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Jabbar V and 2015
Jabbar V and 2015
Surgery
Outcomes of More Than 480 000 Cataract Surgeries,
Epidemiologic Features, and Risk Factors
Mahmoud Jabbarvand, MD,1 Hesam Hashemian, MD,1 Mehdi Khodaparast, MD,1 Mohammadkarim Jouhari, MD,1
Ali Tabatabaei, MD,1 Shadi Rezaei, BSC2
Purpose: To report the incidence of endophthalmitis after senile cataract surgery and to describe the
epidemiology and main risk factors.
Design: Retrospective, single-center, cross-sectional descriptive study.
Participants: Patients who underwent cataract surgery in Farabi Eye Hospital from 2006 through 2014.
Methods: All patients were evaluated retrospectively to compare risk factors, epidemiologic factors, and
prophylaxis methods related to endophthalmitis. Patient records were used to gather the data.
Main Outcome Measures: Epidemiologic factors, systemic diseases, other ocular pathologic characteristics, complications during the surgery, technique of cataract surgery, intraocular lens type, method of antibiotic
prophylaxis, surgeon experience, vitreous culture, and vision outcome were evaluated in these patients.
Results: One hundred twelve endophthalmitis cases among 480 104 operations reported, equaling an
incidence of 0.023%. Patients with diabetes mellitus (14.3%) and of older age (mean age, 81 years), perioperative
communication with the vitreous (17.9%), extracapsular cataract surgery procedure (11%), and surgery on the left
eye (58.9% vs. 41.1% for right eye; P 0.03) showed a statistically signicant association with endophthalmitis.
Short-term treatment with topical or systemic preoperative antibiotics or postoperative subconjunctival injection
was associated with a 40% to 50% reduced odds of endophthalmitis compared with no prophylaxis (P 0.2). No
cases of endophthalmitis were observed among the 25 920 patients who received intracameral cefuroxime,
suggesting that this approach to antibiotic prophylaxis may be far more effective than traditional topical or
subconjunctival approaches.
Conclusions: The incidence of endophthalmitis after cataract surgery in our center was 0.023%, comparable
with that of other previously published international studies. Older rural patients with immune suppressive diseases, such as diabetes mellitus, are particularly more prone to endophthalmitis. Vitreous loss at the time of
surgery was associated with a signicantly increased risk. Whereas antibiotic prophylaxis overall showed a 40%
to 50% reduction in risk, intracameral cefuroxime was 100% effective in preventing endophthalmitis in this
series. Ophthalmology 2015;-:1e7 2015 by the American Academy of Ophthalmology.
http://dx.doi.org/10.1016/j.ophtha.2015.08.023
ISSN 0161-6420/15
Methods
We retrospectively analyzed the electronic medical records of 480
104 eyes of patients who had undergone senile cataract surgery at
Farabi Eye Hospital, Tehran, Iran, from 2006 through 2014. The
Farabi Eye Hospital Institutional Review Board approved the study
protocol. We identied all cases of endophthalmitis occurring after
cataract surgery within this interval. We reexamined the patients
who had endophthalmitis and evaluated their risk factors and their
nal visual results.
The diagnosis of endophthalmitis was based on clinical examination indicating an inammatory reaction out of proportion to the
surgical trauma during the normal course of postoperative care,
warranting intraocular sampling for bacterial culture. All the patients with a diagnosis code for endophthalmitis using the International Classication of Diseases, Ninth Revision, Clinical
Modication codes or similar codes in older records were
considered as endophthalmitis: 360.00, purulent endophthalmitis,
unspecied; 360.01, acute endophthalmitis; 360.02, panophthalmitis; 360.03, chronic endophthalmitis; and 360.04, vitreous
abscess.3
We retrospectively evaluated the following variables between
the cases and the entire study population: demographic factors,
systemic diseases, prophylactic antibiotic regimen (preoperative,
intraoperative, or postoperative antibiotics), bacterial species of
infection, management of the endophthalmitis, experience level
of the cataract surgeon, patient socioeconomic status, method of
surgery, intraoperative complications, and nal visual acuity.
