Postoperative endophthalmitis after cataract surgery: a worldwide review of etiology, incidence and the most studied prophylaxis measures

ABSTRACT

Introduction: Endophthalmitis is a significant and potentially severe complication of cataract surgery. Cataract surgeons have several intraoperative prophylactic maneuvers to choose from to prevent this rare but serious complication.

Areas covered: The epidemiology, etiology, and practice patterns regarding endophthalmitis prophylaxis are discussed; including a detailed review of the medications used intracamerally and use of povidone iodine. Articles were identified by PubMed literature search of published English-language articles. Literature in PubMed before June 2019 was reviewed without a date limit in the past. The terms ‘intracameral antibiotic,’ ‘povidone-iodine,’ ‘moxifloxacin,’ ‘vancomycin,’ ‘cefuroxime,’ ‘prophylaxis’, and ‘incidence’ were combined with the terms ‘prevention,’ ‘endophthalmitis,’ and ‘antisepsis protocol.’ The reference lists of relevant articles were reviewed to identify additional articles, and this process was iterated several times.

Expert opinion: The use of intracameral antibiotic prophylaxis (ICAP), after considering availability, cost and the postoperative endophthalmitis rate (POER) without ICAP, should be considered. Povidone iodine (PI) was shown to be an effective prophylactic measure against POE. Frequent topical application of dilute PI solution during surgery has an excellent safety profile, and significantly reduces the anterior chamber contamination rate after cataract surgery. Further studies of dilute PI in cataract surgery are needed.

KEYWORDS:

• Post-operative endophthalmitis
• intracameral antibiotics
• povidone iodine
• endophthalmitis prevention
• endophthalmitis

Article highlights

• ICAP can decrease POER; after considering availability, cost and the POER without ICAP, its use should be considered.

• This effect of ICAP, however, was shown particularly in high POER; there is no evidence that ICAP can decrease POER lower than 0.02%.

• Intraoperative complications, esp. PCR with vitreous loss increase the POER significantly, thus the use of ICAP seems to be reasonable in these situations.

• There is some evidence that with ICAP topical antibiotics are not needed, this should be further studied and if appropriate a recommendation to avoid topical antibiotics with ICAP included in official practice guidelines.

• Dilute PI solution has an excellent safety profile, and significantly reduces the anterior chamber contamination rate after cataract surgery.

• Further study of dilute PI in cataract surgery is needed, if an antiseptic could achieve POER rates similar to ICAP it could reduce antibiotic use, cost and the risk of promoting bacterial resistance.

Declaration of interest

A Grzybowski reports grants, personal fees and non-financial support from Bayer, non-financial support from Novartis, non-financial support from Alcon, non-financial support from Thea, personal fees and non-financial support from Valeant, non-financial support from Santen, outside the submitted work.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

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Funding

This paper was not funded.