ESCRS endophthalmitis guidelines provide rational approach for surgeons to follow

Issue: January 2014

ByRichard B. Packard, MD, FRCS, FRCOphth

Infectious endophthalmitis after cataract surgery, although thankfully a rare event, can lead to a devastating loss of vision for the patient. This may happen as an isolated incident or in clusters, which can defy investigation as to the root cause.

It is now 10 years since we had a cluster of nine cases in 4 months in the Prince Charles Eye Unit in Windsor. This had come out of the blue with no change in practice. We tried to determine and isolate from whence the problem might have arisen. We called in an independent team from the Royal College of Ophthalmologists to head the investigation. We wanted to determine if any pattern was present as to surgeon, nurse, type of anesthesia, type and site of incision, machine used, handpieces used, mask worn or not, patient factors and surgical complications. In the U.K., all instruments are sterilized in designated facilities; ours was off site, and we involved them, too. The air conditioning was checked with multiple tests on the filters and plates set out in the operating theater.

At the conclusion of this exercise, we found no correlation to a single surgeon or nurse. These infected cases covered all types of anesthesia, incision site and type, and machines and handpieces used. There was no association to masks or no masks being worn. There were no special patient factors, and only two out of nine were complicated cases. We did identify the following potential risk areas:

Some condensation in our trays after autoclaving instruments (although nothing had changed by way of practice at the sterilization facility)
Timing of introduction of preoperative povidone-iodine, particularly in relation to topical anesthetic gel
Use of instruments with lumens that were not disposable
Ability to check wound closure at the end of surgery
Most appropriate delivery of antibiotics

Because no pattern had emerged from our investigations into the outbreak, we determined to address all these issues:

New trays specifically designed for our instruments that allowed improved steam passage and evaporation were purchased.
Povidone-iodine 5% was instilled before the patient came to the theater, and lignocaine gel was only ever used after this.
Pre- and postoperative antibiotics were changed to ofloxacin — instilled on the day of surgery and at the completion of surgery and then for 1 week (no fourth-generation fluoroquinolones were available in Europe at that time).
We had always only used phaco needles once but now commissioned disposable bimanual irrigation and aspiration handpieces to our own design.
After refilling the eye with balanced salt solution, intracameral cefuroxime was injected according to the Swedish protocol.
The conjunctival fornices were sterilized at the end of surgery with povidone-iodine 5%. This also acted as a Seidel test for wound leakage.

Some may say that we overreacted to our outbreak and had little evidence for these changes. The literature is clear on the beneficial use of preoperative povidone-iodine, but it needs to be used for a sufficient period of time to be effective. We place it in patients’ eyes just before they go to the anesthetic room, which is thus several minutes before any anesthetic gel is instilled. The use of intracameral cefuroxime as described in the Swedish experience impressed us, and we decided to adopt this protocol. This was, of course, before the ESCRS endophthalmitis study had been completed and reported upon. We believe our subsequent experience has justified our new approach.

Since May 2004, when all surgeons in the department started to use the same regimen described above, we have completed more than 27,400 cataract procedures. The Prince Charles Eye Unit is a teaching unit, so many of the cases are performed by residents in training. As a result, in the last nearly 10 years, seven consultants, four associate specialists and 32 doctors in training have performed cataract surgery. It has all been done through clear corneal incisions with steel knives. Since May 2004, we have had five cases of postoperative endophthalmitis, of which only one was culture positive, the organism being Streptococcus pneumoniae. This was the only eye that was lost. The other four regained useful vision. Since adopting a new knife, the Windsor Knife (Core Surgical), which gives improved wound architecture, there has been only one case in the last 3 years.

Overall, for the past nearly 10 years, this represents a rate of 0.018%. There is only one reported series with a lower rate, that of Shorstein et al with 0.014%. What is interesting about this report from Northern California, U.S.A., is the decision to adopt intracameral antibiotics at the outset, initially cefuroxime. U.S. opinion has almost entirely discounted the use of cefuroxime. Multiple studies have now shown the improvements that can be achieved in endophthalmitis rates by using intracameral cefuroxime vs. not using it.

As we have seen, endophthalmitis is a multifactorial subject involving prophylaxis pre-, peri- and postoperatively. Further, should endophthalmitis occur, the investigation and appropriate treatment regimens need to be systematized for best outcomes.

At ESCRS in Amsterdam in 2013, an important event took place in the fight against endophthalmitis with the release of the ESCRS Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery. It can be downloaded at www.escrs.org/downloads/Endophthalmitis-Guidelines.pdf. This has been very much the work of Peter Barry, past president of ESCRS, who was the motivator for the ESCRS endophthalmitis study. This pamphlet brings together current knowledge on prophylaxis, recognition and treatment of post-cataract surgery endophthalmitis. Many standard practices, such as the use of postoperative antibiotic drops, are called into question as being of little use. While it will be impossible to remove the risk of endophthalmitis completely, the ESCRS guidelines show an extensive evidence base to back up the statements made and should provide a rational approach for all ophthalmic surgeons to adopt.

References:
Barry P, et al. ESCRS guidelines for prevention and treatment of endophthalmitis following cataract surgery: data, dilemmas and conclusion. www.escrs.org/downloads/Endophthalmitis-Guidelines.pdf. Published 2013.
Shorstein NH, et al. J Cataract Refract Surg. 2013;doi:10.1016/j.jcrs.2012.07.031.
For more information:
Richard B. Packard, MD, FRCS, FRCOphth, OSN Europe Edition Chairperson of the Editorial Board, can be reached at Arnott Eye Associates, 22a Harley St., London W1G 9BP, England; +44-20-7580-1074; email: eyequack@vossnet.co.uk.

Disclosure: Packard has no relevant financial disclosures.