Put an End to Endophthalmitis

Endophthalmitis is a rare, but potentially devastating, eye infection that can cause permanent loss of vision. Advances in instrument sterilization practices, more effective antisepsis of the eye before surgery, and more proactive patient and staff education are helping to ensure these infections don't occur.

"When physicians perform outpatient surgery or administer injections in an office setting, infections rates are relatively low," says Abdhish R. Bhavsar, MD, clinical spokes-person for the American Academy of Ophthalmology and director of the Retina Center in Minneapolis.

So, what leads to these exceedingly rare infections at surgery centers and ophthalmology offices? "Occasionally," says Dr. Bhavsar, "there are breaches in sterility."

Dr. Bhavsar says the two most important endophthalmitis prevention steps are proper sterilization of instrumentation, and preoperative and intraoperative antisepsis of the ocular surface as well as the eye lids and lashes. A large portion of his instrumentation is single-use, and the remaining multi-use tools are sterilized according to strict guidelines. For antisepsis, he usually prepares the skin around the eyelids and the ocular surface with povidone-iodine. He often employs a topical anesthetic before the povidone-iodine application because the latter can sting.

Dr. Bhavsar suggests reacting rapidly and performing a root cause analysis when cases occur. "Examine all of your processes to determine if there are any risk factors that could be leading to infection," he says. "For example, infections might be linked to sterilizing instruments in a different manner or using a different solution in the eye."

Dr. Bhavsar says facilities should self-audit to identify these issues before any cases occur. "We all should be auditing ourselves continuously," he says.

The onset of postoperative endophthalmitis symptoms varies, according to Dr. Bhavsar, although he says most infections become evident within the first week. "Symptoms include decreased vision, pain, light sensitivity, increased floaters and increased discharge from the surface of the eye," he says.

It's vital to educate patients on recognizing infections so they know to come in as soon as possible when symptoms develop. "We want the patient to come in the same day of noticing symptoms," says Dr. Bhavsar. "All patients who have procedures on the eye need to be warned about the same symptomatology."

Dr. Bhavsar describes postoperative infection symptoms for patients before surgery, and reinforces that information after surgery, including within discharge paperwork. He then brings it up again on the first postoperative visit.

Outcomes for endophthalmitis patients vary. "In cases where we can treat the infection earlier, or when the case is less severe, generally the vision prognosis is better," says Dr. Bhavsar. "When cases are extremely severe, the prognosis is much more guarded or poor. Many patients who have this infection still recover vision to varying extents, and some recover vision very well. A high percentage end up with 20/40 vision, which is very good considering the eye had a severe infection."

Annice Bacsik, RN, CAPA, practice administrator at the Surgery Center of Central New Jersey in New Brunswick, has worked at the facility for more than 20 years. Endophthalmitis cases have been exceedingly rare, but an inflection point in 2018 caused her to redouble her center's infection prevention protocols. "We were getting one infection per quarter, which was unusual," she says.

The center performed 6,300 cases that year, so the infections were nowhere near prevalent. But one case per quarter was too much for Ms. Bacsik, who sought to determine the cause and implement corrective action.

The most important thing we’ve done is administering intracameral moxifloxacin injections at the end of surgery.
— Annice Bacsik, RN, CAPA

"We discussed what we could do better or different, and performed a quality improvement study to see if there were any similarities within any of the cases," she says. "There really weren't."

Ms. Bacsik quickly shifted from reactive to proactive mode, and focused her attention on the sterile processing department by implementing instrument verification testing. "We clean and test the water in our ultrasonic cleaner twice a day or as needed if it's soiled," she says. "We perform our last rinse of the instruments with distilled water and check instruments under a magnifier between every case to make sure the tips are free of rust and viscoelastic, which has been found on instrument tips after the cleaning process."

The discovery of viscoelastic on cleaned tools have led Ms. Bacsik to implement several improvements to the facility's instrument care practices: Chipped and rusting instruments are replaced; biological testing is performed on both of the facility's sterilizers every morning, per AAMI guidelines; random surgical instruments are tested for residual protein on a weekly basis, which allows the reprocessing system to be constantly monitored and improved.

The center also uses povidone-iodine to prep eye lids and lashes; patients known to have MRSA receive a dual prep of povidone-iodine and an antimicrobial eyelid cleanser. "The most important thing we've done is administering intracameral moxifloxacin injections at the end of surgery," says Ms. Bacsik.

Patient education is just as important. "After surgery, we tell patients to expect to feel a little bit of discomfort, and that if they experience sharp pain, a decrease in vision or cloudiness, they should immediately call for follow-up care to make sure they don't have endophthalmitis," says Ms. Bacsik.

Her recovery room nurses also emphasize to patients the importance of proper handwashing before administering postoperative eyedrops. "That is extremely important because patients, especially in the elderly population, may not think about washing their hands prior to touching their eyelids after surgery," she says.

Handwashing reminders are given because postoperative endophthalmitis might not always be caused intraoperatively. "You have a pretty good idea it was introduced during surgery if symptoms occur one to three days post-op," says Ms. Bacsik. "But if they happen a week out, the infection probably wasn't due to the procedure. Maybe the wound wasn't sealed tightly, or the patient didn't use proper hand hygiene when they administered their drops." 

A member of the facility's staff calls patients 48 hours after surgery to check on their condition. "If a patient expresses concern or reports a decrease in vision, we tell them immediately to call their surgeon, and then we follow up with the surgeon to make sure the patient has been seen so we can document it in our records," says Ms. Bacsik.

Patients who report post-op vision issues are referred to a retina specialist, who washes out the anterior chamber and cultures the fluid to see which antibiotics they should use to treat the infection. Many cases resolve after patients see the retina specialist, according to Ms. Bacsik.

Ultimately, endophthalmitis prevention efforts can lead to positive change throughout a practice. "You can always improve what you're doing and be proactive in your prevention efforts," says Ms. Bacsik. "I'm knocking on wood, but we've had a zero percent infection rate over the last 14 months." OSM