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Endophthalmitis Occurring after Cataract

Outcomes of More Than 480 000 Cataract Surgeries,
Epidemiologic Features, and Risk Factors
Mahmoud Jabbarvand, MD,1 Hesam Hashemian, MD,1 Mehdi Khodaparast, MD,1 Mohammadkarim Jouhari, MD,1
Ali Tabatabaei, MD,1 Shadi Rezaei, BSC2
Purpose: To report the incidence of endophthalmitis after senile cataract surgery and to describe the
epidemiology and main risk factors.
Design: Retrospective, single-center, cross-sectional descriptive study.
Participants: Patients who underwent cataract surgery in Farabi Eye Hospital from 2006 through 2014.
Methods: All patients were evaluated retrospectively to compare risk factors, epidemiologic factors, and
prophylaxis methods related to endophthalmitis. Patient records were used to gather the data.
Main Outcome Measures: Epidemiologic factors, systemic diseases, other ocular pathologic characteristics, complications during the surgery, technique of cataract surgery, intraocular lens type, method of antibiotic
prophylaxis, surgeon experience, vitreous culture, and vision outcome were evaluated in these patients.
Results: One hundred twelve endophthalmitis cases among 480 104 operations reported, equaling an
incidence of 0.023%. Patients with diabetes mellitus (14.3%) and of older age (mean age, 81 years), perioperative
communication with the vitreous (17.9%), extracapsular cataract surgery procedure (11%), and surgery on the left
eye (58.9% vs. 41.1% for right eye; P 0.03) showed a statistically signicant association with endophthalmitis.
Short-term treatment with topical or systemic preoperative antibiotics or postoperative subconjunctival injection
was associated with a 40% to 50% reduced odds of endophthalmitis compared with no prophylaxis (P 0.2). No
cases of endophthalmitis were observed among the 25 920 patients who received intracameral cefuroxime,
suggesting that this approach to antibiotic prophylaxis may be far more effective than traditional topical or
subconjunctival approaches.
Conclusions: The incidence of endophthalmitis after cataract surgery in our center was 0.023%, comparable
with that of other previously published international studies. Older rural patients with immune suppressive diseases, such as diabetes mellitus, are particularly more prone to endophthalmitis. Vitreous loss at the time of
surgery was associated with a signicantly increased risk. Whereas antibiotic prophylaxis overall showed a 40%
to 50% reduction in risk, intracameral cefuroxime was 100% effective in preventing endophthalmitis in this
series. Ophthalmology 2015;-:1e7 2015 by the American Academy of Ophthalmology.

Cataract surgery is by far the most common ocular surgery

performed worldwide. Postoperative endophthalmitis is a
raredbut disastrousdcomplication of cataract surgery, with
a reported incidence of 0.04% to 0.41%.1 Although it is not
prevalent, it presents an important public health problem.
The worldwide aging population likely will result in a
higher rate of cataract surgeries in the near future.
Postoperative endophthalmitis often is associated with
serious morbidity and high medical care expenses. Visual
outcomes after endophthalmitis often are poor: one third
of individuals do not gain vision better than counting
ngers, and 50% do not recover vision better than 20/40.2
In some cases, even anatomic distortion of the globe

 2015 by the American Academy of Ophthalmology

Published by Elsevier Inc.

In recent years, cataract surgery technique has improved

progressively with the use of injectable lenses and topical
anesthesia, microincisions, and sutureless surgical wounds.
All of these changes may have reduced the rate of postoperative endophthalmitis. So, it is useful to analyze epidemiologic data and the epidemiologic factors associated with
surgical infection to prevent its appearance and consequences.
The objective of this study was to evaluate the effect of
epidemiologic and surgical factors on endophthalmitis
occurring after cataract surgery and to assess prophylaxis
techniques, treatment methods, and outcomes in a referral
center in Iran. One of the advantages of this study in comparison with previous reports is its single-center nature,
which may decrease some confounding factors.
ISSN 0161-6420/15

