocus, e a presença do gene codificador do polissacarídeo capsular foi avaliada por reação em cadeia da polymerase convencional. Os resultados foram avaliados utilizando os prontuários médicos dos pacientes. Resultados: Os testes fenotípicos diferenciaram S. pneumoniae dos outros estreptococos alpha-hemolíticos, consistentes com identificações moleculares posteriores. S. oralis foi significativamente prevalente entre os isolados de endoftalmite, assim como S. pneumoniae nos isolados de ceratite. Foram observados altos níveis de suscetibilidade a antibióticos, incluindo vancomicina, cefalosporinas e fluoroquinolonas. Alta variabilidade genética foi detectada entre as 19 cepas de S. pneumoniae, com 15 previstas para serem encapsuladas. Os prontuários médicos dos pacientes com endoftalmite infecciosa foram revisados (n=15/27; 56%), e a acuidade visual final foi avaliada em 12 casos (44%). Muitos pacientes evoluiram para um estado final de acuidade visual de "sem percepção luminosa" (6/12; 50%), "percepção luminosa" (3/12; 25%) ou "movimentos de mãos" (1/12; 8%). Também foram revisados os prontuários médicos dos pacientes com ceratite infecciosa (n=24/35; 69%), e a acuidade visual final foi avaliada em 18 casos (51%). Da mesma foram, a maioria dos pacientes evoluiu para um estado final de acuidade visual de "sem percepção luminosa" (6/18; 33%), "percepção luminosa" (1/18; 6%) ou "movimentos de mãos" (6/18; 33%). No geral, a maioria dos pacientes evoluiu para um estado final de acuidade visual de "sem percepção luminosa" (12/30), "percepção luminosa" (4/30) ou "movimentos de mãos" (7/30). Conclusões: A distribuição de estreptococos alfa-hemolíticos nas infecções oculares sugeriu a presença de um tropismo de tecido específico da espécie. Os prognósticos dos pacientes com infeções oculares por estreptococos foram altamente desfavoráveis e a resistência a antibióticos contribuiu não para as progressões clínicas des­favoráveis e os maus resultados.

Postoperative Endophthalmitis Before and After Preferred Utilization of Prophylactic Intracameral Antibiotics for Phacoemulsification Cataract Surgeries at Cole Eye Institute.

PURPOSE: To compare the rate of endophthalmitis of intracameral versus topical antibiotic prophylaxis for patients undergoing phacoemulsification at a single-centered, multispecialty ophthalmological institute. METHODS: A retrospective analysis of the rate of endophthalmitis by coding search within 90 days of cataract surgery in periods before (May 15, 2012-May 15, 2014) and after (April 30, 2015-April 30, 2017) intracameral antibiotics became the institution's preferred practice pattern for phacoemulsification. Clinical data were collected for each endophthalmitis case, including timing of onset, presenting symptoms and signs, culture results, treatment performed, and visual acuity outcome. RESULTS: The rate of postphacoemulsification endophthalmitis decreased from 0.18% (29 eyes among 16,201 cataract surgeries) to 0.07% (11 eyes among 16,325 surgeries) when the preferred method was changed from topical to intracameral antibiotics (P=0.004) with an odds ratio of 0.32. Endophthalmitis cases in the 2 groups had comparable visual acuity at initial presentation and at 3 months (P=0.86). The most commonly isolated organism in culture-proven cases of endophthalmitis in both groups was coagulase-negative staphylococcus. The rate of gram-positive endophthalmitis decreased from 0.08% to 0.02% with an odds ratio of 0.23 (P=0.012) while the rate of gram-negative cases remained similar. CONCLUSIONS: The use of intracameral antibiotics during cataract surgery was associated with a statistically significant reduction of postoperative endophthalmitis.

Endophthalmitis Incidence of Cancer Patients After Cataract Surgery: A Nationwide Matched Cohort Study in Taiwan.

