Postcataract endophthalmitis prophylaxis using irrigation, incision hydration, and eye pressurization with vancomycin

Figures & data

Figure 1 Endophthalmitis cases during the study period.

Notes: Starting in early 2006, surgeons switched from BSS to the vancomycin/BSS irrigation fluid for incision hydration and eye pressurization, while maintaining the standard infection control practices of fluoroquinolone-soaked topical pledgets, povidone–iodine antisepsis of the eyelids and ocular surface, and vancomycin irrigation.
Abbreviation: BSS, balanced salt solution.

Table 1 Details of endophthalmitis cases

Case	Year	Intraoperative complications	Culture results	Outcome
1	2003	None	Staphylococcus epidermidis	*
2	2003	None	Propionibacterium acnes	20/30
3	2005	PC tear, vitreous prolapse	α-Hemolytic Streptococcus	20/200
4	2005	PC tear	Staphylococcus non-aureus	20/25
5	2005	None	α-Hemolytic Streptococcus viridans	20/400
6	2008	PC tear, anterior vitrectomy,	Negative	20/40
		ECCE, ACIOL, wound leak

Notes: Case 2, operated in 2003, developed chronic uveitis, for which pars plana vitrectomy and capsulectomy were performed in 2005, with culture results as shown.

* Final visual acuity not available.

Abbreviations: PC, posterior capsule; ACIOL, anterior chamber intraocular lens; ECCE, unplanned manual extracapsular cataract extraction.

Table 2 Cataract cases and endophthalmitis rates for the periods 2002–2005 and 2006–2014

Period	Cataract cases	PCE cases	Rate/1,000	Odds ratio	95% CI	χ^2	P
2002–2005	12,400	5	0.4	18.1	2.11–154.9	13.5	0.00024
2006–2014	44,863	1	0.022

Notes: Baseline, 2002–2005: preoperative pledget soaked with current-generation fluoroquinolone drops, povidone–iodine skin and ocular surface preparation, vancomycin 20 μg/mL irrigation, incision hydration, and eye pressurization with BSS; and intervention, 2006–2014: switch from BSS to the vancomycin/BSS irrigation fluid for incision hydration and eye pressurization, while maintaining the baseline prophylactic measures. Statistics compare the baseline period to the intervention period.

Abbreviations: BSS, balanced salt solution; CI, confidence interval; PCE, postcataract endophthalmitis.

Table 3 Estimated endophthalmitis risk reductions due to confounding variables

Risk factor	OR (RR)	Reference	Prevalence (background)	Prevalence	Risk factor reduction	Estimated PCE rate reduction
Silicone IOL use	3.0	6	0.6 (60%)	0.02 (2%)	0.58 (58%)	1.74
CWV	6.5	6	0.019 (1.9%)	0.009 (0.9%)	0.010 (1%)	1.065
Low surgical caseload (below 350)	1.27 (per 225 cases)	2	221 cases	309 cases	88 cases	1.106
Total						2.05

Notes: Low surgical caseload refers to a 1.27-fold increase in relative risk of endophthalmitis for lower-volume surgeons (range: 51–200 cases/year, mean: 125 cases), to higher-volume surgeons (range: 201–500 cases/year, mean: 350 cases).

Abbreviations: OR, odds ratio; RR, relative risk; PCE, postcataract endophtalmitis; IOL, intraocular lens; CWV, communication with vitreous (posterior capsule tear and/or vitreous loss).