Ophthalmology Volume -, Number -, Month 2015

We retrospectively analyzed the electronic medical records of 480
104 eyes of patients who had undergone senile cataract surgery at
Farabi Eye Hospital, Tehran, Iran, from 2006 through 2014. The
Farabi Eye Hospital Institutional Review Board approved the study
protocol. We identied all cases of endophthalmitis occurring after
cataract surgery within this interval. We reexamined the patients
who had endophthalmitis and evaluated their risk factors and their
nal visual results.
The diagnosis of endophthalmitis was based on clinical examination indicating an inammatory reaction out of proportion to the
surgical trauma during the normal course of postoperative care,
warranting intraocular sampling for bacterial culture. All the patients with a diagnosis code for endophthalmitis using the International Classication of Diseases, Ninth Revision, Clinical
Modication codes or similar codes in older records were
considered as endophthalmitis: 360.00, purulent endophthalmitis,
unspecied; 360.01, acute endophthalmitis; 360.02, panophthalmitis; 360.03, chronic endophthalmitis; and 360.04, vitreous
We retrospectively evaluated the following variables between
the cases and the entire study population: demographic factors,
systemic diseases, prophylactic antibiotic regimen (preoperative,
intraoperative, or postoperative antibiotics), bacterial species of
infection, management of the endophthalmitis, experience level
of the cataract surgeon, patient socioeconomic status, method of
surgery, intraoperative complications, and nal visual acuity.
When endophthalmitis was suspected, a vitreous biopsy was
performed immediately and sent to the microbiological laboratory
for smear and culture and antibiogram analyses. Endophthalmitis
was managed according to the recommendations of the Endophthalmitis Vitrectomy Study.4
According to an antibiotic protocol for cataract surgery in
Farabi Eye Hospital, which is followed by all ophthalmologists, all
patients received 5% povidoneeiodine for 5 minutes before surgery. At the time of discharge, the patients were prescribed a
topical antibioticecorticosteroid solution (betamethasone 0.1%
combined with either ciprooxacin 0.3% or chloramphenicol
0.5%) in tapering dosages during a 45-day postoperative period.
Records were excluded if data indicated the eye had undergone
previous intraocular surgery.
Based on the level of surgeon experience, surgeries were
classied as performed by full-time attending or in-training surgeons. Analysis of the latter groups records was carried out
depending on whether the surgeon was a resident or fellow. Fulltime attending physicians performed 72% of surgeries.

Statistical Analysis
All statistical analyses were performed using SPSS software
(SPSS, Inc., Chicago, IL). Means and standard deviations of
quantitative variables and distribution of frequencies of qualitative
variables were studied. A Pearson chi-square test and an independent sample test were used for risk factors analysis. P values
less than 0.05 were considered statistically signicant. Multivariate
logistic regression analysis was performed to evaluate diabetes,
vitreous loss, and antibiotic prophylaxis as independent risk factors
for endophthalmitis.

Analysis of medical records revealed 112 endophthalmitis cases
among 480 104 operations, indicating a postoperative endophthalmitis incidence of 0.023%. The mean agestandard deviation

of the entire cataract surgery population was 799.5 years.