PURPOSE: To compare the incidence rate of endophthalmitis after cataract surgery between cancer cohort and matched noncancer cohort. DESIGN: Matched cohort study. METHODS: Patients with cataract surgery of both eyes among a nationwide cancer cohort and 1:1 matched noncancer cohort were enrolled from the years 1998 to 2012 in the Taiwan National Health Insurance Research Database. Both the cancer group and the control group were followed for 3 months after the cataract surgery to obtain the rate of endophthalmitis. RESULTS: There were 23 362 patients each in the cancer cohort and in the matched noncancer cohort. The mean age of receiving first cataract surgery was 71 years. The mean duration of receiving cataract surgery was 4.3 years after cancer diagnosis. The mean duration between 2 cataract surgeries was 8-9 months. The rate of endophthalmitis within 3 months after cataract surgery was similar between the 2 study groups: 2.4‰ (95% confidence interval = 1.9‰-2.8‰) for the cancer group and 2.3‰ (95% confidence interval = 1.9‰-2.8‰) for the noncancer group, respectively (P = .892). CONCLUSIONS: Cancer patients have a similar risk of endophthalmitis following cataract surgery as the noncancer population, and the current study suggests that cataract surgery can be considered as appropriately indicated for cancer patients.

Infectious postoperative endophthalmitis after cataract surgery performed over 7 years. The role of azithromycin versus ciprofloxacin eye drops.

OBJECTIVE: Although topical antibiotics have been used as antimicrobial prophylaxis after ocular surgery, recent studies have determined that intracameral cefuroxime at the end of surgery significantly reduce the risk to suffer an infection and suggest that the use of topical antibiotics in the prophylaxis of infectious postoperative endophthalmitis (IPOE) is controversial. Moreover, there is no evidence to confirm the higher effectiveness of topical ciprofloxacin, considered the standard of care, or topical azithromycin in preventing IPOE of cataract surgeries. METHODS: IPOE topical prophylaxis was performed with two different strategies: with azithromycin from January 1st, 2010 to December 31st, 2014 (group I) and with ciprofloxacin from January 1st, 2015 to January 31st, 2017 (group II). Patient characteristics and clinical signs and symptoms of IPOE from all consecutive cataract surgeries performed over a 7-year period were collected. RESULTS: A total of 15,146 cataract surgeries were conducted; 10,756 in group I and 4,390 in group II. Two cases of IPOE in each group were diagnosed, showing a 0.019% and 0.046% rate respectively, with no statistically significance. IPOE cases were related with aging, systemic and ocular comorbidities or with a complicated cataract surgery. CONCLUSIONS: The benefit of the application of topical antibiotics after cataract surgery is questionable when intracameral cefuroxime prophylaxis is performed and no better effectiveness with ciprofloxacin or azithromycin was observed.

Endophthalmitis Reduction with Intracameral Moxifloxacin Prophylaxis: Analysis of 600 000 Surgeries.

PURPOSE: To compare the postoperative endophthalmitis rate before and after initiation of intracameral (IC) moxifloxacin prophylaxis for both phacoemulsification and sutureless, manual small-incision cataract surgery (M-SICS), as well as in patients with posterior capsular rupture (PCR). DESIGN: Retrospective, clinical registry. PARTICIPANTS: All cataract surgeries (617 453) performed during the 29-month period from January 2014 to May 2016 at the 10 regional Aravind eye hospitals were included. METHODS: The electronic health record data for all study eyes were analyzed. Endophthalmitis rates before and after moxifloxaxin were statistically compared for all eyes and separately for both phacoemulsification and M-SICS, and for the eyes complicated by PCR. MAIN OUTCOME MEASURES: The postoperative endophthalmitis rates before and after initiation of IC moxifloxacin prophylaxis. RESULTS: Overall, 302 815 eyes did not receive IC moxifloxacin and 314 638 eyes did, and there was a significant decline in the endophthalmitis rate, from 0.07% (214/302 815) to 0.02% (64/314 638) (P < 0.001), with moxifloxacin. For the 194 252 phacoemulsification eyes, the endophthalmitis rate was 0.07% (75/104 894) without IC moxifloxacin prophylaxis, compared with 0.01% (11/89 358) with moxifloxacin (P < 0.001). For the 414 657 M-SICS eyes, the endophthalmitis rate was 0.07% (135/192 149) without IC moxifloxacin prophylaxis, compared with 0.02% (52/222 508) with moxifloxacin (P < 0.001). Approximately half of the 8479 eyes that had PCR received IC moxifloxacin, and half did not. Without IC moxifloxacin, PCR increased the endophthalmitis rate nearly 7-fold to 0.48% (20/4186); IC moxifloxacin reduced the endophthalmitis rate with PCR to 0.21% (9/4293) (P = 0.034). No adverse events were due to IC moxifloxacin. CONCLUSIONS: Routine IC moxifloxacin prophylaxis reduced the overall endophthalmitis rate by 3.5-fold (3-fold for M-SICS and nearly 6-fold for phacoemulsification). There was also a statistical benefit for eyes complicated by PCR, and IC antibiotic prophylaxis should be strongly considered for this high-risk population. These conclusions are strengthened by the high volume of cases analyzed at a single hospital network over a comparatively short time frame. Considering the association of hemorrhagic occlusive retinal vasculitis with vancomycin and the commercial unavailability of IC cefuroxime in many countries, moxifloxacin appears to be an effective option for surgeons electing IC antibiotic prophylaxis.

