Endophthalmitis following cataract surgery: The sucking corneal wound

Abstract

We were quite surprised, and also concerned, to note that a patient given the proposed Northern European panacea for prevention of endophthalmitis following cataract surgery 1 (that is, intracameral cefuroxime) developed bilateral postoperative endophthalmitis. 2 This occurred 4 days after bilateral cataract surgery performed at the same sitting.A recent editorial 3 stated that the major risk factors for the development of postoperative endophthalmitis included corneal incisions, age (especially older than 80 years), and loss of posterior capsule integrity, which would allow direct access of bacteria into the vitreous. Further, it was recognized that there are essentially 2 opportunities for bacteria to enter the eye during cataract surgery: at the time of surgery and in the early postoperative period before epithelialization of an unsutured wound. This leads to the notion that sutured corneal incisions may reduce the risk for developing endophthalmitis in the postoperative period.In a laboratory model using India ink, Taban et al. 4 demonstrated that aqueous aspirates from 3 eyes with sutureless clear corneal incisions had increased spectrophotometric readings (P!.01). This was in contrast to the readings from aspirates in eyes with sutured corneal incisions, which showed no increase in absorbance level from baseline. This demonstrates that ingress of India ink occurs through sutureless clear corneal incisions, representing the potential passage of microorganisms into the eye.In sutureless cataract surgery, wound sealing is generally achieved by stromal hydration at the completion of the case. However, some evidence suggests that the wound is compromised when closure is not reinforced with suturing. Vasavada et al. 5 demonstrated in routine cataract surgery that wounds sealed by stromal hydration allowed ingress of trypan blue into the anterior chamber. Notably, trypan blue was detected in the anterior chamber within 2 minutes of stromal hydration. A recent study by Praveen et al. 6 confirmed this finding in 3 phacoemulsification techniques; the ingress was worst with bimanual phacoemulsification. Herretes et al. 7 reported ingress of blood-tinged fluid into the anterior chamber after the incisions were sealed by stromal hydration. These results have led to the conclusion that clear corneal incisions may not always be self-sealing.

Fibres found in the eye during and after phacoemulsification cataract surgery

“…The most serious postoperative wound complications relate principally to endophthalmitis. 13 Even for the most capable cataract surgeon, the largest bacteria will always be smaller than the smallest incision. 13 Thus, definitively suturing the corneal wound should further diminish the opportunity for a fibre to enter the eye postoperatively.…”

“…13 Even for the most capable cataract surgeon, the largest bacteria will always be smaller than the smallest incision. 13 Thus, definitively suturing the corneal wound should further diminish the opportunity for a fibre to enter the eye postoperatively. Table 1 The mechanisms proposed for introduction of fibres into the anterior chamber during phacoemulsification surgery…”

“…Endophthalmitis was excluded. 13 There were two subcohorts, namely, those with retained intraocular fibres and those without. These were compared for their CDVA, their incidence of postoperative CMO, and for endophthalmitis.…”

“…Definitive corneal wound suturing is likely to prevent fibres being implanted postoperatively. 13 Indeed, in the practice of the authors, a number of these measures have been implemented. It is likely that the fibres demonstrated in this study were representative of the various textiles that enter the operating theatre in the form of scrubs, sterile operating gowns, draping materials, and sponges.…”

Technique to exclude temporal lash incursion in phacoemulsification surgery

“…1 Although we recognise that wound suturing is one of the most important factors in preventing acute postoperative bacterial endophthalmitis, 1-5 we believe lash exclusion must also be considered.…”