Endophthalmitis developed in patients with a mean age  standard
deviation of 817.8 years. Table 1 shows the summary of clinical
ndings and specications of patients with endophthalmitis.
The average period between surgery and the diagnosis of
endophthalmitis was 8 days. One hundred cases (89%) were
diagnosed with acute-onset endophthalmitis (within 6 weeks of
surgery) and 12 eyes (11%) had late-onset endophthalmitis (>6
weeks from the time of surgery).
The cataract surgery technique was reported in all cases. In
approximately 98.3% of the entire study population, phacoemulsication surgery was performed with a clear corneal 3.2-mm
incision. Endophthalmitis occurred in 100 eyes (89%) after
phacoemulsication and in 12 eyes (11%) after extracapsular
cataract extraction. Nearly one-fth of postcataract surgery
endophthalmitis cases (17.9%) had experienced posterior capsule
rupture and vitreous loss in the initial cataract surgery. Table 2
shows the distribution of cataract surgery techniques performed
and the incidence of vitreous loss. A higher incidence of
endophthalmitis was present in the extracapsular cataract
extraction (P 0.006), vitreous loss, and diabetic groups. Of all
the patients who underwent cataract surgery, 5.4% were diabetic,
whereas 16 of 112 endophthalmitis cases (14.3%) occurred in
patients with diabetes mellitus (P 0.004).
Multivariate logistic regression analysis demonstrated that
diabetes (P 0.018) and vitreous loss (P < 0.001) were independent risk factors for endophthalmitis. We observed a 7-fold and
3-fold increase in the rate of endophthalmitis among those with
vitreous loss and diabetes, respectively (odds ratios, 7.83 and 2.92,
respectively, for vitreous loss and diabetes).
Among the 112 cases of endophthalmitis, 4 cases (3.6%) were
aphakic, 34 of the implanted lenses were hydrophobic (30.4%), and
74 lenses were hydrophilic (66%). Among the entire cataract surgery population, 42.4% had hydrophobic lenses and 57.6% had
hydrophilic lenses.
A total of 15.3% of patients received preoperative antibiotic
eye drops (ciprooxacin 0.3%). Intracameral cefuroxime was
used at the end of cataract surgery in 25 920 patients (5.4%);
endophthalmitis did not develop in any of these patients (P
0.0001). Table 3 shows the single risk factor analysis for
prophylaxis antibiotic usage. Single-variable analyses showed
that the use of intracameral antibiotics was the decisive prophylactic factor for the development of postoperative
Among all vitreous samples obtained from endophthalmitis
cases, 41 samples (36.6%) showed positive culture results; the

Table 1. Summary of Demographic Data of All Endophthalmitis

Affected eye
Lacrimal drainage disease
Vitreous loss
Data are no. (%).

52 (46.4)
60 (53.6)


28 (25)
84 (75)

Jabbarvand et al

Endophthalmitis after Cataract Surgery

Table 2. Rate of Endophthalmitis According to Different Factors

Surgery type
Vitreous loss
Diabetes mellitus
IOL type

Cases in the Total

Population, No. (%)

No. of Endophthalmitis Cases and

Rate (%) of Endophthalmitis by Variable

471 840 (98.3)

8160 (1.7)

100 (0.021)
12 (0.14)

12 960 (2.7)
467 040 (97.3)

20 (0.15)
92 (0.019)

25 926 (5.4)
454 178 (94.6)

16 (0.06)
96 (0.02)

202 604 (42.2)

276 540 (57.6)

38 (0.018)
74 (0.026)

Odds Ratio

95% Condence












P Value

ECCE extracapsular cataract extraction; IOL intraocular lens.

The percentage in the third column is the rate of the variable among the entire population (e.g., 98.3% of the entire population underwent phacoemulsication). The percentage in the fourth column is the rate of endophthalmitis in the specic variable group (e.g., 0.021% of the patients who underwent phacoemulsication had endophthalmitis).


remaining 71 cases (63.4%) with a clinical diagnosis of endophthalmitis showed negative culture results. Gram-positive species
were the main cause, accounting for 33 cases (80%).
The nal visual acuity was better in patients with negative culture results or coagulase-negative staphylococci. In contrast, eyes
with enterococci and Pseudomonas species had worse nal vision.
Final visual acuity was no light perception in 2 eyes, and 1 of these
eyes was eviscerated because of severe corneal melting (Table 4).
Patients were categorized into 2 groups based on their location:
38 880 patients (8.1%) were from rural areas and 441 120 patients
(91.9%) were from urban areas. Records showed that endophthalmitis had signicantly higher occurrence rates among rural
patients (0.07%) versus urban patients (0.02%; P 0.001).
Table 5 compares the endophthalmitis rates among different
surgeon groups based on their level of experience. The ratio of
the cases with endophthalmitis to the number of all patients
undergoing cataract surgery was higher among residents
compared with surgical fellows and attending surgeons.
However, no statistically signicant differences were observed in
endophthalmitis rates between residents, fellows, and full-time
attending physicians when analyzed by linear-by-linear association or the chi-square test.
The distribution of endophthalmitis cases according to eye
laterality demonstrated a higher incidence of endophthalmitis in the
left eye (58.9%); in contrast, a higher number of right eyes underwent cataract surgery (264 000 [55%]), so the endophthalmitis
rate was statistically signicantly higher in the left eye compared
with the right eye (P 0.03).