Efficacy of Intracameral Moxifloxacin Endophthalmitis Prophylaxis at Aravind Eye Hospital.

PURPOSE: To compare the rate of postoperative endophthalmitis before and after initiation of intracameral (IC) moxifloxacin for endophthalmitis prophylaxis in patients undergoing cataract surgery. DESIGN: Retrospective, clinical registry. PARTICIPANTS: All charity and private patients (116 714 eyes) who underwent cataract surgery between February 15, 2014, and April 15, 2015, at the Madurai Aravind Eye Hospital were included. Group 1 consisted of 37 777 eyes of charity patients who did not receive IC moxifloxacin, group 2 consisted of 38 160 eyes of charity patients who received IC moxifloxacin prophylaxis, and group 3 consisted of 40 777 eyes of private patients who did not receive IC moxifloxacin. METHODS: The electronic health record data for each of the 3 groups were analyzed, and the postoperative endophthalmitis rates were statistically compared. The cost of endophthalmitis treatment (groups 1 and 2) and the cost of IC moxifloxacin prophylaxis (group 2) were calculated. MAIN OUTCOME MEASURES: Postoperative endophthalmitis rate before and after initiation of IC moxifloxacin endophthalmitis treatment cost. RESULTS: Manual, sutureless, small incision cataract surgery (M-SICS) accounted for approximately all of the 75 937 cataract surgeries in the charity population (97%), but only a minority of the 40 777 private surgeries (21% M-SICS; 79% phacoemulsification). Thirty eyes in group 1 (0.08%) and 6 eyes in group 2 (0.02%) were diagnosed with postoperative endophthalmitis (P < 0.0001). The group 3 endophthalmitis rate was 0.07% (29 eyes), which was also higher than the second group's rate (P < 0.0001). There were no adverse events attributed to IC moxifloxacin in group 2. The total cost of treating the 30 patients with endophthalmitis in group 1 was virtually identical to the total combined cost in group 2 of routine IC moxifloxacin prophylaxis and treatment of the 6 endophthalmitis cases. CONCLUSIONS: Routine IC moxifloxacin prophylaxis achieved a highly significant, 4-fold reduction in postoperative endophthalmitis in patients undergoing M-SICS. Compared with previous studies, having such a high volume of patients undergoing surgery during a relatively short 14-month time period strengthens the conclusion. This study provides further evidence that moxifloxacin is an effective IC prophylactic antibiotic and suggests that IC antibiotics should be considered for M-SICS and phacoemulsification.

Prevalence and antimicrobial susceptibilities of anaerobic bacteria isolated from perforated corneal ulcers by culture and multiplex PCR: an evaluation in cases with keratitis and endophthalmitis.

