Clinical Features of Endophthalmitis Clusters following Cataract Surgery and Practical Recommendations to Mitigate Risk: A Systematic Review
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Author Block: Jeff Park1, Marko M. Popovic2, Ravin Alaei3,
Sherif R. El-Defrawy2, Peter J. Kertes2.
Disclosure Block: J. Park: None. M.M. Popovic: None. R. Alaei: None. S.R. El-Defrawy: None. P.J. Kertes: Membership on advisory boards or speakers’ bureaus; Name of for-profit or not-for-profit organization(s); Novartis, Roche, Bayer. All other investments or relationships that could be seen by a reasonable, well-informed participant as having the potential to influence the content of the educational activity; Name of for-profit or not-for-profit organization(s); Financial support (to institution) - Allergan, Bayer, Roche, Novartis; Financial support - Novartis, Bayer; Equity owner - ArcticDx.
Purpose:
Intraocular transmission of exogenous pathogens in cataract surgery can lead to
devastating consequences such as endophthalmitis. The aim of this study is to
systematically evaluate the clinical features of infections that arise from
pathogen transmission in cataract surgery, specifically with respect to the
reported routes of transmission, etiologies and practical strategies to
mitigate the associated risk.
Study Design: Systematic review.
Methods: A search strategy was employed using Ovid MEDLINE, EMBASE, and
Cochrane CENTRAL (January 1990 to July 2020) to identify all articles reporting
on endophthalmitis clusters following cataract surgery. All original studies
with at least five patients that developed endophthalmitis from pathogen
transmission during cataract surgery were included. The confirmed or suspected
etiology and clinical features of endophthalmitis were recorded and presented.
As well, collected variables included sample microbiology, plausible route of
transmission, pathogen isolated from suspected source and recommendations for
prevention of pathogen transmission. Risk of bias assessment was performed
using a modified observational study risk of bias tool and quality of evidence
was evaluated using the GRADE criteria.
Results: Following this review of 4418 identified articles, ten articles
met the inclusion criteria and were considered for this review. Ninety-six
patients from ten studies across eight countries were included. The
phacoemulsification set (i.e. handpiece, tubing, and cassette) was the most
commonly involved source of transmission identified in five studies, followed
by fluid solutions identified in two studies. Nine studies reported on
microbiological growth from patient ocular specimens, while four of the nine
studies isolated the same pathogen from the suspected source of transmission.
Patients with diabetes demonstrated worse visual outcomes following
endophthalmitis in four of five studies included. Practical strategies to
minimize risk of transmission and optimize pathogen detection included cleaning
hollow instruments immediately after use, using molecular techniques to detect
pathogens, refraining from reusing surgical materials, implementing
environmental control strategies for the operating room, and instituting a
governance strategy to oversee transmission risk. All included studies were
assessed to have low risk of overall bias, but quality assessment revealed that
clinical outcomes were of low to medium quality secondary to significant
inconsistencies across studies.
Conclusions: Pathogen transmission during cataract surgery may occur via
various routes and requires novel strategies for diagnosis, prevention and
management. Recommendations from multiple domains of transmission risk
prevention should inform future guidelines and comprehensive strategies for the
prevention of endophthalmitis secondary to exogenous pathogen transmission.