Prevention of endophthalmitis

Kurt Buzard, MD, Stergios Liapis, MD

Purpose: To report the incidence of postoperative endophthalmitis in a series of
patients who had cataract surgery with intraocular lens (IOL) implantation and to
apply guidelines toward the prevention of postoperative endophthalmitis.
Setting: The Buzard Eye Institute for Corneal, Refractive and Cataract Surgery,
Las Vegas, Nevada, USA.
Methods: In this prospective institutional study, 5131 cataract surgery cases with
IOL implantation were performed from 1998 to 2002 by 1 surgeon at a single institute. The surgeon used a blue-line incision at the superior location, povidone
iodine prophylaxis, and postoperative injection of subconjunctival antibiotics. The
incidence of endophthalmitis in the study was compared with the general incidence in the United States (range 0.07% to 0.13%) and in published studies
(range 0.02% to 0.57%).
Results: The 5131 cases were followed for a mean of 2 years (range 3 months to
4 years). The mean patient age was 69.6 years 10.9 (SD). No case of endophthalmitis occurred. The zero incidence of endophthalmitis was below the general
incidence in the United States and in published studies.
Conclusions: The findings suggest that the absence of postoperative endophthalmitis may be related to 4 factors: povidoneiodine prophylaxis, meticulous draping of the eyes, operative technique (blue-line incision), and postoperative
injection of subconjunctival antibiotics.
J Cataract Refract Surg 2004; 30:19531959 2004 ASCRS and ESCRS

ndophthalmitis is a serious complication for both

surgeon and patient, and its prevention has been the
subject of discussion since the inception of intraocular
surgery. The incidence of endophthalmitis after extracapsular cataract extraction and phacoemulsification is
0.07% to 0.13%15 and the incidence after trauma,
2.4% to 17.0%.3 The incidence of endophthalmitis in
the United States is approximately 2000 cases per year.
Various prophylactic measures have been used to prevent endophthalmitis and are mainly based in retrospective studies and case series.
Accepted for publication December 3, 2003.
From the Buzard Eye Institute for Corneal, Refractive and Cataract
Surgery (Buzard, Liapis), and the University of Nevada School of
Medicine, Department of Surgery (Buzard), Las Vegas, Nevada, USA.
Neither author has a financial or proprietary interest in any material
or method mentioned.
Reprint requests to Kurt Buzard, MD, Buzard Eye Institute for Corneal,
Refractive and Cataract Surgery, 7135 West Sahara Avenue, Las Vegas,
Nevada 89117, USA. E-mail: kurt@buzard.com.
2004 ASCRS and ESCRS
Published by Elsevier Inc.

The patients ocular flora or microorganisms that

have colonized surface eye structures (eyelids and conjunctiva) are the usual causes of infection.6,7 Thus, isolating the eyelids and eyelashes from the surgical field is
crucial. The most common cultured microorganisms
are gram-positive coagulase-negative cocci (about 70%
of cases), with Staphylococcus epidermidis the most prevalent and streptococci species seen less frequently.7 The
most accepted practice to prevent endophthalmitis is
the topical use of povidoneiodine 5% in the conjunctival sac before surgery.8,9 Although there is no extensive
published evidence, based on our clinical experience
and recent studies,1013 we do not recommend routine
prophylactic use of topical antibiotics preoperatively or
in the infusion bottle intraoperatively (S.A. Fridkin,
Update on VISA, presented at the 40th Interscience
Conference on Antimicrobial Agents and Chemotherapy, Toronto, Ontario, Canada, September 2000).1419
However, there is a rationale for the recommendation
of subconjunctival administration of simple antibiotics
0886-3350/04/$see front matter
doi:10.1016/j.jcrs.2003.12.057

PREVENTION OF ENDOPHTHALMITIS

(eg, gentamicin and cephazolin) at the conclusion of

surgery.10,11,20
The site and geometry of the incision are also important in preventing endophthalmitis.2125 We use the
blue-line incision, which is essentially a scleral tunnel
that combines optimal location and architecture.2527
We performed a clinical study to evaluate the incidence of endophthalmitis after cataract surgery with intraocular lens (IOL) implantation and determine which
factors may prevent postoperative endophthalmitis.

