Watertight wound closure without stromal hydration paramount for reducing endophthalmitis risk

Good surgical technique that includes maintenance of a sterile environment, antisepsis of thelids and ocular surface, thoughtful prophylactic antibiotic use, and most importantly, assurance ofwatertight wound closure without stromal hydration should result in a rare occurrence ofendophthalmitis, said James P. McCulley, MD.

"In the interest of saving a few seconds and a few dollars, cataract surgeons will performstromal hydration and skip suturing the wound," said Dr. McCulley, chairman, Department ofOphthalmology, University of Texas Southwestern Medical Center, Dallas. "However, the effect ofstromal hydration lasts only a few minutes, and so it is critical to make sure that theincision, with or without a suture, is watertight without stromal hydration.

"If we employ all of these factors, we can approach a better and lesser rate of endophthalmitsafter cataract surgery," he said.

As evidence for this premise, Dr. McCulley reported that at his own institution, only a singlecase of endophthalmitis occurred in 11,928 cataract procedures performed through a temporalclear corneal incision. This translates into a rate of 0.08 per 1,000, which is comparable withthe rate associated with intracameral cefuroxime use in the European Society of Cataract andRefractive Surgeons (ESCRS) study of postcataract surgery endophthalmitis prophylaxis and ismuch lower than the rate of 38 per 1,000 cases reported in the control group of thatprospective, randomized trial where no intracameral cefuroxime or preoperative levofloxacin wasused.

"The ESCRS study also found an increased risk of endophthalmitis associated with use of a clearcorneal incision," Dr. McCulley said. "My best guess is that not having a watertight woundclosure at the end of surgery was a major factor for that and the high rate of endophthalmitisin the ESCRS control group."