BACKGROUND: Anaerobic bacteria play an important role in eye infections; however, there is limited epidemiologic data based on the the role of these bacteria in the etiology of keratitis and endophthalmitis. The aim of this re- search is to determine the prevalence of anaerobic bacteria in perforated corneal ulcers of patients with keratitis and endophthalmitis and to evaluate their antimicrobial susceptibilities. METHODS: Corneal scrapings were taken by the ophthalmologist using sterile needles. For the isolation of anaerobic bacteria, samples were inoculated on specific media and were incubated under anaerobic conditions obtained with Anaero-Gen (Oxoid & Mitsubishi Gas Company) in anaerobic jars (Oxoid USA, Inc. Columbia, MD, USA). The molecular identification of anaerobic bacteria was performed by multiplex PCR and the susceptibilities of an- aerobic bacteria to penicillin, chloramphenicol, and clindamycin were determined with the E test (bioMerieux). RESULTS: 51 strains of anaerobic bacteria belonging to four different genuses were detected by multiplex PCR and only 46 strains were isolated by culture. All of them were found susceptible to chloramphenicol whereas penicillin resistance was found in 13.3% of P.anaerobius strains, clindamycin resistance was found in 34.8% of P.acnes and 13.3% of P. anaerobius strains. Additionnaly, one strain of P. granulosum was found resistant to clindamycin, one strain of B. fragilis and one strain of P.melaninogenica were found resistant to penicillin and clindamycin. CONCLUSIONS: Routine analyses of anaerobes in perforated corneal ulcers is inevitable and usage of appropriate molecular methods, for the detection of bacteria responsible from severe infections which might not be deter- mined by cultivation, may serve for the early decision of the appropriate treatment. Taking into account the in- creasing antimicrobial resistance of anaerobic bacteria, alternative eye specific antibiotics effective against anaer- obes are needed to achieve a successful treatment.

Microbial spectrum and resistance patterns in endophthalmitis: a 21-year (1988-2008) review in northeast United States.

PURPOSE: To study the microbial spectrum and antibacterial susceptibility of vitreous cultures in a tertiary referral center in Northeast United States. METHODS: All vitreous samples sent to the microbiology laboratory at a tertiary referral center from January 1988 to December 2008 were included in the study. The distribution and antibiotic susceptibility of all isolates from culture-positive samples were compared across 3 equal time periods 1988-1994, 1995-2001, and 2002-2008. RESULTS: One hundred forty-three positive cultures, where 11.9% (n=17) were polymicrobial, yielded a total of 160 isolates that consisted of 80.6% (n=129) gram-positive isolates, 12.5% (n=20) gram-negative isolates, and 6.9% (n=11) fungal isolates. The most prevalent organisms were coagulase-negative Staphylococcus (CoNS) (37.5%, n=60), Viridans Streptococcus (11.3%, n=18), and Streptococcus pneumoniae (6.9%, n=11). Other common gram-positive isolates include Propionibacterium acnes (5.6%, n=9), other Streptococcus species (4.4%, n=7), Staphylococcus aureus (4.4%, n=7), and Enterococcus faecalis (3.8%, n=6). The most common gram-negative isolates were Klebsiella species (3.1%, n=5), Moraxella species (3.1%, n=5), and Haemophilus species (2.5%, n=4). Vancomycin was effective against all CoNS, Sta. aureus, Viridans Streptococcus, and E. faecalis tested, and all Sta. aureus isolates were oxacillin sensitive. Of all CoNS isolates, 83.3% during 1988-1994, 73.1% during 1995-2001, and 100% during 2002-2008 were resistant to at least 1 of the antibiotics tested in the study with the last time period showing an increase in resistance (P=0.021, adjusted standard residual=2.0). CoNS showed a decreasing resistance over time to chloramphenicol and gentamicin (P=0.010, P=0.007, respectively) and an increase in resistance to penicillin and tetracycline during 2002-2008 (P=0.003, P=0.040, respectively). Susceptibility to other antibiotics did not show significant dependence on time. CONCLUSION: Bacteria causing endophthalmitis showed variable resistance to antibiotics over time. The importance of adequately treating endophthalmitis in the setting of these resistance pattern changes stresses the importance of periodic evaluation of causative organisms to ensure appropriate empiric treatment.

Incidence of endophthalmitis after intravitreal injection of antivascular endothelial growth factor medications using topical lidocaine gel anesthesia.

