Shaleen Belani, MD,
Samuel Masket, MD
Contents
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Introduction |
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Preoperative Measures to Reduce Infection |
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Operative Measures to Reduce Infection |
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Inflammation |
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Operative Measures for Control of Intraocular Pressure |
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Conclusion |
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CHAPTER HIGHLIGHTS |
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Introduction
Clear corneal cataract surgery has been implicated as a causative factor in the rising rates of bacterial endophthalmitis. The accuracy of this implication regarding cause vs correlationas well as the mechanism of causation are not clear. The literature suggests that bacterial endopthalmitis following cataract surgery is more common with clear corneal incisions than with scleral tunnel incisions[1,][2,][3] and that this incidence is on the rise.[4,][5] Regardless of mechanism, however, it is clear that measures to reduce infection rates are crucial to successful surgery. These measures include preoperative evaluation and treatment, operative measures to ensure sterility and close monitoring of the patient throughout the postoperative period.
If bacterial endophthalmitis is, indeed, on the rise, the main factor that is contributing to this is wound construction. Unstable wounds allow for bacterial contaminants from the tear film and ocular adnexa to enter into the anterior chamber.[6] Careful attention to wound construction is, therefore, imperative for clear corneal cataract surgery. It is important to be aware of other risk factors as well. For example, it is well known that diabetics have a higher incidence of endophthalmitis[7] and surgical complications, such as posterior capsule rupture, can at least quadruple that risk.[8]
However, as the incidence of infection is relatively low (currently 1 in 1000 in the United States) and there are a large number of variables in routine cataract surgery that might be implicated, it is unlikely that a large, multicentered, randomized controlled study could be completed to study all of the factors that are potentially related to the development of infection.[9] Therefore, measures to reduce infection, from the preoperative stage through the postoperative period, must be implemented routinely.
Postoperative inflammation is common after routine intraocular surgery and while it is usually self-limited, in rare cases it can result in permanent visual loss. An attempt should be made to minimize postoperative inflammation after routine cataract surgery. An increasingly reported problem in the past few years is an entity now well-described and known as toxic anterior segment syndrome (TASS). Believed to be caused by several factors including improper sterilization of instruments, ophthalmic ointments entering the eye, preservative-containing solution, and denatured viscoelastic agents, TASS must be recognized early and treated with high-dose topical steroids for the best prognosis.
Intraocular pressure (IOP) after cataract surgery and IOL implantation is readily controlled by the surgeon at the conclusion of the procedure in the presence of a well-constructed, hermetically sealed wound. Thorough removal of viscoelastic agents at the conclusion of the procedure is essential. However, in patients with pre-existing glaucoma, pharmacologic agents may be beneficial in providing additional IOP reduction.
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Preoperative measures to reduce infection
As bacterial flora implicated in bacterial endophthalmitis originate from fluid contaminated by the tear film, conjunctiva, lids and lashes, it is important to carefully examine these structures at the preoperative visit. One of the proposed mechanisms for infection is the ingress of fluid into the anterior chamber secondary to hypotony in the immediate postoperative period from physically unstable, potentially leaking wounds. This negative pressure gradient then allows periocular fluid with bacterial flora to enter into the anterior chamber.[10] Patients with blepharitis should be placed on a regimen to control their disease, including lid scrubs, warm compresses, antibiotics ointments or oral doxycycline in advanced or refractory cases. It may even be prudent to re-examine these patients once again before proceeding with surgery in order to ensure that the lashes are free of material that may be a source of contamination.
Although there is no good evidence to support a reduced risk of infection, preoperative antibiotic drops started 2–4 days prior to surgery have become common practice. This is based on studies which have shown a decrease in microbial flora in the tear film after a short course of antibiotics given topically.[10] To be effective in preventing endophthalmitis, a topical antibiotic must penetrate the eye with a significant concentration that well exceeds the MIC of the bacterial pathogens of concern, without causing significant toxicity to ocular structures. Studies involving fourth-generation fluoroquinolones have shown that they have good absorption into the aqueous humor[11] when applied topically, without causing toxicity to ocular structures. Moxifloxacin 0.5% may have better penetration compared to gatifloxacin 0.3% and the second-generation ciprofloxacin 0.3% when applied to the surface of the eye.[12,][13] Although preoperative topical antibiotics are becoming the “standard of care,” the downsides must be considered since these medications are expensive, can induce allergic reactions and widespread use may lead to bacterial resistance in the future. In addition, further studies are warranted to prove the efficacy of preoperative topical antibiotics with respect to infection prevention.