When endophthalmitis was suspected, a vitreous biopsy was
performed immediately and sent to the microbiological laboratory
for smear and culture and antibiogram analyses. Endophthalmitis
was managed according to the recommendations of the Endophthalmitis Vitrectomy Study.4
According to an antibiotic protocol for cataract surgery in
Farabi Eye Hospital, which is followed by all ophthalmologists, all
patients received 5% povidoneeiodine for 5 minutes before surgery. At the time of discharge, the patients were prescribed a
topical antibioticecorticosteroid solution (betamethasone 0.1%
combined with either ciprooxacin 0.3% or chloramphenicol
0.5%) in tapering dosages during a 45-day postoperative period.
Records were excluded if data indicated the eye had undergone
previous intraocular surgery.
Based on the level of surgeon experience, surgeries were
classied as performed by full-time attending or in-training surgeons. Analysis of the latter groups records was carried out
depending on whether the surgeon was a resident or fellow. Fulltime attending physicians performed 72% of surgeries.
Statistical Analysis
All statistical analyses were performed using SPSS software
(SPSS, Inc., Chicago, IL). Means and standard deviations of
quantitative variables and distribution of frequencies of qualitative
variables were studied. A Pearson chi-square test and an independent sample test were used for risk factors analysis. P values
less than 0.05 were considered statistically signicant. Multivariate
logistic regression analysis was performed to evaluate diabetes,
vitreous loss, and antibiotic prophylaxis as independent risk factors
for endophthalmitis.
Results
Analysis of medical records revealed 112 endophthalmitis cases
among 480 104 operations, indicating a postoperative endophthalmitis incidence of 0.023%. The mean agestandard deviation
52 (46.4)
60 (53.6)
46
66
16
16
20
(41.1)
(58.9)
(14.3)
(14.3)
(17.9)
28 (25)
84 (75)
Jabbarvand et al
Surgery type
Phacoemulsication
ECCE
Vitreous loss
Yes
No
Diabetes mellitus
Yes
No
IOL type
Hydrophobic
Hydrophilic
100 (0.021)
12 (0.14)
12 960 (2.7)
467 040 (97.3)
20 (0.15)
92 (0.019)
25 926 (5.4)
454 178 (94.6)
16 (0.06)
96 (0.02)
38 (0.018)
74 (0.026)
Odds Ratio
95% Condence
Interval
0.078
0.0428e0.1420
<0.001
7.83
4.83e12.70
0.004
2.92
1.72e4.96
0.08
0.7
0.47e1.04
P Value
0.006
Discussion
remaining 71 cases (63.4%) with a clinical diagnosis of endophthalmitis showed negative culture results. Gram-positive species
were the main cause, accounting for 33 cases (80%).
The nal visual acuity was better in patients with negative culture results or coagulase-negative staphylococci. In contrast, eyes
with enterococci and Pseudomonas species had worse nal vision.
Final visual acuity was no light perception in 2 eyes, and 1 of these
eyes was eviscerated because of severe corneal melting (Table 4).
Patients were categorized into 2 groups based on their location:
38 880 patients (8.1%) were from rural areas and 441 120 patients
(91.9%) were from urban areas. Records showed that endophthalmitis had signicantly higher occurrence rates among rural
patients (0.07%) versus urban patients (0.02%; P 0.001).
Table 5 compares the endophthalmitis rates among different
surgeon groups based on their level of experience. The ratio of
the cases with endophthalmitis to the number of all patients
undergoing cataract surgery was higher among residents
compared with surgical fellows and attending surgeons.
However, no statistically signicant differences were observed in
endophthalmitis rates between residents, fellows, and full-time
attending physicians when analyzed by linear-by-linear association or the chi-square test.