Patients and Methods

The study comprised 5131 consecutive cataract surgery
cases with IOL implantation performed at the Buzard Eye
Institute from 1998 to 2002. All procedures were done by
1 surgeon (K.A.B.).
No prophylactic antibiotic drops were given preoperatively. The eye was dilated in the usual manner with 3 sets
of dilating drops (phenylephrine hydrochloride [Neo-Synephrine 10%], cyclopentolate [Cyclogyl 1%], and tropicamide [Mydriacyl 1%]) administered 5 minutes apart.
Retrobulbar anesthesia of 3.5 mL lidocaine 4%, 3.5 mL lidocaine 2%, and 0.2 mL hyaluronidase was administered with
a 23-gauge 1.25-inch needle in a 10 cc syringe. A Honan
balloon was applied for 10 minutes. In the operating room,
the eyelids were prepped with povidoneiodine 10% solution. The lids were covered with povidoneiodine swabs, and
the surrounding skin was painted with the swabs in a spiral
fashion approximately 2 inches in each direction. The lid
was opened with a sterile Q-Tip, and diluted povidone
iodine was instilled in the cul-de-sac. The area was dried by
patting a sterile 4 4 to enhance adherence of the sticky
plastic drape.
The eye was draped just before surgery; the surgeon took
meticulous care to keep the eyelashes out of the surgical field.
Steri-Strips (3M) were applied to the lids to keep them
apart. Two Steri-Strips were used on the upper eyelid, the
first to roll the lashes and the second to hold them back. A
single Steri-Strip was used on the lower eyelid. This technique
was used to keep the lashes out of the surgical field (Figure
1). The plastic drape with adhesive on the bottom was placed
over the open lids. The drape was incised in the midpoint
of the open lids with Westcott scissors without abrading the
cornea by lifting it up in a single motion to avoid serrated
edges. A wire lid speculum was used to fold the edges of the
plastic drape into the superior and inferior cul-de-sacs (Figure
2). Stray lashes were gently swept under the plastic with the
closed Westcott scissors.
After the surgical field was prepared, a blue-line incision
was constructed under continuous application of topical anesthetic drops by an assistant. The blue-line incision is essentially a scleral tunnel. In general, the incision allows rapid,
1954

Figure 1. (Buzard) Steri-Strips are used to maintain lid opening

before use of the plastic drape.

safe entrance into the eye and surgery to proceed more easily
and the surgeon can grasp the wound edge for stabilization
when inserting instruments.
The blue-line incision technique has been described.26,27
Briefly, the incision is constructed superiorly at the 12 oclock
meridian. With the side of the diamond knife, a 4.0 mm
incision is created through the conjunctiva and Tenons tissue
about 1.5 to 2.0 mm behind the surgical limbus (represented
by the anatomic appearance of a blue line, representing the
adherence line of the conjunctiva). In most cases, the conjunctiva naturally sags away from the incision and the resulting
conjunctival gaping creates a miniperitomy (Figure 3, A).
Although bleeding is not a problem if the initial incision
does not significantly penetrate the sclera, the assistant continuously applies drops to maintain visualization of the exterior incision. Light cautery is applied when the incision is
completed. The knife is placed parallel to the posterior sclera,
and pressure is applied to slightly indent the sclera with the

Figure 2. (Buzard) The drape material is wrapped around the lids

and lashes to isolate these areas from the surgical field.

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PREVENTION OF ENDOPHTHALMITIS

Figure 4. (Buzard) Appearance of subconjunctival injection of antibiotics at the conclusion of a case.

Figure 3. (Buzard) The blue-line incision. A: A miniperitomy after

transconjunctival incision 2.0 mm from the limbus. B: Diamond knife
insertion beginning with downward applanation and forward movement. C: A diamond insertion showing the tip of the diamond at the
limbus, at which point the heel of the diamond is rotated downward.
D: The final step of diamond insertion when the heel of the diamond
is rotated upward, creating a dimple in the cornea with subsequent
entrance of the diamond in the anterior chamber.

knife, pushing forward to begin the scleral tunnel incision

(Figure 3, B). During scleral tunnel construction, progressive
pressure is applied on the heel of the diamond knife to
prevent early interior entry caused by the changing curvature
at the limbus between the sclera and cornea (Figure 3, C).
Finally, when the tip of the knife approaches the desired
location for the internal corneal incision, the heel of the knife
is rotated slightly upward and the pressure transferred toward
the tip of the knife. At that point, a slight dimple becomes
visible in the corneal surface and disappears when the knife
penetrates the anterior chamber (Figure 3, D). The knife is
inserted until the shoulders are at the level of the internal
corneal incision, which is 2.5 mm wide.
The blue-line incision results in an approximately
3.0 mm 3.0 mm square transconjunctival corneoscleral
incision. Light cautery is applied to the conjunctival edge to
control bleeding. The same knife is used to create the sideport incision through the bloody edge of the posterior limbus.
This creates a wound with a wide exterior incision and a
narrow interior port. Manipulation through the side port
causes little corneal distortion, and the incision closes easily.
At the end of the cataract procedure, wound integrity is
checked with a wound leakage test; corneal hydration to seal
the incision is not required in most cases. Finally, moderate
cautery is done at the ends of the incision to induce a small
amount of scleral contraction and help seal the external
mouth of the incision.28,29

Figure 5. (Buzard) Histogram of skin-to-skin surgery time and percentage of cases.

