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Seeing through rhetoric: is the fear of simultaneous bilateral endophthalmitis justified?
Session Title: Cystoid Macular Oedema and Infection
Session Date/Time: Sunday 06/10/2013 | 16:30-18:00
Paper Time: 17:44
Venue: Forum (Ground Floor)
First Author: : O.Li UK
Co Author(s): : C. Claoué
Simultaneous bilateral endophthalmitis (SBE) is rightly a much feared complication of immediately sequential bilateral cataract surgery (ISBCS), and is the oft cited reason for reluctance to perform ISBCS. Given the many benefits of ISBCS to the patient, clinician, and the ever-stretched healthcare budget world-wide, there is an urgent need to assess this risk. We attempt to quantify the risk of SBE as well as final bilateral visual loss following bacterial endophthalmitis to enable both clinicians and patients to make informed decisions about the risks involved when choosing ISBCS, and to have realistic expectations of the eventual visual potential.
The role of routine ISBCS divides cataract surgeons worldwide. Some countries have adopted it as routine whilst others financially penalise surgeons who perform ISBCS. Much of the literature maligns ISBCS because of the potential risk of SBE and the devastating outcome of bilateral blindness. In times when practical and procedural advances are continually being made to reduce complications from cataract surgery and as the numbers of ISBCS performed grows, it is important for some estimation of the risk of SBE to be calculated. In particular, this risk must be relevant to surgeons operating today, taking the available and accepted measures applicable to all surgeries, including intracameral antibiotics and full segregation of each procedure.
A literature search was performed through PubMed. Studies reporting rates of endophthalmitis and visual outcomes following cataract surgery related endophthalmitis mostly from the past 5 years were reviewed. Recognising that practices will differ and there will be many limitations, we performed a meta-analyses to estimate the risk of SBE following ISBCS. We also aim to quantify the risk of having final vision in both eyes below that of the driving standard in the United Kingdom SBE.
Fungal endophthalmitis were excluded, but we included cases where no organisms were identified.
There have only been 4 cases of SBE ever published. All 4 cases breached the aseptic protocol published by the International Society of Bilateral Cataract Surgeons (iSBCS) and the Royal College of Ophthalmologists of the United Kingdom. In 95606 ISBCS cases reported there have been no bilateral simultaneous endophthalmitis.
In the most recent large published studies, the rate of endophthalmitis with the use of prophylactic intracameral cephalosporin is less than 0.05%, corroborating the findings of the European Society of Cataract and Refractive Surgeons" landmark 2006 trial.
Visual outcomes following bacterial endophthalmitis secondary to phacoemulsification and IOL implantation was analysed. The use of intracameral antibiotics varied, and the data collected came from multiple centres world-wide, including Greece, Turkey, the United States, India, Nepal and China. Of the 189 reported cases analysed with final BCVA published, 34% had final best corrected visual acuity (BCVA) of 0.3 LogMAR or better, the minimum level of vision required for driving in the United Kingdom. A further 30% had vision between 0.3 logMar and 1.0 logMAR. 32% had count fingers, hand motion or light perception vision. 5% had no perception of light, mostly through eviscerations.
Multiple large studies have shown that endophthalmitis rate following cataract surgery of less than 0.05% is achievable. If the iSBCS and the UK Royal College of Ophthalmologists guidelines were followed to ensure bilateral surgeries are performed as completely separate procedures, that is the risk of both eyes becoming infected would be random events, then the risk of SBE would be roughly estimated to be 0.05% multiplied by 0.05%, which would be a 0.000025% risk. In other words, there would be one case of endophthalmitis for every 4 million ISBCS (i.e. 8 million eyes) performed. Moreover, if in a third of endophthalmitis cases we can expect BCVA to be 0.3logMAR or better, then the chances of having bilateral vision of worse than the minimum driving standard vision following ISBCS would be in the region of 1 in over 9 million.
If the true risk reflects the rough calculations above, it would seem that ophthalmologists have a duty to consider ISBCS when assessing bilateral cataracts. There are other concerns regarding bilateral surgery that still needs addressing, but it would be unreasonable to continue waving the shroud of SBE in an attempt to deny patients ISBCS when much evidence point to the contrary.
Therefore we would urge all cataract surgeons to look beyond the rhetoric and consider the risks and merits of iSBCS. We encourage greater familiarity with the recommended precautions for safe ISBCS. Finally we ask all ophthalmologists to continue audit of local endophthalmitis rates and publish both pre-operative and final BCVA. This will enable better counselling of patients on risks and potential outcomes, and for us all to continue striving for better treatment of endophthalmitis. With the increasingly widespread use of intracameral antibiotics, infection rates should continue to fall, making the need to share data and practices more urgent.