PURPOSE: The purpose of this study was to determine the incidence of infectious endophthalmitis after intravitreal injection of antivascular endothelial growth factor medications using 2% topical lidocaine gel anesthesia. METHODS: Retrospective chart review of 4690 consecutive intravitreal injections of antivascular endothelial growth factor medications using 2% topical lidocaine gel anesthesia. All patients had at least 6 weeks of follow-up. RESULTS: A total of 608 patients underwent intravitreal injection of antivascular endothelial growth factor medications during the study period. There were 428 injections of pegaptanib sodium, 1841 injections of bevacizumab, and 2421 injections of ranibizumab. There were no cases of infectious endophthalmitis. The per-injection infection rate was 0.0% (95% confidence interval, 0.0-0.06%). CONCLUSION: The incidence of infectious endophthalmitis after intravitreal injection of antivascular endothelial growth factor medications using 2% topical lidocaine gel anesthesia is low.

Risk factors for acute endophthalmitis after cataract surgery: a population-based study.

OBJECTIVE: To identify risk factors for suspected acute endophthalmitis after cataract surgery. DESIGN: Population-based retrospective cohort. PARTICIPANTS: Administrative data from more than 440,000 consecutive cataract surgeries in Ontario, Canada, from April 1, 2002, to March 31, 2006. METHODS: Consecutive physician billing claims for cataract surgery and specific intraoperative and postoperative procedures related to complications of cataract surgery were identified. Acute endophthalmitis was defined using surrogate markers for intraocular infection, including vitrectomy, vitreous injection, or aspiration procedures not in combination with air/fluid exchange or dislocated lens extraction, performed 1 to 14 days after cataract surgery. Anterior vitrectomy performed on the day of surgery was used as a surrogate marker for capsular rupture. MAIN OUTCOME MEASURES: Overall rates of endophthalmitis were calculated and grouped by patient demographics, surgical facility, season, year, and association with capsular rupture. RESULTS: There were 617 suspected acute endophthalmitis cases of 442,177 cataract surgeries over the 4 years. The overall unadjusted and adjusted rates of suspected acute endophthalmitis were both 1.4 per 1000 cataract surgeries. Men had higher rates than women (1.70 vs. 1.19/1000 surgeries, P<0.0001) with an adjusted odds ratio of 1.40 (95% confidence interval, 1.19-1.64).The oldest age group (>or= 85 years) had the highest rate (2.18/1000), and the youngest group (20-64) had the second highest rate (1.76/1000). The endophthalmitis rates for these age groups were significantly different from those aged 65 to 84 years. The endophthalmitis rate was approximately 10-fold higher in those with capsular rupture compared with those without (13.11 vs. 1.34/1000, P<0.0001), with an adjusted odds ratio of 9.56 (95% confidence interval, 6.43-14.2). CONCLUSIONS: The overall rates of suspected acute endophthalmitis are low but significantly higher in certain patient groups. Our population-based analysis can be used as a benchmark for quality-improvement initiatives and can assist clinicians in educating their patients regarding the risks associated with cataract surgery. Future work is required to address the higher rate of endophthalmitis in men, those with capsular rupture, and the oldest patients undergoing cataract surgery.

Third- and fourth-generation fluoroquinolones: retrospective comparison of endophthalmitis after cataract surgery performed over 10 years.

