BOOK REVIEW

Endophthalmitis is an uncommon but serious complication of cataract surgery that often carries a poor prognosis. It has thus garnered a great deal of attention in terms of how to avoid this devastating condition. However, due to the low incidence, high-quality studies of postoperative endophthalmitis are difficult to perform. In order to help bring the current knowledge into focus, the ESCRS recently published the new 2013 “Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery: Data, Dilemmas and Conclusions.”

The authors acknowledging that “although cataract surgery ranks among the most frequently performed surgical procedures worldwide, data to define the most effective prophylactic measures have been nearly impossible to generate, given the large patient numbers needed to conduct clinical trials”. Nevertheless, the 39-page document comprises an extensive summary and attempts to develop a consensus regarding postoperative endophthalmitis.

Central to the recommendations contained in the Guidelines are the results of the ESCRS Endophthalmitis Study1, which investigated the effects of perioperative antibiotic prophylaxis. Published in 2007, it evaluated effects of an intracameral injection of cefuroxime 1mg at the close of surgery, and compared postoperative endophthalmitis rates with other study groups that included perioperative antibiotic drops and controls. The study was conducted in 24 medical centres in nine European countries and included over 16,000 patients. The endpoint of the study was infective endophthalmitis, whether proven or presumed.

Postoperative endophthalmitis

All four study groups received standard preoperative povidone-iodine as well as topical levofloxacin drops four times daily postoperatively for six days, and were randomised then into four groups in a 2x2 factorial design:

Group A: Placebo perioperative drops and no intracameral cefuroxime injection;

Group B: Placebo perioperative drops and an intracameral cefuroxime injection;

Group C: Topical perioperative levofloxacin but no intracameral cefuroxime injection;

Group D: Topical perioperative levofloxacin and an intracameral cefuroxime injection.

The ESCRS study found that the risk of contracting postoperative endophthalmitis was significantly reduced, approximately five-fold, by an intracameral injection of 1mg cefuroxime at the close of surgery. Among the four study groups, the lowest incidence rate was observed in Group D, where both intracameral cefuroxime and perioperative topical levofloxacin were used, with a rate of 0.049 per cent for presumed endophthalmitis and 0.025 per cent for proven endophthalmitis. Five cases of endophthalmitis did occur in cefuroxime- treated groups in the ESCRS study.

In the unfortunate situation of postoperative endophthalmitis, the management is largely dictated by the results of the Endophthalmitis Vitrectomy Study2, which concluded that patients who presented with hand motion or better vision may be treated with tap or biopsy; patients presenting with light perception only vision should be considered for immediate vitrectomy; and that intravenous antibiotics were of no proven benefit.

1. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicentre study and identification of risk factors. J Cataract Refract Surg 2007; 33: 978-88.

2. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995; 113: 1479-1496

A PDF copy of the guidelines is available to download from the ESCRS website: www.escrs.org.

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