In this series of cases, cautery was used sparingly at the

beginning of the procedure and most bleeding resolved by
the end of surgery. At the conclusion of the case, patients were
given subconjunctival injections of 0.25 mL betamethasone
(Celestone), 0.25 mL lidocaine 2% with epinephrine,
0.25 mL gentamicin, and 0.25 mL cephazolin (Figure 4).

Results
In the series of 5131 consecutive cataract procedures, the mean patient age was 69.6 years 10.9 (SD)
The mean follow-up was 2 years (range 3 months to
4 years). The mean surgical time was 10 minutes and
the mean phaco time, 0.6 minutes (Figures 5 and 6).
There were no cases of endophthalmitis. The posterior capsule ruptured in 0.10% of cases, and the
sclera was perforated from the retrobulbar block in
0.02% of cases. No eye had wound leak through the
primary cataract incision (flat or shallow anterior chamber) postoperatively.

J CATARACT REFRACT SURGVOL 30, SEPTEMBER 2004

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PREVENTION OF ENDOPHTHALMITIS

Figure 6. (Buzard) Histogram of actual phaco time and percentage of cases.

Discussion
The mean patient age in our study is consistent
with the mean age of the usual cataract population.
The relatively short surgery and phaco times increased
the chances for uneventful surgery and faster patient
rehabilitation.
Several steps are important in preventing endophthalmitis. These include the position and type of incision, surgical technique, and preventive antiseptic
regimen (eg, povidoneiodine preparation and subconjunctival antibiotic injection at the completion of
surgery).
Table 1 compares the surgical parameters in a series
of clinical studies. Phacoemulsification was the prevalent cataract procedure in most series. The incidence
of endophthalmitis after a temporal clear corneal incision was between 0.10% (Schmitz and coauthors30) and
0.57% (Kalpadakis et al.31) and after a superior scleral
tunnel incision, between 0.02%32 and 0.20%.33 In the
study by John and Noblitt,32 the incidence of endophthalmitis was 0.29% with a temporal clear corneal incision and 0.02% with a superior scleral tunnel incision
(odds ratio 14:1). In the Nagaki et al.34 study, the
incidence of endophthalmitis was 0.29% with a temporal clear corneal incision and 0.05% with a superior
sclerocorneal incision (relative odds ratio 4:6). In a
large-scale study by Schmitz and coauthors,30 the overall
incidence of endophthalmitis was 0.07% with a superior
scleral tunnel incision and 0.10% with a temporal clear
corneal incision. The generalized higher incidence of
postoperative infection with a clear corneal incision (up
to 0.57%, Kalpadakis et al.31) than with a scleral tunnel
1956

incision should not be underestimated. In our series

with no cases of endophthalmitis, we used a blue-line
(superior scleral tunnel) incision.
A watertight incision is critical for safe wound healing and preventing infection; wound leakage can lead
to various complications21 (eg, poor visual outcome,
choroidal effusion, optic nerve edema, iris prolapse,
epithelial downgrowth, astigmatism, and infection). We
believe that a well-sealed wound offers excellent insurance against endophthalmitis, whereas if an open conduit exists between the anterior chamber and the
external world, endophthalmitis is almost a foregone
outcome. Histologic analysis shows that starting incisions in the vascular region (limbus) results in an increased fibroblastic response that enhances incision
stability and promotes healing within 7 days rather than
the 60 days for avascular sites (cornea).24
The geometry of the incision is also key to the
healing process. Ernest at al.25 found that a square corneal incision (1.0 mm 2.0 mm, 2.0 mm 2.0 mm,
3.0 mm 3.0 mm) gives the same stability as a square
scleral corneal incision with a 1.5 mm corneal component. They also showed that a change in tunnel length
from 2.0 mm to 2.5 mm with an incision width of
3.2 mm offers up to 10 times more resistance to deformation at an intraocular pressure (IOP) of 20 to 25 mm Hg
than a clear corneal incision. Langerman22 and Ernest
and coauthors23 also found that straight-in and 2-plane
clear corneal incisions can leak, even when the wound
appears watertight and the IOP is normal on the first
postoperative day. The blue-line incision, located near
the vascular limbus, promotes wound healing. This incision also has the architecture of a 3.0 mm 3.0 mm
square with a 1.5 mm corneal lip, which previous studies
show offers maximum resistance to high external and
intraocular pressures.23,25
The incidence of a flat anterior chamber is 1.0%
to 1.5% with clear corneal incisions but almost 0%
with scleral tunnel incisions.35 It has also been reported23
that a temporal clear corneal incision takes 6 months
to heal and a vascular scleral tunnel incision, 1 to 2
weeks.23 In addition, the clinical series of John and
Noblitt32 and Nagaki et al.34 suggest that clear corneal
incisions result in a higher incidence of endophthalmitis
than comparable scleral tunnel incisions. Similarly, mechanical considerations such as fish mouthing and ex-