PURPOSE: To determine differences in endophthalmitis rates with prophylactic use of third- versus fourth-generation fluoroquinolones in cataract surgery. SETTING: University hospitals. METHODS: This retrospective cross-sectional (prevalence) study looked at patients who had phacoemulsification at a university eye center over a 10-year period. A nosocomial infectious reporting database was used to report endophthalmitis occurrences. The following were performed: a retrospective analysis of prospectively collected data to establish endophthalmitis rates, a prevalence analysis of the postoperative quinolone antibiotic prescribed, and a comparative analysis of endophthalmitis rate versus postoperative quinolone prescribed for all reported endophthalmitis cases. The main outcome measure was occurrence of endophthalmitis after cataract surgery. RESULTS: From January 1997 to December 2007, 29276 patients had phacoemulsification cataract surgery. Forty cases of postoperative bacterial endophthalmitis were reported. The endophthalmitis rate from January 1997 to August 2003 associated with use of third-generation fluoroquinolones (ciprofloxacin, ofloxacin) was 0.197% (33/16710). The rate from September 2003 to December 2007 associated with fourth-generation fluoroquinolones (gatifloxacin, moxifloxacin) was 0.056% (7/12566). The difference between third- and fourth-generation drugs was statistically significant (P = .0011). Of fourth-generation fluoroquinolone infections, 0.015% (1/6651) and 0.1% (6/5915) were associated with gatifloxacin and moxifloxacin, respectively. The difference between drugs was statistically significant (P = .040). CONCLUSIONS: The differences in the pharmacokinetic and pharmacodynamic properties of quinolone antibiotics may affect the endophthalmitis incidence after cataract surgery. The significant difference in endophthalmitis rates between gatifloxacin and moxifloxacin requires further study.

Isolates and antibiotic sensitivity of eighty culture-proven endophthalmitis cases from Istanbul.

PURPOSE: To investigate the spectrum of organisms causing endophthalmitis and their sensitivity to commonly used antimicrobial agents. METHODS: Medical records of 80 consecutive patients treated at Beyoglu Eye Hospital for endophthalmitis from January 2001 to April 2006 were reviewed. Specimens were obtained from either the vitreous (93%, 81/87) or anterior chamber (7%, 6/87) during pars plana vitrectomy or vitreous tap, and were inoculated into blood culture bottles. A Kirby-Bauer disk diffusion test was performed to determine antibiotic susceptibility. The outcome measures included isolates identified and antibiotic sensitivity of the specimens. RESULTS: Fifty-six of 87 (64.4%) isolates were Gram-positive organisms, 29 (33.3%) were Gram-negative organisms, and 2 (2.3%) were fungi. The most common organism group identified was coagulase-negative staphylococci in 26.4% (23/87). While vancomycin was active against all Gram-positive isolates tested (100%), ceftazidime had the highest susceptibility rate (100%) for Gram-negative organisms isolated. CONCLUSIONS: Although coagulase-negative micrococci predominated in this series, a high isolation rate for Gram-negative organisms was obtained. High susceptibility rates for ofloxacin make it an alternative to ceftazidime and vancomycin in both Gram-negative- and Gram-positive-derived endophthalmitis, respectively. Studies with larger series and additional antibiotics are needed to confirm these findings.

Topical anesthesia: possible risk factor for endophthalmitis after cataract extraction.

PURPOSE: To assess the relationship between the risk for acute endophthalmitis after cataract extraction and whether certain factors, such as surgeon qualification, numerical order, duration of surgery, operating theater, and type of anesthesia (topical or retrobulbar), could be modified to decrease the risk. SETTING: Single-center academic practice. METHODS: Two epidemiological studies were performed: a case-control study and a retrospective cohort study. The surgical records of all patients with clinically diagnosed endophthalmitis within 30 days after cataract surgery performed between February 2002 and September 2003 were reviewed. The endophthalmitis cases were compared with 108 randomly selected controls (4 controls per case). The global incidence of endophthalmitis and the incidence according to type of anesthesia were calculated. RESULTS: Of 5011 cataract extractions performed, 27 cases of endophthalmitis occurred. The incidence was 5.39 per 1000 procedures. An independent statistically significant relationship was found between endophthalmitis and the use of topical anesthesia (odds ratio [OR], 11.8; 95% confidence interval [CI], 2.4-58.7) and surgery longer than 45 minutes (OR, 7.2; 95% CI, 1.7-29.7) but not between the other variables. The incidence of endophthalmitis was 1.8 per 1000 cataract extractions with retrobulbar anesthesia and 6.76 per 1000 with topical anesthesia (relative risk [RR], 3.76; 95% CI, 0.89-15.85). After the start of the study period was extended to May 2001, the incidence of endophthalmitis was 1.3 per 1000 cataract extractions with retrobulbar anesthesia and 8.7 per 1000 with topical anesthesia (RR, 6.72; 95% CI, 1.63-27.63). CONCLUSION: Results suggest that there may be an association between topical anesthesia and endophthalmitis after cataract extraction.