This study is one of the largest studies of endophthalmitis

occurring after cataract surgery. We designed this study to
evaluate the prevalence, the clinical and surgical aspects,
and the role of systemic disease and prophylactic antibiotics
in endophthalmitis after cataract surgery. This study established rates of endophthalmitis secondary to cataract surgery
in the Farabi Eye Hospital, a tertiary care referral hospital in
Tehran, Iran. The surgeries were performed by residents
engaged in surgical training as well as fellows and full-time
attending physicians.
Previous reports stated different incidence rates for
endophthalmitis occurring after cataract surgery ranging
from 1 per 300 cataract procedures to no events over several
years.5e8 We found a global endophthalmitis prevalence of
0.023%, comparable with the incidences of 0.029%9 and
0.048%10 in Sweden, and lower than the incidences of
0.06% in China,11 0.09% in the United Kingdom,12 0.14%
in Ontario, Canada,13 and 0.15% in Quebec, Canada.14 A
systematic review of publications from 1964 through 2003
that included 3 140 650 cataract extractions estimated an
endophthalmitis rate of 0.128%.15 The differences among
these studies may be the result of differences in
prophylactic regimens, differences in sensitivity of the

Table 3. Single Risk Factor Analysis for Prophylactic Antibiotic Use

No antibiotic
Preoperative systemic
Preoperative topical
Intracameral antibiotic

Total No.
of Cases

Proportion of
Cases (%)

No. of Endophthalmitis
Risk of
Endophthalmitis (%)

Odds of


260 744
47 520






76 800






25 920
69 120






Ophthalmology Volume -, Number -, Month 2015

Table 4. Culture Results and Final Visual Outcomes

No. (%)

Coagulase-negative Staphylococci 14
Staphylococcus aureus
Pseudomonas species
Enterobacteriaceae species
Other gram-positive bacteria
Other gram-negative bacteria

Mean Corrected
Distance Visual Acuity*




*Logarithm of the minimum angle of resolution (Snellen equivalent).

Two patients had no light perception vision. Pseudomonas aeruginosa was
found in one culture and Enterococci was found in the other.

denition of endophthalmitis, and nally racial and

socioeconomic differences.
One of the main advantages of this study over previous
endophthalmitis studies is that we enrolled patients who
underwent cataract surgery at a single eye hospital with the
same operating rooms, surgical instruments, and protocols
of sterilization so we could eliminate the confounding factors that may affect the result. An unavoidable drawback
directly related to the retrospective nature of studies of
endophthalmitis is missing cases (e.g., if a patient who underwent cataract surgery in our center goes to another center
after endophthalmitis occurs). The primary assumption for
all of these studies is that all patients who underwent surgery
would return to the same center in case of any complications. We believe that because of the position of Farabi Eye
Hospital in Iran, this bias is very unlikely to happen. Farabi
Eye Hospital is by far the largest referral center in Iran, and
most of the referrals across the country are made to it. The
relationship between Farabi Eye Hospital and ophthalmologists nationwide makes it extremely unlikely that patients
who undergo surgery at Farabi Eye Hospital receive treatment for postoperative complications elsewhere. All ophthalmologists who perform surgery in Farabi Eye Hospital
visit postoperative patients there.
We identied a 7-fold increase in the odds of endophthalmitis associated with intraoperative vitreous loss, and
this complication was identied in association with 18% of
endophthalmitis cases in this study. The role of vitreous loss
in promoting endophthalmitis was rst identied by Javitt