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PREVENTION OF ENDOPHTHALMITIS

Table 1. Comparison of surgical parameters and prophylactic antibiotic regimen in endophthalmitis studies.
Surgical Parameters
Technique

Preop
Antibio

PI

Infusion
Antibio

Subcon
Inject

Endoph
Cases, n (%)

Phaco

ST/sup

Yes

Yes

Vancgent

No

1 (0.02)

Study*

Year

John32

19921996

5 216

32

John

19921996

3 126

Phaco

CC/temp

Yes

Yes

Vancgent

No

9 (0.29)

Speaker8

19891990

4 507

Phaco/ECCE

ST/sup

Yes

No

Yes

Yes

8 (0.18)

19891990

3 489

Phaco/ECCE

ST/sup

Yes

Yes

Yes

Yes

2 (0.06)

Phaco/ECCE

ST/sup

Yes (59%)

No

No

Yes

16 (0.07)
150 (0.07)

Speaker
5

Cases (n)

Prophylactic Regimen

Incision
Type/Location

19841989

22 791

30

Schmitz

19961999

214 599

Phaco

ST/sup

Yes (95%) Yes (68%)

Yes (60%)

Yes (52%)

Schmitz30

19961999

54 501

Phaco

CC/temp

Yes (95%) Yes (68%)

Yes (60%)

Yes (52%)

Phaco

CC/temp

No

No

Kattan

31

Kalpadakis

No

Yes

54

(0.1)

19961999

1 381

33

8 (0.57)

Montan

19901993

14 495

ECCE

Lim/sup

No

Yes

No

Yes

39 (0.27)

Montan33

19901993

7 490

Phaco

ST/sup

No

Yes

No

Yes

15 (0.20)

Aaberg2

19841989

23 124

Phaco/ECCE

ST/sup

Yes (58%)

Yes

No

Yes (96%)

17 (0.074)

Aaberg

19901994

18 530

Phaco/ECCE

ST/sup

No (76%)

Yes

No

Yes (79%)

17 (0.092)

15

Desai

19971998

19 000

Phaco/ECCE

ST/sup

No

Yes

No

No

5 (0.03)

Current

19972002

5 131

Phaco

BL/sup

No

Yes

No

Yes

Antibio antibiotics; BL blue line; CC clear corneal; ECCE extracapsular cataract extraction; Endoph endophthalmitis; gent
gentamicin; Lim limbal; Phaco phacoemulsification; PI povidoneiodine; ST scleral tunnel; Subcon Inject subconjunctival injection;
sup superior; temp temporal; Vanc vancomycin
*First author

posure to trauma with temporal incisions make the

superior entrance to the cataract wound preferable.
Table 1 also compares the prophylactic use of antibiotics in the series of clinical studies. Povidoneiodine
and subconjunctival antibiotics were used almost universally. Speaker et al.8 studied this specific issue and
found a 3-fold increase in the incidence of endophthalmitis, 0.18% versus 0.06%, when no povidoneiodine
prophylaxis was used. Antibiotics in the infusion bottle
were used in almost half the series; however, their use
did not prevent the relatively high incidence of endophthalmitis, as illustrated in the John and Noblitt32 series
(0.29%), despite the use of vancomycin and gentamicin
in the irrigating solution. In contrast, Aaberg et al.2 and
Kattan et al.5 did not use antibiotics in the infusion
bottle in their large series and had a relatively low
incidence of endophthalmitis, 0.09% and 0.06%, respectively. In our series of 5131 eyes with no endophthalmitis, all cases were performed by 1 surgeon who
personally draped the patient. No antibiotics were given
preoperatively or intraoperatively through the irrigating
solution. At the completion of the case, a single subconjunctival injection of antibiotics (cephazolin and gentamicin) was given.

