Cataract Surgery Feature Story

RICHARD B. PACKARD, FRCS , FRCOPHTH The issue of appropriate prophylaxis to minimize the risk of endophthalmitis after cataract surgery has long vexed ophthalmic surgeons. Most reports on series of patients have either been retrospective or had insufficient numbers to provide genuinely statistically sound data. The ESCRS has just closed its very large prospective study early, because one arm showed a fivefold advantage in terms of the reduced incidence of endophthalmitis. The difference in that arm was the use of intracameral cefuroxime at the end of the operation, a technique that Montan et al1,2 described in their groundbreaking reports from Sweden. We now have to assess the effect that this information will have on clinical practice for all ophthalmologists who perform cataract surgery. In King Edward VII Hospital in Windsor, United Kingdom, at the beginning of 2004, my colleagues and I had a cluster of nine cases of endophthalmitis after cataract surgery in 3 months. We reviewed our practices extensively and tried to isolate the cause. Despite looking at the type and site of the incision, the use or not of a topical gel, the subconjunctival injection, etc, we failed to find a single reason for the outbreak. We found no pattern. Among the changes we instituted was the routine use of intracameral cefuroxime, as prepared by the scrub nurse, for each patient. Since that time, we have performed more than 5,000 cases. Our first incident of endophthalmitis was reported 2 weeks ago. It was culture negative, and the anterior segment cleared in 2 days with some residual vitreous haze, which is dissipating. I would endorse the findings of the ESCRS’ study, because, although the rate of endophthalmitis may be higher than previously reported, the difference between the study arms is striking and statistically valid.