Risk factors for endophthalmitis after cataract extraction

AORN Journal,  Oct, 2007  by George Allen

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Journal of Cataract and Refractive Surgery June 2007

Endophthalmitis, characterized by major inflammation of the vitreous cavity and anterior chamber, is a rare but severe complication of cataract extraction. Factors known to increase the risk for postoperative endophthalmitis include vitreous loss, the patient's relative immunosuppression, and chronic dacryocystitis. Recently, the clear corneal incision and use of topical anesthesia are being investigated as potential risk factors for this complication. In 2003, after an increase in endophthalmitis was detected at a medical center in Spain, an epidemiological study was initiated. The purpose of this study was to assess the relationship between the risk for acute endophthalmitis and modifiable factors including the surgeon's qualification; the OR used (ie, room A or room B); numerical order of surgery; the duration of surgery; and the type of anesthesia used (ie, topical or retrobulbar).

A case-control study and a retrospective-cohort study were performed. A case was defined as a patient with clinically diagnosed endophthalmitis occurring within 30 days after cataract extraction. Cases were identified by reviewing the clinical records of patients who had undergone surgery between February 1, 2002, and September 30, 2003. Four control cases for each endophthalmitis case were randomly selected from the same time period. Data recorded for each patient included

* the date of surgery,

* whether OR A or B was used,

* the order of surgery,

* the duration of surgery,

* whether the surgeon was a specialist or a resident, and

* whether topical or retrobulbar anesthesia was used.

Common statistical techniques, including univariate and multivariate logistic regression analyses, were used to analyze the data for independent risk factors for endophthalmitis.

FINDINGS. Between February 2002 and September 2003, surgeons performed 5,011 cataract extractions at the medical center. Twenty-seven cases of endophthalmitis resulted for an incidence rate of 5.39 per 1,000 procedures (95% confidence interval [CI] 3.7-10.3). There was no significant difference in regard to the OR used, surgeon's qualification, or order of the surgery. An independent, statistically significant relationship was found between endophthalmitis and the use of topical anesthesia (odds ratio [OR] 11.8, 95% CI 2.4-58.7) and between endophthalmitis and surgery that lasted longer than 45 minutes (OR 7.2, 95% CI 1.7-29.7). The incidence of endophthalmitis was 1.8 per 1,000 cataract extractions with retrobulbar anesthesia versus 6.76 per 1,000 with topical anesthesia (relative risk 3.76, 95% CI 0.89-15.85).

CLINICAL IMPLICATIONS. The results of this study suggest that there may be an association between use of topical anesthesia and endophthalmitis after cataract surgery. According to this study, there was a sixfold greater risk for endophthalmitis when topical anesthesia rather than retrobulbar anesthesia was used. Perioperative nurses and managers should be prepared to assist in prospective studies to confirm these results. Additionally, they should redouble their efforts to maintain strict asepsis during cataract extractions, especially when topical anesthesia is being administered.

Garcia-Arumi J, Fonollosa A, Sararols L, et al. Topical anesthesia: possible risk factor for endophthalmitis after cataract extraction. J Cataract Refract Surg. 2007;33(6):989-992.

GEORGE ALLEN

PHD, RN, CNOR, CIC

DIRECTOR OF INFECTION CONTROL

DOWNSTATE MEDICAL CENTER

BROOKLYN, NY

COPYRIGHT 2007 Association of Operating Room Nurses, Inc.
COPYRIGHT 2008 Gale, Cengage Learning