INFLAMMATORY REACTION Using pre-loaded IOL injection systems and disposable instruments can help reduce the risk of endophthalmitis.

Endophthalmitis is the most dreaded complication of cataract (or any other intraocular) surgery. Even when it's diagnosed and treated immediately and appropriately, the risk of vision loss is high. Fortunately, the post-operative inflammatory reaction is extremely rare, but not so rare that we can allow ourselves to be overconfident or fail to do everything in our power to prevent it. Research is ongoing, and new theories are emerging, but the best current path to prevention involves a combination of old-school knowledge and discipline, and new-school technology. Here's how to steer clear of one of the most devastating diagnoses in ophthalmology.

1. Povidone—iodine is proven effective. Most ophthalmologists agree that the most effective preventive measure against endophthalmitis is to use a povidone-iodine product both in the eye, and also as a prep around the eye. In fact, cleaning the surgical site with povidone-iodine is the only technique scientifically proven to reduce the risk of endophthalmitis after intraocular surgeries (osmag.net/fqbh8x).

We have 9 surgeons who operate at our facility and although there's some slight variation in timing — some administer povidone-iodine in the pre-op area, some in the OR — all use it, and generally within 5 minutes before starting the procedure.

Because it's so important as a prophylactic measure, if patients tell us they're allergic to iodine, we make sure there's no confusion. Patients may think they're allergic because they've had injections of iodinated contrast material for an intravenous pyelogram or are allergic to shellfish. But that particular sensitivity doesn't necessarily mean they're allergic to topical iodine, so we administer a skin test. On those rare occasions when patients turn out to be allergic, we use a product that contains a small amount of hypochlorous acid.

2. Know your compounders. All products we use in eyes are from manufacturers or accredited 503B compounding pharmacies. We never dilute or mix our own cocktails. We get sterility reports from the compounding pharmacies we use, so we know their products have gone through all necessary processes and meet sterility standards.

INTRACAMERAL INJECTIONS
Could One "Little Squirt" Be All That's Needed?

ONE SHOT An intracameral antibiotic injection may be all that's needed to prevent endophthalmitis.

Two retrospective studies suggest that intracameral antibiotic injections at the end of cataract surgery can prevent endophthalmitis.

The first (osmag.net/jdtm6j) involved a California hospital that gradually increased its use of intracameral injections of cefuroxime, moxifloxacin or vancomycin during cataract surgeries between 2007 and 2011. As injections increased, the number of endophthalmitis cases per 1,000 surgeries decreased from 3.13 in 2007, to 1.43 in 2008-9, to 0.14 in 2010-11.

The study also called into question whether topical antibiotics reduce the likelihood of infection, says cataract and refractive surgeon T. Hunter Newsom, MD, founder of the Newsom Eye & Laser Center in Tampa and Sebring, Fla. "In theory, you could just give intracameral antibiotics and nothing else, and you'd be fine," he says.

Another study, done in France (osmag.net/xeg6fy), found that administering antibiotics intracamerally — especially cefuroxime — dramatically reduced the incidence of endophthalmitis. Examining more than 5,000 patients who'd had cataract surgery, the study found that only one of the roughly 2,300 who'd been given intracameral cefuroxime developed endophthalmitis. But among the roughly 2,800 who were not given the injection, 35 developed endophthalmitis. And no intraoperative factor was significantly associated with the infections.

To be clear, intracameral injections are not the "dropless" approach that's recently been touted. "The 'dropless' is injected into the vitreous," says Dr. Newsom. "This is all just into the anterior chamber. It's just a little squirt at the end of the case."

Another study found a significant correlation between posterior capsular ruptures that occur during anterior vitrectomies and the development of endophthalmitis. That makes sense, says Dr. Newsom. "When you hit the interior vitreous, you go from a 5-minute cataract surgery to a 15- to 20-minute cataract surgery. You have to clean it up, so you're in the eye longer. There's just a higher risk of all kinds of complications, and endophthalmitis is one of those complications."

Specifically, according to data culled from the Royal College of Opthalmologists' National Ophthalmology Database, (osmag.net/3yrzca), which looked at more than 180,000 eyes from nearly 128,000 patients, "the rate of endophthalmitis within 3 months of cataract surgery was approximately 8 times higher in cases with posterior capsular rupture than [it was in] those without."

Ruptures happen to every ophthalmologist, says Dr. Newsom. "If you do enough surgeries, you're going to have a broken capsule. There's no way around it. But when it happens, you need to think about that much higher risk and always give intracameral antibiotics."

In Dr. Newsom's case, when ruptures happen, he'll be doing everything he can to keep an impressive streak of success alive. "Luckily, I'm 40,000 surgeries in and have had zero cases of endophthalmitis," he says.

— Jim Burger

3. Antibiotic drops before and after. Antibiotic drops are proven effective, as long as patients understand instructions, can afford their medications and are compliant. We use Gentamycin and Polytrim most often, but patient compliance can be a challenge. We give patients written pre-op instructions and call them to remind them to use their medications before surgery. If a patient forgets, or comes in without having used his antibiotics, we'll give several doses of that medication before surgery. The challenges in this area have spurred interest on the part of pharmaceutical companies, and some of the prospects are intriguing, including so-called dropless cataract surgery, in which antibiotics and anti-inflammatories are combined and injected into the patient's eye at the time of surgery, so patients don't have to put in drops. But Medicare and Medicaid don't reimburse for injections, and Medicare rules also prohibit doctors from passing the cost along to patients.

4. Preloaded IOL injection systems. We're using preloaded injectable lenses more and more and there's a lot to like about them. Not only do they enhance microbiological safety and thereby reduce the possibility of endophthalmitis, but they're also a lot faster and more efficient for staff members and surgeons, because we no longer have to load IOLs. You use the injector once and then discard it, which essentially eliminates the possibility of cross-contamination.

5. Disposables are indispensable. In addition to disposable injectors, we use disposable cannulas, disposable phaco tips and one-time-use-only knives. Anything you use only once and then throw away is bound to be better for patient safety and infection control.

KEY STEP Use a syringe or an automated instrument rinse system to thoroughly rinse instruments with lumen and tubing before they're sterilized.

6. Clean and sterilize. As with any procedure, the importance of both cleaning and sterilizing equipment can't be overstated. All non-disposable instruments should be washed to remove bioburden and thoroughly rinsed. All cannulated instruments and reusable tubings and handpieces should be washed and copiously flushed between cleaning and sterilization. When the TASS (toxic anterior segment syndrome) outbreak some years back was studied, it was found that some of the problems were associated with improper cleaning of the injectors, cannulas and phaco and irrigation/aspiration handpieces — that the viscoelastic used during procedures was not being cleaned adequately from those instruments. If an instrument is sterilized without having been rid of bioburden, it can release an endotoxin the next time it's used.

7. Powdered gloves should be gone. We phased ours out quite a while ago, and now, of course, the FDA has made it clear that all powdered gloves should be eliminated from surgical procedures. They're another culprit that's been connected to endophthalmitis, so if you haven't gotten rid of yours yet, what are you waiting for? OSM