We are happy to respond to Dr Lauschke and Associates regarding our publication. At our hospital, an infection control committee identifies patients with postoperative infections and investigates medical records and operating room details to protect patients and to prevent epidemics. Nearly all of our patients are followed up after surgery at our facilities. Therefore, we stated in the Methods: “Using the constraints of postoperative endophthalmitis occurring within 6 weeks of the surgical procedure, it is unlikely that this study missed patients who developed endophthalmitis and moved or sought care by another institution.” The next sentence in our article recognizes the potential shortcomings of this statement: “However, if such an instance did occur, the rates reported herein would be underreported.”
Our study reported all patients who underwent surgery at Bascom Palmer Eye Institute, including surgery by faculty, fellows, and residents. Of 56 672 intraocular surgeries performed during the most recent 8-year period, 14 eyes were diagnosed with endophthalmitis (0.025%). Our cataract surgery-related rate was low, 8 (0.03%) of 28 568 surgeries. In comparison, our rate of endophthalmitis was remarkably high in other categories, including a rate of 0.11% after penetrating keratoplasty (3 of 2788 surgeries).
In many institutions, there has been a trend toward clear corneal cataract surgery since the mid 1990s. With this trend, concern has arisen about an increased risk of postoperative endophthalmitis. Typically at our institution, corneal wounds are assessed at the completion of surgery, and if a suture is needed to close the wound adequately, an appropriate suture is placed. We have no systematic way of determining how many corneal wounds were sutured.
The optimal perioperative antibiotic regimen is unknown, and physicians at our institution have the flexibility to use or not to use antibiotics. The correspondents stated: “It is salutary that although BPEI has the lowest purported world incidence of endophthalmitis, intracameral antibiosis was not used in any of their patients.” This statement misquotes the published report. The correspondents are directed to the Discussion in our article: “Antibiotics were used in the irrigation fluid (gentamicin) during cataract surgery by only 1 surgeon over the course of the study.” Indeed, 1 patient in whom postoperative endophthalmitis developed was treated with irrigation fluid containing antibiotics during surgery, as stated in the Results: “1 was given gentamicin (8 μg/mL) in the irrigation fluid during cataract surgery.” The most thorough data available are from a multicenter European trial in which the rate of endophthalmitis decreased from 2.96 to 0.62 per 1000 cases with the addition of intracameral cefuroxime. Despite this, most cataract surgeries are performed without intracameral antibiotics. At our hospital, the use of topical povidone–iodine before intraocular surgery is part of a formal protocol and is perhaps more important.
In the United States, the vast majority of intraocular surgeries and postoperative complications such as endophthalmitis are managed on an outpatient basis. The use of hospital admission statistics would not be of value in our health care system for identifying additional cases. The same retrospective methodology was used to identify all clinically diagnosed and treated patients with nosocomial endophthalmitis at our university teaching hospital. The frequency of postoperative endophthalmitis in our study is low and has not increased over the last 25 years.