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Operative measures to reduce infection
The only proven method of prophylaxis against postoperative endophthalmitis is sterile ophthalmic preparation using povidone iodine solution on the skin (5–10%) and in the conjunctival sac (5%).[9,][14,][15] Povidone iodine is effective against a wide variety of pathogens including bacteria, fungi, spores, viruses and protozoa.[16] After the skin and ocular preparation with povidone iodine is completed, it is important to drape the patient so that the lashes and lid margin are isolated from the surgical field. After the drape is cut and lid speculum placed, it is helpful to push back or snip stray lashes before the procedure is begun. However, routine lash trimming prior to surgery has not been shown to be effective in reducing periocular bacterial flora and is not recommended.[17]
A 2005 survey of 800 ophthalmologists in UK teaching hospitals revealed that 99% of those surveyed used povidone iodine for skin preparation and 70% used povidone iodine 5% or 10% in the conjunctival sac. A large portion of surgeons surveyed also routinely use subconjunctival cefuroxime (66.4%) intraoperatively[18] and 18% of surgeons used intracameral antibiotics either directly into the eye or as part of the irrigation fluid. There is no definitive evidence to support the use of subconjunctival antibiotics at the conclusion of surgery or supplementation of the irrigating fluid with antibiotics. While studies involving antibiotic supplementation to the irrigation fluid have not yielded any conclusive benefit, recent studies involving intracameral antibiotics have shown promise. A large, multinational study conducted by the ESCRS Study group showed a significant benefit of intracameral cefuroxime in reducing rates of bacterial endophthalmitis following routine cataract surgery. In this randomized controlled study, patients were given either intracameral cefuroxime or perioperative topical levofloxacin and a significantly reduced rate of endophthalmitis was reported in the cefuroxime group.[19] This result prompted the study to be halted early. However, while a fivefold reduction in infection was noted in the treatment group, the infection rate in the control group was higher than shown in other published data on post-cataract endophthalmitis and warrants further investigation. Regardless, the benefit of intracameral cefuroxime in reducing infection is apparent from this study. A recently published safety study of intracameral moxifloxacin 0.5%, instilled into the anterior chamber (0.1mL) of 65 patients at the conclusion of surgery, demonstrated a lack of toxicity to ocular structures. Measures used to evaluate toxicity included endothelial cell counts, corneal pachymetry, anterior chamber reaction and visual recovery after phacoemulsification. While it appears to be safe for intraocular use, further studies are warranted to demonstrate the efficacy of intracameral moxifloxacin 0.5% for the prevention of infectious endophthalmitis.
The routine use of preoperative and/or operative antibiotics for infection prophylaxis must be carefully weighed against its risks, as bacterial resistance has become an increasing problem. Particularly, resistance to vancomycin has become a concern of the Centers for Disease Control who specifically recommend against the routine use of vancomycin for perioperative antibiotic prophylaxis.[20]
The most important step that the surgeon can make in controlling infection is to construct a wound with the proper surface architecture to allow for a hermetic seal and optimal stability. Several characteristics of wound construction are important, the most important being wound architecture. Ex vivo studies in cadaver eyes[21] have shown that square incisions are more stable than rectangular ones. The stability of square and nearly square clear corneal incisions has been confirmed by studies in human eyes.[22] There are several blades currently in use to create clear corneal wounds, many of which achieve similar results. More important than blade selection, however, is aiming for a square or nearly square incision to increase the probability of a stable, hermetically sealed wound. Other factors play a role such as size of incision, angle of insertion and shelving. Future standards for wound architecture and construction are warranted in order to determine the optimal surface architecture for wound stability with regards to reduced infection rates. (See Video 1 – Masket 2min.)
Perhaps equally as important as wound construction is wound sealing, and confirmation of incisional sealing at the conclusion of surgery is mandatory. Manipulation of the clear corneal wound by surgical instrumentation can lead to wound stretch and threaten the stability of the wound.[23] It has been suggested that the use of unsleeved, rigid, round tubes, as in bimanual phacoemulsification, may compromise wound integrity.[24] If there is a suspicion of the potential for wound stretch because of surgical instrumentation during phacoemulsification or IOL placement, the Steinert-Deacon gauge can be used to confirm wound size (Figure 12-1). We recommend the use of intraoperative Seidel testing to demonstrate incisional sealing, however, other methods can be utilized as long as a hermetic seal is confirmed at the conclusion of the procedure. A fluorescein strip is applied to the wound after the wound has been hydrated and the wound is observed for leakage. If leakage is found, the wound is re-hydrated and/or a corneal suture is placed. In our view, hydration of the wound allows for apposition of the internal wound lips, thus facilitating wound seal. Although the efficacy of this technique has not been proven, it has become common practice. Attention should be given to hydration of the roof of the incision, as well as the sides, if stromal hydration is performed. There should be no hesitation in using a 10-0 suture to close the clear corneal incision in the presence of vitreous loss, iris prolapse, thermal burns or an unstable wound. Finally, a recheck of the intraocular pressure should be done, either with the use of a tonometer (Figure 12.2) or by digital palpation as hypotonous IOPs lead to unstable wounds.[25] It has been demonstrated that in the presence of a well-constructed, well-sealed wound, postoperative hypotony can be avoided.[22] (See Video 2 – Wound end.)