et al16 in 1991 and has been conrmed in numerous

subsequent reports.5,9,17,18
Nearly 20% of our patients with endophthalmitis had
diabetes mellitus, which is much higher than the rate of total
cataract surgery (4.3%). Diabetes increased the odds of
endophthalmitis approximately 3-fold. Other previous reports also have mentioned diabetes as an independent risk
factor of endophthalmitis.17e19
Because the source of most of the bacterial causes of
postoperative endophthalmitis is the patients fornix, eyelid,
and conjunctiva,20,21 preoperative disinfection of periocular
surfaces is very effective for endophthalmitis prophylaxis.
As the accepted protocol in Farabi Eye Hospital, all surgeons perform periorbital disinfection using gauze soaked
with povidoneeiodine for 5 minutes. Povidoneeiodine is
applied in the conjunctival sac at least 1 minute before
surgery. This may help to reduce the endophthalmitis rate in
Farabi Eye Hospital compared with previously mentioned
studies. Ciulla et al,22 in a literature review, concluded that
preoperative povidoneeiodine is the single most effective
means for reducing the risk for postoperative
The role of antibiotics in surgical prophylaxis continues
to be controversial. No cases of endophthalmitis were
observed among the 25 920 patients who received intracameral cefuroxime, suggesting that this approach to antibiotic prophylaxis may be far more effective than traditional
topical or subconjunctival approaches. This nding is in
accordance with previous prospective and retrospective
Recently, a study from Portugal reported a decrease in
the endophthalmitis rate from 0.26% to 0% after use of
intracameral cefuroxime.26 A 5-fold risk reduction also was
reported in the randomized, multicenter European Society of
Cataract and Refractive Surgeons study.5,23 A Spanish
study27 reported a reduction in the risk of endophthalmitis,
from 0.59% to 0.043%, after cefuroxime.
However, some studies28 reported lower rates of
endophthalmitis with no use of intracameral antibiotics
compared with the European Society of Cataract and
Refractive Surgeons (ESCRS) cefuroxime group (0.07%).
In this study, we observed a lower total rate of
endophthalmitis also.
An appropriate antibiotic for intracameral use should be
safe for intracameral use, have broad antimicrobial
coverage, and be prepared easily. Cefuroxime is a broadspectrum drug, and although intracameral use is off label,

Table 5. Distribution of Endophthalmitis According to Surgeon Experience and Eye Laterality

Surgeon Skill
Resident in training
<5 mos*
>5 mosy
Fellow in training
Full-time attending physician

No. (%) of Patients

(n [ 480 104)
90 740
34 567
346 155

No. (%) of Endophthalmitis

Cases (n [ 112)


*Residents with fewer than 5 months of experience in cataract surgery.

Residents with more than 5 months of experience in cataract surgery.



Endophthalmitis Rate (%)

P Value



Jabbarvand et al

Endophthalmitis after Cataract Surgery

it has been proven to be safe.29,30 A review of the preferred

practice in European countries reported that intracameral
cefuroxime still is not used widely by European
The main drawback of its use is the risk of miscalculation
of dosage or contamination during preparation because it is
not available in many countries, including Iran, as a commercial preparation for intracameral use. Although there
were no reports of side effects in Farabi Eye Hospital, there
are some reports of adverse effects resulting from overdoses
of the drug in the literature.30,32 Fortunately, a specic
commercial preparation with the necessary concentration
(0.1 mg/ml) for intracameral use, called Aprokam (Laboratoires Tha, Clermont-Ferrand, France),33 has been
available in Europe since 2012. The other drawback of
this drug is its insufcient antibacterial coverage over
highly virulent enterococci and some gram-negative bacteria.9 We believe that because of the proven effect of
intracameral cefuroxime, it should be used at least in
patients with a higher risk of endophthalmitis (i.e., those
with diabetes or whose cataract surgery was complicated).
This study showed that short-term pretreatment with
topical or systemic antibiotics or postoperative subconjunctival injection of antibiotics can reduce postoperative
endophthalmitis, but the difference was not statistically
signicant (P 0.2). These prophylaxis roots were associated with a 40% to 50% reduced odds of endophthalmitis
compared with no prophylaxis. It should be recognized that
our study was retrospective and observational, and therefore, we could not change the antibiotic types or dosage.
There is no consensus in the literature for the effect of
prophylactic antibiotics to prevent endophthalmitis. Shortterm pretreatment of topical antibiotics reduced the
conjunctival microbial burden in several reports.34e37
However, another study38 reported that using
postoperative antibiotic adds no benet for reducing the
rate of endophthalmitis after intracameral usage of
cefuroxime. Intracameral cefuroxime has been reported to
be 3 times more effective for endophthalmitis prophylaxis
than subconjunctival cefuroxime.24 However, we believe
that a prospective clinical trial is required to evaluate
completely the effectiveness of different kinds and routes
of prophylactic antibiotics on cases of postsurgical
Older age was a risk factor for endophthalmitis in this
study, which is consistent with previous reports.10,14,39,40
Two possible causes would explain this nding. First,
with aging, a cataract hardens and zonules weaken, so the
operation will be more prone to complication, and
endophthalmitis is more prevalent in complicated cataract
surgery. Second, more bacteria are present in the conjunctiva of older patients compared with that of younger
Isolating the organism is the mainstay of the antibacterial
therapy of endophthalmitis. Only 41 of 112 vitreous culture
results were positive. Previous studies reported grampositive bacteria as the most common isolated bacteria.43
In this study, coagulase-negative Staphylococcus was the
most prevalent isolated bacteria, which is consistent with
previous reports.43