The distribution of endophthalmitis cases according to eye
laterality demonstrated a higher incidence of endophthalmitis in the
left eye (58.9%); in contrast, a higher number of right eyes underwent cataract surgery (264 000 [55%]), so the endophthalmitis
rate was statistically signicantly higher in the left eye compared
with the right eye (P 0.03).
No antibiotic
Preoperative systemic
antibiotic
Preoperative topical
antibiotic
Intracameral antibiotic
Subconjunctival
antibiotic
Total No.
of Cases
Proportion of
Cases (%)
No. of Endophthalmitis
Risk of
Cases
Endophthalmitis (%)
Odds of
Endophthalmitis
Condence
Interval
260 744
47 520
54.6
9.8
84
6
0.032
0.012
1
0.51
0.18e1.44
76 800
15.9
12
0.015
0.62
0.28e1.35
25 920
69 120
5.4
14.3
0
10
0.000
0.014
0
0.58
0.90e0.98
0.25e1.34
No. (%)
Negative
71
Coagulase-negative Staphylococci 14
Staphylococcus aureus
6
Enterococci
7
Pseudomonas species
4
Enterobacteriaceae species
2
Other gram-positive bacteria
6
Other gram-negative bacteria
2
Total
112
Mean Corrected
Distance Visual Acuity*
(63.4)
(12.5)
(5.4)
(6.3)
(3.6)
(1.8)
(5.4)
(1.8)
(100)
0.42
0.47
0.55
0.9
1.12
0.65
0.5
0.4
0.5
(20/52)
(20/59)
(20/70)
(20/158)y
(20/260)y
(20/89)
(20/63)
(20/50)
(20/63)
(18.9)
(7.2)
(1.8)
(72.1)
30
14
1
67
(26.7)
(12.5)
(0.9)
(59.8)
P Value
0.03
0.04
0.01
0.01
0.46
Jabbarvand et al
This study also demonstrated a higher rate of endophthalmitis in the left eye. It may be the result of the incision
site being placed in the left eye by a right-handed surgeon:
the main incision is near the upper lid margin, but in the
right eye, the stab incision is near upper lid and the main
incision is in the palpebral ssure. Considering lid margin
ora as the main cause of endophthalmitis, it may justify the
difference of the infection rate between the 2 eyes.
Previous studies3,44,45 reported that longer surgical
experience and a higher annual volume of surgery decreased
the risk of postoperative endophthalmitis, but they did not
involve surgeons still in training. We found a higher rate of
endophthalmitis patients treated by residents, but the difference was not signicant. This is comparable with the
previous report by Ravindran et al.46
The effect of intraocular lens materials is controversial.
Baillif et al47 found greater bacterial adherence to
hydrophobic lenses compared with hydrophilic lenses. In
our study, the endophthalmitis rate was higher in the
hydrophilic group (0.026% vs. 0.018%), but the difference
was not signicant (P 0.08).
In this report, the incidence of endophthalmitis among
patients who underwent phacoemulsication was only
0.021%. This is comparable with reported rates after
phacoemulsication from the United States and other
countries.1,9,10,48 The endophthalmitis rate was signicantly
higher in patients who underwent extracapsular cataract
extraction for cataract extraction (0.14%). Norregaard et al49
reported a comparable rate of 0.18% in a study of
extracapsular cataract surgery performed in Denmark.
Because phacoemulsication is the preferred cataract
surgery technique in Farabi Eye Hospital, extracapsular
cataract surgery is performed primarily either in mature
cataracts or in cases with higher rates of complications
(e.g., zonulysis), or secondarily in cases of failed
phacoemulsication. So the higher rate of endophthalmitis
associated with the extracapsular technique may be the
result of different patient specications and not of a higher
risk associated with the technique.
In conclusion, older age, intraoperative vitreous communication, systemic diseases such as diabetic mellitus, and rural
residence are associated with a higher risk of postoperative
endophthalmitis. Whereas antibiotic prophylaxis overall showed
a 40% to 50% reduction in risk, intracameral cefuroxime was
100% effective in preventing endophthalmitis in this series.
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Author Contributions: