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- Medically Reviewed by Mr Mfazo Hove Consultant Ophthalmologist
- Author: Chris Dunnington
- Published: December 16, 2024
At Blue Fin Vision® Eye Clinic in London, we understand that the prospect of cataract surgery can be daunting. While it’s one of the most common and successful eye procedures performed worldwide, like any surgery, it carries some risks. One rare but serious complication that we take great care to prevent is endophthalmitis.
Endophthalmitis is a severe inflammation of the interior of the eye, typically caused by a bacterial or fungal infection. Although uncommon, occurring in less than 0.1% of cataract surgeries, it can have devastating effects on vision if not promptly diagnosed and treated. In this comprehensive guide, we’ll explore the prevention and treatment of endophthalmitis following cataract surgery, providing you with the knowledge to approach your procedure with confidence.
Understanding Endophthalmitis
What is Endophthalmitis?
Endophthalmitis is an inflammatory condition of the eye, presumed to be due to an infectious process from bacteria, fungi or, on rare occasions, parasites that enter the eye during the perioperative period. It can affect both the anterior (front) and posterior (back) chambers of the eye, including the vitreous and aqueous humours.
Types of Endophthalmitis
There are two main types of endophthalmitis:
- Exogenous Endophthalmitis: This type occurs when microorganisms enter the eye from an external source. It is the most common form and is often associated with postoperative complications, especially after cataract surgery.
- Endogenous Endophthalmitis: This less common type occurs when infection spreads to the eye through the bloodstream from another part of the body.
In the context of cataract surgery, we are primarily concerned with exogenous endophthalmitis.
Prevention of Endophthalmitis
At Blue Fin Vision® Eye Clinic, we take extensive measures to prevent endophthalmitis. Mr Hove has performed over 14,000 cataract surgeries at SpaMedica without a single case of endophthalmitis. While the risk can never be completely eliminated, the following strategies significantly reduce its occurrence:
Preoperative Measures
Patient Selection and Management: We carefully assess each patient’s risk factors, including conditions like blepharitis or systemic infections. If necessary, we manage these conditions before proceeding with surgery.
Preoperative Antisepsis: The use of povidone-iodine (PVI) for ocular surface preparation is a cornerstone of our prevention strategy. We apply PVI 5-10% to the cornea, conjunctival sac, and periocular skin for a minimum of three minutes prior to surgery. This simple step has been shown to reduce ocular surface flora by nearly 90%.
Intraoperative Measures
Strict Aseptic Technique: We adhere to rigorous sterilisation protocols for all instruments and materials. Our operating theatre is equipped with standardised quality control systems, including proper air flow and regular maintenance of HEPA filters.
Proper Wound Construction: Our surgeons ensure watertight closure of surgical incisions to prevent the entry of microorganisms postoperatively.
Intracameral Antibiotics: One of the most significant advancements in endophthalmitis prevention has been the use of intracameral antibiotics. At the end of surgery, we inject antibiotics directly into the anterior chamber of the eye. The most commonly used antibiotic for this purpose is cefuroxime.
Postoperative Measures
Topical Antibiotics: We prescribe antibiotic eye drops for use after surgery to further reduce the risk of infection.
Patient Education: We provide thorough instructions on proper postoperative care and signs to watch for that might indicate infection.
Prompt Follow-up: We schedule early postoperative visits to monitor for any signs of infection.
The Impact of Intracameral Antibiotics
The use of intracameral antibiotics, particularly cefuroxime, has revolutionised the prevention of postoperative endophthalmitis. The European Society of Cataract and Refractive Surgeons (ESCRS) study, published in 2007, demonstrated a five-fold reduction in postoperative endophthalmitis rates in patients who received a 1 mg intracameral injection of cefuroxime at the close of cataract surgery.
Since then, numerous studies have confirmed these findings. For example, a report from Sweden showed that endophthalmitis rates dropped from 0.35% to 0.026% after the introduction of intracameral cefuroxime. Similar results have been reported from other countries, including France, Spain, and the United States.
At Blue Fin Vision® Eye Clinic, we have adopted this evidence-based practice, significantly reducing our already low endophthalmitis rates.
Recognising the Signs of Endophthalmitis
Despite our best prevention efforts, it’s crucial for patients to be aware of the signs of endophthalmitis. Early recognition and treatment are key to preserving vision. Symptoms typically appear within a few days to a week after surgery and may include:
- Sudden decrease in vision
- Eye pain, ranging from mild discomfort to severe pain
- Redness and swelling of the eye and eyelid
- Increased sensitivity to light (photophobia)
- Floaters or flashes in vision
We instruct all our patients to contact us immediately if they experience any of these symptoms after their cataract surgery.
Diagnosis of Endophthalmitis
If endophthalmitis is suspected, prompt diagnosis is crucial. At Blue Fin Vision® Eye Clinic, we employ a comprehensive approach to diagnose this condition:
Clinical Examination
We begin with a thorough eye examination, including:
- Visual acuity testing to assess the extent of vision loss
- Slit-lamp examination to view the eye’s structures in detail
Imaging Studies
In some cases, we may use additional imaging techniques:
- Ultrasound, particularly useful if the interior of the eye cannot be visualised due to severe inflammation
- Optical Coherence Tomography (OCT) to assess retinal involvement
Microbiological Testing
The definitive diagnosis of endophthalmitis requires microbiological testing:
- We collect samples from the vitreous and aqueous humours for culture and sensitivity testing
- Polymerase Chain Reaction (PCR) may be used for rapid identification of causative organisms
Treatment of Endophthalmitis
The treatment of endophthalmitis is a medical emergency requiring immediate intervention. Our goal is to quickly control the infection and inflammation to preserve vision. At Blue Fin Vision® Eye Clinic, we follow evidence-based protocols for managing endophthalmitis:
Immediate Interventions
Intravitreal Antibiotics: The mainstay of treatment involves injecting antibiotics directly into the vitreous. Common choices include:
- Vancomycin for Gram-positive coverage
- Ceftazidime or Amikacin for Gram-negative coverage
Vitreous Tap and Inject: In less severe cases, we take a sample of vitreous for culture, followed by antibiotic injection.
Vitrectomy: For severe cases or those not responding to initial treatment, we may perform a vitrectomy (surgical removal of infected vitreous). This procedure:
- Removes infected material
- Allows for better distribution of antibiotics
- Provides a larger sample for culture
Adjunctive Treatments
Systemic Antibiotics: We may use intravenous antibiotics, especially in cases of endogenous endophthalmitis.
Topical Antibiotics: Eye drops are often prescribed to treat any surface infection.
Intravitreal Steroids: These may be used to reduce inflammation, but their use is decided on a case-by-case basis.
Monitoring and Follow-up
Close monitoring of the patient’s condition is essential. We conduct frequent follow-up examinations to assess response to treatment and adjust our approach as needed based on culture results and clinical response.
Outcomes and Prognosis
The prognosis for endophthalmitis can vary widely depending on several factors:
- The causative organism
- The timing of diagnosis and treatment
- The severity of the infection at presentation
With prompt and appropriate treatment, many patients can recover useful vision. However, in severe cases, there may be permanent vision loss. This underscores the importance of prevention and early intervention.
Conclusion
At Blue Fin Vision® Eye Clinic in London, we are committed to providing the highest standard of care for our cataract surgery patients. Our comprehensive approach to preventing and treating endophthalmitis reflects the latest evidence-based practices in ophthalmology.
While endophthalmitis is a rare complication, its potential severity underscores the importance of rigorous preventive measures. From preoperative antisepsis to the use of intracameral antibiotics, every step of our process is designed to minimise your risk.
Remember, your role as a patient is crucial too. By following postoperative instructions carefully and reporting any concerning symptoms promptly, you play an essential part in ensuring the best possible outcome from your cataract surgery.
If you have any questions or concerns about cataract surgery or the risk of endophthalmitis, we encourage you to discuss them with your ophthalmologist at Blue Fin Vision® Eye Clinic. Our team is here to provide you with the information, reassurance, and expert care you need for a safe and successful cataract surgery experience.