This study also demonstrated a higher rate of endophthalmitis in the left eye. It may be the result of the incision
site being placed in the left eye by a right-handed surgeon:
the main incision is near the upper lid margin, but in the
right eye, the stab incision is near upper lid and the main
incision is in the palpebral ssure. Considering lid margin
ora as the main cause of endophthalmitis, it may justify the
difference of the infection rate between the 2 eyes.
Previous studies3,44,45 reported that longer surgical
experience and a higher annual volume of surgery decreased
the risk of postoperative endophthalmitis, but they did not
involve surgeons still in training. We found a higher rate of
endophthalmitis patients treated by residents, but the difference was not signicant. This is comparable with the
previous report by Ravindran et al.46
The effect of intraocular lens materials is controversial.
Baillif et al47 found greater bacterial adherence to
hydrophobic lenses compared with hydrophilic lenses. In
our study, the endophthalmitis rate was higher in the
hydrophilic group (0.026% vs. 0.018%), but the difference
was not signicant (P 0.08).
In this report, the incidence of endophthalmitis among
patients who underwent phacoemulsication was only
0.021%. This is comparable with reported rates after
phacoemulsication from the United States and other
countries.1,9,10,48 The endophthalmitis rate was signicantly
higher in patients who underwent extracapsular cataract
extraction for cataract extraction (0.14%). Norregaard et al49
reported a comparable rate of 0.18% in a study of
extracapsular cataract surgery performed in Denmark.
Because phacoemulsication is the preferred cataract
surgery technique in Farabi Eye Hospital, extracapsular
cataract surgery is performed primarily either in mature
cataracts or in cases with higher rates of complications
(e.g., zonulysis), or secondarily in cases of failed
phacoemulsication. So the higher rate of endophthalmitis
associated with the extracapsular technique may be the
result of different patient specications and not of a higher
risk associated with the technique.
In conclusion, older age, intraoperative vitreous communication, systemic diseases such as diabetic mellitus, and rural
residence are associated with a higher risk of postoperative
endophthalmitis. Whereas antibiotic prophylaxis overall showed
a 40% to 50% reduction in risk, intracameral cefuroxime was
100% effective in preventing endophthalmitis in this series.

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Footnotes and Financial Disclosures

Originally received: March 20, 2015.
Final revision: August 13, 2015.
Accepted: August 15, 2015.
Available online: ---.

Author Contributions:

Manuscript no. 2015-467.

Department of Ophthalmology, Ophthalmology Research Center, Farabi

Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran.

Department of Ophthalmology, Farabi Eye Hospital, Tehran University of

Medical Sciences, Tehran, Iran.
Presented at: American Society of Cataract and Refractive Surgery Annual
Meeting, April 2015, San Diego, California.
Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials
discussed in this article.
No funding was received.

Conception and design: Jabbarvand, Hashemian, Khodaparast, Tabatabaei

Analysis and interpretation: Jabbarvand, Hashemian, Khodaparast, Tabatabaei, Jouhari, Rezaei
Data collection: Hashemian, Khodaparast, Rezaei, Jouhari
Obtained funding: Jabbarvand
Overall responsibility: Hashemian
Abbreviations and Acronyms:
ECCE extracapsular cataract extraction; ESCRS European Society of
Cataract & Refractive Surgeons; IOL intraocular lens.
Hesam Hashemian, MD, Farabi Eye Hospital, Qazvin Square, Tehran, Iran.