The new “ESCRS Guidelines on prevention, investigation and
management of post-operative endophthalmitis” released at this
year's congress in Stockholm, represent the world's most
comprehensive protocol on cataract surgery's most devastating
complication.

These latest guidelines represent an update on guidelines first
released at the XXIII Annual ESCRS Congress in Lisbon in 2005.
This second version of the guidelines has been updated specifically
to take into account the final results of the ESCRS Study of Prophylaxis of Postoperative Endophthalmitis after Cataract Surgery.

The four editors of the ESCRS guidelines, Peter Barry FRCS, of
St Vincent's University Hospital and the Royal Victoria Eye & Ear
Hospital, in Dublin, Ireland;Wolfgang Behrens-Baumann MD, of
Universitäts-Augenklinik, in Magdeburg, Germany; Uwe Pleyer MD,
of Charité – Universitätsmedizin Berlin, Campus Virchow-Klinikum,
in Berlin, Germany; and David Seal PhD, of the Applied Vision
Research Centre at City University in London, UK.

Dr Barry reported to the XXIV ESCRS Congress in London last
year that ophthalmologists can significantly reduce the risk of
endophthalmitis after cataract surgery if they use an intracameral
injection of cefuroxime following each procedure.

The partially masked, randomised placebo-controlled study,
which involved 24 clinical centres in nine European countries,
began in September of 2003, with patients randomised into four
treatment groups to receive:

■ placebo drops perioperatively and no intracameral injection;
■ placebo drops and an intracameral injection of 1.0mg of cefuroxime in 0.1ml of saline at the end of surgery;
■ levofloxacin eye drops perioperatively but no intracameral injection
■ both perioperative levofloxacin eye drops and intracameral cefuroxime.

All groups received povidone iodine pre-operatively and
topical levofloxacin postoperatively for six days.
Although the study's organisers had originally planned to
include 35,000 patients in the trial, they terminated the trial on
January 13, 2006 with just under 16,000 patients, after finding
that an intracameral injection of cefuroxime at the end of
phacoemulsification cataract surgery reduced by five-fold the
risk of contracting endophthalmitis.
At that point, among the 8,244 patients in the two groups that
did not receive intracameral cefuroxime there were 23 – or
0.28 per cent – presumed and 16 – or 0.15 per cent – proven
cases of endophthalmitis.
In contrast, among the 7,997 patients in the two groups that
had received intracameral cefuroxime there were five – or 0.06
per cent – presumed and three proven – or 0.038 per cent –
cases of endophthalmitis.

Based on the background incidence of endophthalmitis after
cataract surgery and the number of cataract operations
performed in Europe each year, the introduction of the
guidelines – and in particular, the use of intracameral cefuroxime
– could arguably prevent thousands of cases of endophthalmitis
each year in Europe alone.

Such a conclusion is based on the background incidence of
endophthalmitis – which the ESCRS study found was between
0.05 per cent and 0.35 per cent when only povidone-iodine was
administered pre-operatively – and statistics from the
government think-tank, the Organisation of Economic
Cooperation and Development (OECD). Extrapolating the
latest statistics from the OECD, ophthalmologists are now
carrying out more than three million cataract operations per
year in the EU alone.
The updated guidelines, which run over more than 40 pages,
include numerous flow charts, refer to more than 200 sources,
and list two dozen contributors.

The new ESCRS guidelines provide cataract surgeons with
easy-to-follow, step-by-step procedures that they can readily
adapt to heir daily practice.

After an introduction and discussion of risk factors, causes,
and incidences of endophthalmitis, the guidelines highlight the
prophylactic measures that cataract surgeons should undertake
every time they operate.

In addition to mandating the pre-operative use of povidone
iodine, the guidelines also recommend that surgeons consider
the use of a topical quinolone one to two days before surgery,
an hour before surgery, immediately after surgery, and four times
daily for one to two weeks after surgery.
Of course, the guidelines highlight the central finding of the
ESCRS study with a recommendation that surgeons apply 1.0mg
cefuroxime in 0.1ml saline (0.9 per cent) by intra-cameral
injection. Because this use of the drug is still unlicensed, the
guidelines note that its use must be based on the surgeon's
discretion.

Common sense also pervades the guidelines in flow charts
that remind surgeons not only about drug prophylaxis but also
about such critical issues as the use of sterile – and where
possible single-use – instruments, sufficient airflow, hand washing,
and use of sterile masks, gloves, and drapes.

The guidelines note that even in the best hands and after
following the best practice, a patient can still develop
endophthalmitis.When such cases arise the guidelines
recommend that surgeons remember that endophthalmitis is a
“medical emergency” that must be tackled quickly and expertly
to reduce the risk of blindness or vision loss. Again, using flow
charts, the guidelines set out the necessary and recommended
steps for ophthalmic surgeons confronted by a patient with
endophthalmitis, including the performance of an anterior
chamber tap and investigation of the bacteria or fungi by
polymerase chain reaction test.The guidelines even provide the
names and contact details for two laboratories that can
provide overnight results.

The guidelines also remind surgeons to prepare for
endophthalmitis when it occurs.“ALWAYS have a chosen
empirical regime of antibiotics ready in advance for intravitreal
use in a clinic or OT setting. Have instructions
prepared for making-up correct dilutions and have necessary
sterile equipment (bottles and syringes) available in an
'endophthalmitis pack' within the operating theatre,” the
guidelines read.

In treating endophthalmitis, the guidelines recommend three
port pars plana vitrectomy by a vitreo-retinal surgeon but
readily admit that such a course is a “gold standard” that may
be impossible to meet because of the lack of a vitreo-retinal
surgeon or vitreo-retinal operating room.
In such cases, the “silver standard” of the intra-vitreal
injection of the antibiotics may be the best option after a
vitreous biopsy.

This SILVER STANDARD has the advantage of time over
completeness,” the guidelines note. “While it ignores the
fundamental surgical principle of "Ubi pus, ibi evacuat" (where
there is pus, let it out) and it provides a smaller sample, it
permits the earlier injection of intra-vitreal antibiotics and
earlier microbiology. It also buys time pending the availability
of a vitreo-retinal surgeon and vitreo-retinal operating room
and the technique should be mandatory for all cataract
surgeons.”

Free copies of the ESCRS Guidelines on prevention,
investigation and management of post-operative
endophthalmitis – Version 2 are being distributed during the
congress and are available at the ESCRS booth.
Intracameral antibiotics will be among the subjects discussed at
the JCRS session on Monday morning at 8am.This topic will also
be discussed at the ESCRS symposium “Supra Cataract Surgery”
at 11am, and at a Free Paper session dedicated to
endophthalmitis at 2pm.