Rare potential complication of cataract surgery
Infective endophthalmitis is, unfortunately, a most severe potential infective complication of cataract surgery because it can result in a poor visual outcome or even loss of your eye.
I do not like having to write this blog post about endophthalmitis, but I have to because the risk of endophthalmitis can never be eliminated from your cataract surgery. Fortunately, it happens very rarely, estimated at around 1 in 1000 cases of cataract and this risk can be minimised by a range of measures.
In most cases, endophthalmitis has come from the patient’s eyelids where bacteria are the source of infection, but there can be a range of external causes such as incomplete sterilisation of the instruments used in the eye, and this has to be considered, mainly if there is a cluster of cases within one unit.
The Royal College of Ophthalmologists advises and investigates on the management of cluster cases of endophthalmitis in a unit. This is called an outbreak of postoperative endophthalmitis. It happens very rarely, but there have been some units where this has happened over the last ten years, and therefore there are unambiguous guidelines by the college concerning endophthalmitis.
The Royal College of Ophthalmologist Guidelines on postoperative endophthalmitis stresses first early identification of the condition and then the management of postoperative endophthalmitis.
Acute endophthalmitis is a severe intraocular information presumed to be due to the entry of microbes or bacteria into the eye during the perioperative period. It can enter during the surgery or immediately afterwards. The at-risk time has been identified as the first two weeks after surgery with a peak time around five days. But, it can happen as early as one to two days or as late as two weeks and usually presents with a painful red eye with severe anterior uveitis, often with haziness in the front of the eye and even a little white line called a hypopyon and haziness in the vitreous.
It is one of the most serious postoperative complications and can result in a very poor outcome. The incidence in the developed world is very low and estimated to be approximately 0.14% after cataract surgery. The most common cause has been said to be the patient’s commensal bacteria which can be staphylococcus or streptococcus which are gram-positive. However, in 20% there is no identifiable cause. The surgeons carry out routine prophylactic antibiotic use against endophthalmitis, and this helps keep the incidence of endophthalmitis low.
How surgeons minimise the risks of complications?
For instance, in the operating theatre, there are stringent checks to ensure that the risk of inadvertent complications or harm is minimised.
Theatre procedures including thorough hand washing, strict theatre discipline, sterile areas and separating clean and used instrument areas and minimising people going in and out of the operating theatre unnecessarily. They have had particular ventilation airflow systems for intraocular lens surgery to make sure that the air is clean and they have to follow the guidelines by the manufacturers for single use instruments and cleaning, disinfection and sterilisation of instruments.
The surgeon makes sure there is no significant active non-ocular infection, and they have to treat local eyelid disease such as blepharitis and correct any eyelid malposition such as eyelashes turning inwards, infective conjunctivitis or nasolacrimal duct infection before surgery can go ahead.
During the actual procedure of the cataract surgery the surgeon prepares the skin with Povidone-iodine (or Chlorhexidine if they are allergic to Povidone-iodine) and they also put 5% Povidone-iodine eyedrops into the conjunctival sac on the surface of the eye which significantly reduces infection.
They use proper draping technique, and they ensure that all the equipment, the lens, the viscoelastic, the drugs and solutions are from reliable sources. They use excellent wound construction and closure, and they try to avoid any perioperative complications using non-touch techniques, and at the end of the surgery, they use prophylactic antibiotic injection to prevent infection and use postoperative antibiotic drops.