Endophthalmitis: prevention better than cure

According to Zdenek Gregor of Moorfields Eye Hospital, London, UK, prevention of endophthalmitis will always be preferable to a cure. While the use of preoperative povidone iodine has managed to decrease the incidence of the infection, the hope is that per-operative intracameral antibiotics will further fuel a decrease in incidence of this worrying consequence of cataract surgery.

Speaking at the "Endophthalmitis following cataract surgery" symposium, Dr Gregor reminded his audience that the visual prognosis for postoperative endophthalmitis has improved dramatically since the 1960s. At that time, around 75% of cases resulted in a loss of hand motion visual acuity (HM), however, the prospects are now much brighter with vision of 6/12 or more being seen in between 53 to 90% of patients. This improvement came about when it was realised that damage to the posterior segment could be minimised with immediate administration of intravitreal antibiotics, with or without pars plana vitrectomy.

The pivotal Endophthalmitis Vitrectomy Study (EVS) of 1995 confirmed the value of this procedure, finding that the systemic use of the antiobiotics on the day was not useful whereas immediate vitrectomy yielded positive results, but only in those patients with the poorest visual function (<HM).

Dr Gregor then moved on to outline the most recent developments. Vitrectomy techniques have advanced considerably since the EVS report, and are much safer even in the absence of posterior vitreous detachment. Wide-angle viewing has allowed for larger laboratory samples, earlier and more extensive evacuation of causative organisms and toxins, greater access to the aqueous and for better distribution of injected antibiotics. In addition to these technical advancements developments in drug use has also had an impact. Intraocular steroids are gaining credibility as a method of reducing the effects of the inflammatory cytokines on the retina and new systemic antibiotics, such as fourth generation fluoroquinolones, are proving effective against Gram positive and negative organisms.

Dr Gregor's presentation supported the notion that prevention is indeed better than a cure, and with the evolution of a new generation of antibiotics and steroids, such as the per-operative intracameral antibiotics currently being tested in the ESCRS-sponsored study, the future of endophthalmitis treatment is looking promising.

Ophthalmology Times Europe reporting from the XXIV Congress of the ESCRS, London, 9-13 September, 2006.