The use of povidoneiodine in the preparation of

the eye before cataract surgery has been recognized as
an important prophylactic regimen in several clinical
and theoretical studies.8,9 Our clinical experience seems
to confirm that it is valuable in the prevention of endophthalmitis. As most flora that cause endophthalmitis
come from the lids, the specific method of preparing
the surgical field may be important in helping prevent
endophthalmitis.
Preoperative use of antibiotics does not seem to influence postoperative infection, as indicated in recent studies.10,11 Even modern antibiotics such as fluoroquinolones
used preoperatively have not proved more effective than
povidoneiodine against resistant coagulase-negative staphylococci species and S aureus (common bacteria in the
pathogenesis of endophthalmitis).11 There is evidence in
the literature13 that topical preoperative application of
ciprofloxacin fails to achieve levels near the minimum
inhibitory concentration 90% (MIC90) (n 20). Of
special concern is a trend toward increasing resistance of
Streptococcus and Pseudomonas against fluoroquinolones.
The resistance of some strains of Staphylococcus to ciprofloxacin has been reported as high as 76% to 82%,
whereas resistance of total gram-positive bacteria to cip-

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PREVENTION OF ENDOPHTHALMITIS

rofloxacin was 41% in 1997, compared with 19% in

1993.12 Clinical failure of this approach may be caused
by a combination of antibiotic resistance to the drops
and the practical matter of giving enough antibiotics
topically to influence anterior chamber concentrations
of the drug. In our clinical series, we found no need
to include this prophylactic measure and the results did
not suffer by this exclusion. Future studies may be
required to further support this practice.
The use of vancomycin in the irrigating solution has
also been criticized.15,16 Most studies found no scientific
evidence justifying its routine use. Ferro et al.17 and
Feys and coauthors18 report that the addition of vancomycin to the irrigation solution did not have a statistically significant bactericidal effect (based on the recovery
of bacteria from the anterior chamber). When used in
the infusion bottle at 20 mcg/mL, vancomycin is washed
from the anterior chamber in fewer than 4 hours and
does not achieve concentrations above MIC90 of the
most common gram-positive pathogens.17,18 There has
been reference in the literature to vancomycins toxicity
and the increased risk for cystoid macular edema after
its intraoperative use.19 Emerging resistance to vancomycin is a critical public health issue as deaths from confirmed cases of vancomycin-resistant staph infections
have been reported by the Centers for Disease Control
(CDC) (S.A. Fridkin, Update on VISA, presented
at the 40th Interscience Conference on Antimicrobial
Agents and Chemotherapy, Toronto, Ontario, Canada,
September 2000). The CDC15 and Academy of Ophthalmology16 issued guidelines against the routine use
of vancomycin in the irrigation bottle intraoperatively.
Thus, considering the low benefit:risk ratio, we do not
use or recommend routine prophylactic use of antibiotics in the infusion bottle.
An immediate postoperative subconjunctival injection of antibiotics has been widely used to prevent
infection. There is evidence that subconjunctival gentamicin administration at the time of surgery reduces
S aureus endophthalmitis in animal models.20 Also, subconjunctival cephazolin administration in vitro resulted
in statistically significant reductions in ocular microflora
up to 48 hours after surgery (providing gram-positive
and gram-negative coverage) compared with preoperative administration of topical antibiotics.10,11 We recommend the use of simple antibiotics such as gentamicin
and cephazolin for efficacy and safety. In most cases,
1958

these antibiotics provide more than adequate bacterial

coverage against S aureus and streptococci species as it
is the flooding of the exterior entrance to the anterior
chamber, not the strength of the antibiotic, that plays
an important role in providing a safe barrier against
infection. The flooding saturates the surrounding tissues
and virtually guarantees a barrier to infection, even if
the wound allows communication with the outside
world for a short time postoperatively. Future studies
may be required to support this practice.
It is accepted that the more prolonged the surgery,
the greater the chance for complications. Although the
surgeon should not pursue speed at the expense of
safety, we believe that faster uneventful surgery leads
to faster recovery.
In summary, there were no cases of endophthalmitis
in our study. We believe that the steps we followed
were important in this outcome. These include povidoneiodine prophylaxis, meticulous draping of the
eyes, a blue-line incision in the superior location, and
subconjunctival injections of gentamicin and cephazolin
postoperatively. However, because of an overall low
incidence of endophthalmitis, further studies are required to establish which aspects of our surgical technique reduced the incidence of endophthalmitis.

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