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Figure 12-1 Steinert Deacon Gauge. |
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Figure 12-2 Barraquer Tonometer. |
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Inflammation
Postoperative inflammation following cataract surgery is largely mediated by the arachidonic acid cascade (Figure 12.3). This results in the production of prostaglandins, which can ultimately lead to a breakdown of the blood–aqueous barrier. This inflammation results from surgical trauma and contributes to common postoperative complications including corneal edema, uveitis, and cystoid macular edema. Anti-inflammatory medications, such as corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs), are commonly used to control the inflammatory response and reduce the frequency of the aforementioned complications. Whereas corticosteroids prevent the production of prostalglandins by inhibiting phospholipase A2, NSAIDs inhibit the cyclooxygenase enzyme later in the arachidonic acid cascade.[26]
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Figure 12-3 Arachidonic acid cascade. |
Cystoid macular edema (CME) after cataract surgery was first described by Irvine in 1953 and results from the leakage of fluid from the perifoveal capillaries. CME can be categorized as either acute (less than 4 months after surgery) or chronic (persistence for more than 4 months after surgery). Several studies have examined the use of NSAIDs in the treatment of acute CME.[27,][28] Although small, some of these studies have suggested that topical NSAIDs may have a therapeutic benefit in acute CME. In chronic CME, topical NSAIDs do appear to have a statistically significant benefit.[29] Newer NSAIDs, such as nepafenac, may prove to be more effective in controlling posterior segment inflammation because of their superior corneal penetration and bioactivation at target tissues.[30]
Because corticosteroids interfere with the arachidonic acid cycle at an earlier step, there is a higher incidence of adverse effects compared to that of NSAIDs. For example, in addition to their known anti-inflammatory properties, corticosteroids can be associated with elevations in intraocular pressure and impaired wound healing.[26] However, newer topical corticosteroids, such as loteprednol and rimexolone, have a lower risk of intraocular pressure changes.
Preoperative measure to reduce inflammation
NSAIDs
Since NSAIDs inhibit the production of prostaglandins, it is logical that they would be beneficial in preventing the inflammatory cascade before it begins. The use of preoperative NSAIDs has been shown to reduce postoperative inflammation, the incidence of cystoid macular edema, and patient discomfort.[31,][32] It has become commonplace to use NSAIDs preoperatively and continue them postoperatively with topical steroids to reduce these complications.[33] The NSAID is started between 3 days and 1 h prior to surgery. Patients with diabetes mellitus are at increased risk of developing retinal edema, including CME, which has been confirmed by OCT.[34] While it has not been definitively shown that treating diabetics with topical NSAIDs preoperatively leads to reduced rates of postoperative CME, this should be considered in the preoperative evaluation, especially in patients with evidence of active retinopathy.
Patients with pre-existing inflammation prior to cataract extraction, such as those with chronic uveitis will likely require topical corticosteroids preoperatively and in some cases may also benefit from oral steroids in the immediate preoperative period. Active intraocular inflammation should be eliminated prior to scheduling surgery.
Prostaglandin analogs
Prostaglandin analogues may also lead to intraocular inflammation after routine cataract surgery and increase the chance of CME by disrupting the blood–aqueous barrier.[35]Hypotensive lipids such as latanoprost, travoprost, and bimatoprost, have been implicated in causing pseudophakic cystoid macular edema.[35–38] Is has been shown, however, that it is the preservative, benzalkonium chloride (BAK) in these medications that is responsible for inciting the inflammatory cascade; this is now termed pseudophakic preservative maculopathy.[39] A survey of UK ophthalmologists in 2003 revealed that 40.3% of ophthalmologists stopped prostaglandin analogs less than 1 week prior to surgery and resumed the medication 1–2 months after surgery.[40] Fortunately, in most instances, the induced CME is reversible upon discontinuation of the medication and administration of topical NSAIDs. A study to demonstrate a clear benefit to discontinuing the medication does not exist and most patients will probably not have a problem in uncomplicated surgery; however, consideration should be given to discontinuing the medication in selected patients who are at high risk of developing postoperative CME.
Operative measures to reduce inflammation
Factors which contribute to increased postoperative inflammation include prolonged surgery time, iris trauma, malpositioned IOLs, retained lens material and surgical complications including vitreous loss. Anterior chamber IOLs may be associated with postoperative inflammation if they are too large, too small, or positioned incorrectly. The introduction of immunogenic foreign material into the eye can incite a severe postoperative inflammatory reaction; this has been reported with increasing frequency in the past few years.