Acute-onset endophthalmitis after cataract surgery (2000-2004): incidence, clinical settings, and visual acuity outcomes after treatment.

PURPOSE: To report the incidence, clinical settings, and visual acuity outcomes of acute-onset endophthalmitis after cataract surgery. DESIGN: Retrospective, observational case series. METHODS: Annual cataract surgery statistics were determined by review of electronic surgical records. The clinical and microbiologic records were reviewed of all patients with clinically diagnosed endophthalmitis within 6 weeks after cataract surgery at a single university-affiliated hospital between January 2000 and November 2004. main outcome measures: Operative technique, intraoperative complications, and visual acuity. RESULTS: The incidence of acute-onset endophthalmitis after cataract surgery was 0.04% (7/15,920) for cataract surgeries of all methods, 0.05% (6/11,462) for cataract surgery by clear cornea phacoemulsification, and 0.02% (1/4,458) for cataract surgery by methods other than clear cornea phacoemulsification (P = .681, Fisher's exact test). Six of seven (86%) cases occurred in the right eye, and all cases were performed by right-handed surgeons through temporal incisions. Five of seven (71%) patients had relative immune compromise. Four of seven (57%) patients had an intraoperative complication: vitreous loss in three patients and iris prolapse in one patient. Two patients had topical placement of lidocaine 2% gel before povidone-iodine preparation. The visual acuity at final follow up was 20/25 or better in four patients and count fingers or worse in three patients. CONCLUSIONS: The incidence of acute-onset endophthalmitis after temporal clear cornea incision phacoemulsification is low (0.05%). Potential risk factors for endophthalmitis may include intraoperative complications, relative immune compromise, application of lidocaine 2% gel before povidone-iodine preparation, and inferior incision location.

Epidemiological and health economical evaluation of intraoperative antibiosis as a protective agent against endophthalmitis after cataract surgery.

OBJECTIVE: To evaluate risk factors for endophthalmitis after cataract surgery and to retest recent findings on the protective effect of intraoperative antibiosis and the promoting effect of the clear corneal as compared to sclerocorneal incision. In addition, the economics of intraocular intraoperative antibiosis as a prophylaxis in cataract surgery are asketched. DESIGN: Survey study. PARTICIPANTS: Five hundred thirty-eight ophthalmosurgical centres in Germany. MAIN OUTCOME MEASURE: epidemiological evaluation: responder specific endophthalmitis incidence in year 2000; economical evaluation: direct cost analysis based on incidence data and local cost estimates (health service's perspective). RESULTS: A total of 310 (58%) questionnaires were computed resulting in an overall count of 404,356 cataract surgeries and 291 self-reported endophthalmitis cases (crude rate 0.072%). The risk of postoperative endophthalmitis for sclerocorneal versus clear corneal incisions was not significantly reduced (relative risk 0.97, 99% confidence interval 0.69-1.38). The hypothesis of a protective effect of intraocular antibiosis could be confirmed by a significantly decreased risk ratio of 0.69 (99% confidence interval 0.48-0.99) indicating a significant benefit from intraoperative intraocular antibiosis. A similar tendency was observed for an intraoperative periocular antibiosis with a significantly reduced risk ratio of 0.68 (99% confidence interval 0.49-0.96). These risk estimates had been adjusted for the size of the surgical centre: a significantly reduced risk ratio of 0.70 (99% confidence interval 0.49-0.98) for postoperative endophthalmitis was observed for local centres. Cost evaluation for the prophylactic use of intraocular intraoperative antibiosis in cataract surgery revealed an economically relevant decrease in direct endophthalmitis associated costs. CONCLUSIONS: Whereas this 2000 appraisal of a recent survey in 1996 could not reproduce the benefit of sclerocorneal incision, the protective effect of intraoperative intraocular antibiotic prophylaxis could be confirmed. However, the results of this survey have to be interpreted with care, since it is not based on individual case information, but rather on aggregate questionnaire data.

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

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