In the operating room, sterilization of the fornix is important. A 5% povidone-iodine solution (not scrub or soap) placed in the conjunctival fornix prior to surgery has been associated with a reduction in bacterial colony counts in cultures from the ocular surface at the time of surgery and a decreased risk of culture-proven endophthalmitis. In addition, preparation of the skin around the eye with a 10% povidone-iodine solution can reduce bacterial counts on the eyelid margins. Because eyelid margins may harbor pathogens, it is important to drape the eyelashes out of the operative field (Fig 7-6).
Figure 7-6 Sterile draping of the eye for surgery.
(Courtesy of Lisa Park, MD.)
It is important not only to limit the number of times that instruments are introduced into the eye but also to check for signs of lint, cilia, and other debris on the tips of all instruments inserted. Meticulous wound closure is imperative. Despite surgeons’ best efforts, however, 7%–35% of cataract surgeries result in bacterial inoculation of the anterior chamber. The low incidence of endophthalmitis is a testament to the ability of the anterior chamber to clear itself of a potentially pathologic inoculum. The risk of endophthalmitis increases with a torn posterior lens capsule, vitreous loss, and prolonged surgery.
Some surgeons add antibiotics to the irrigating solution or inject them into the anterior chamber at the conclusion of the operation. The Endophthalmitis Study Group reported a significant reduction in endophthalmitis with the use of intracameral cefuroxime, which has not been universally adopted in the United States because of the lack of commercial antibiotic preparations for intracameral use. Intracameral vancomycin is a popular alternative; however, this antibiotic has been associated with a rare hypersensivity reaction that causes a hemorrhagic vasculitis. Intracameral moxifloxacin has become more popular; to date, it has been predominantly safe and cost-effective. There have been reported cases of pigmentary dispersion and diffuse iris depigmentation after intracameral use as well as systemic use of moxifloxacin.
Subconjunctival corticosteroids can be used in conjunction with intracameral antibiotics. Another option is the injection of a bolus of antibiotic and corticosteroid medications at the conclusion of surgery via transzonular or intravitreal injection, so that the medications are able to act over time postoperatively. “Dropless” cataract surgery can refer to any of these methods in which medications are instilled at the time of surgery and reduce or eliminate the need for postoperative drops.
Whether the risk of endophthalmitis is increased after cataract surgery performed using a sutureless clear corneal wound is controversial. After tracking the flow of fluorescein into the anterior chamber, some have suggested that inflow of bacteria from the ocular surface may be possible via a sutureless incision. For this reason, hydrating the corneal stroma to reapproximate the anterior and posterior aspects of the wound may reduce the risk of wound separation. Any possibility of leakage can be addressed with wound closure by suture or tissue adhesive.
Bowen RC, Zhou AX, Bondalapati S, et al. Comparative analysis of the safety and efficacy of intracameral cefuroxime, moxifloxacin, and vancomycin at the end of cataract surgery: a meta-analysis. Br J Ophthalmol. 2018;102(9):1268–1276.
Chang DF, Braga-Mele R, Henderson BA, Mamalis N, Vasavada A; ASCRS Cataract Clinical Committee. Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2014 ASCRS member survey. J Cataract Refract Surg. 2015;41(6):1300–1305.
Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons (ESCRS). Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33(6):978–988.
Gower EW, Keay LJ, Stare DE, et al. Characteristics of endophthalmitis after cataract surgery in the United States Medicare population. Ophthalmology. 2015;122(8): 1625–1632.
Nentwich MM, Ta CN, Kreutzer TC, et al. Incidence of postoperative endophthalmitis from 1990 to 2009 using povidone-iodine but no intracameral antibiotics at a single academic institution. J Cataract Refract Surg. 2015;41(1):58–66.
Witkin AJ, Chang DF, Jumper JM, et al. Vancomycin-associated hemorrhagic occlusive retinal vasculitis: clinical characteristics of 36 eyes. Ophthalmology. 2017;124(5):583–595.
Excerpted from BCSC 2020-2021 series: Section 11 - Lens and Cataract. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.