TASS is characterized by postoperative inflammation that usually begins in the first 24 h after cataract surgery and is believed to be due to toxic substances that enter the eye during surgery.[41] It was first described in 1992 by Monson et al. and is an inflammatory reaction, not an infectious process, that is limited to the anterior segment structures. Symptoms of TASS are similar to those of infectious endophthalmitis, which makes the diagnosis difficult to distinguish at times. However, the onset of TASS is often sooner than the typical 2–5 day onset of postoperative endophthalmitis. Clinical signs are also similar to patients with endophthalmitis with decreased vision, hypopyon formation and severe anterior segment inflammation. Mamalis et al.[41] describe other typical findings in TASS which include limbus-to-limbus corneal edema due to endothelial cell damage and pupillary abnormalities including a dilated, poorly reactive pupil. Severe intraocular inflammation in TASS can also lead to secondary glaucoma.
Implicated as causes for TASS are a wide variety of substances that are toxic to the eye including: intraocular anesthetics, detergents used to clean instruments, denatured viscoelastic agents, antibiotics, preservatives, ophthalmic ointments, and other contaminants that enter the eye during surgery. An increase in the number of TASS cases was noted in the early part of 2006 by the TASS Task Force, established by the ASCRS. In their published report,[42] a specific etiology responsible for this increase in cases was not identified; however, improper cleaning and sterilization of ophthalmic surgical instruments was believed to be a major factor contributing to the reported TASS cases. In this report, it was emphasized that any reused cannulated instruments, including phacoemulsification and I/A handpieces, be flushed thoroughly at the conclusion of surgery, and that single-use devices be discarded. These instruments may harbor residues of viscoelastic agents or lens material which may incite TASS. In addition, reused instruments that are cleaned with detergents or enzymes must be rinsed thoroughly with sterile, deionized/distilled water before use. They identified a potential contaminant in ultrasound water baths, as well as other water sources, which can harbor bacteria capable of producing heat-stable, unautoclavable endotoxins that can incite TASS. Preservative-containing medications or solutions containing sulfites or other toxic minerals should not be administered directly into the eye. This includes intracameral antibiotics/anesthetics or additives to irrigation solutions. In this report, no particular IOL was found to be more likely to contribute to TASS.
The initial approach to a patient suspected as having TASS is to rule out infection. Whereas infectious endophthalmitis involves the vitreous cavity, TASS related inflammation is typically confined to the anterior segment. However, in many cases, distinguishing the two conditions may be difficult and an aqueous tap may be required. Once the diagnosis of TASS is made, topical steroid should be administered with frequent dosing. The recommendation is to use prednisolone acetate 1% drops every 1–2 h. Intraocular pressure, which may be low initially due to ciliary body shutdown, may rise secondarily from damage to the trabecular meshwork. Gonioscopy as well as specular microscopy should be performed as soon as the cornea clears.
Prevention is the key to reducing the incidence of TASS. Particular attention should be placed on proper sterilization and cleaning of surgical instruments, and careful monitoring of allmedications and solutions that enter the eye. When a new case of TASS is confirmed, a careful review of the operating room procedures and medications administered to the patient should be performed in order to promptly identify causative factors and modify them.
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Operative measures for control of intraocular pressure
Wound construction
Previous work by Shingleton et al. has shown that postoperative hypotony may occur in as many as 20% of patients after clear corneal cataract extraction.[43] While hypotony is certainly a complication of any intraocular procedure, this risk can be reduced in the presence of a square or nearly square incision with meticulous control of incisional sealing. Postoperative IOP is, in fact, relatively stable compared to that set at the immediate conclusion of the procedure in the presence of a sealed wound.[22]
To allow for internal wound lip apposition, it is important that the IOP initially be set to a level higher than physiologic. However, it is not necessary to keep the pressure at this level at the conclusion of the procedure. The use of a Barraquer or Shiotz tonometer (see Figure 12-2) is useful in measuring intraoperative IOP. In our experience,[22] we use one of these devices to measure IOP after incisional sealing has been confirmed. The IOP can then be titrated to the desired level by removing small aliquots of fluid from the anterior chamber and, finally, rechecked using the tonometer.
Use of intracameral miotics
The use of intracameral miotics has been studied to lower early postoperative IOP and may be useful when strict control of postoperative IOP is particularly important. The use of intracameral carbachol 0.01% (Miostat, Alcon) has been shown to result in lower IOPs in the first 24 h after clear corneal phacoemulsification with statistical significance.[44–48]However, the use of intracameral carbachol has also been demonstrated to result in increased postoperative inflammation, believed to be due to delayed restitution of the blood–aqueous barrier. Studies comparing carbachol to acetylcholine chloride (Miochol, Novartis Ophthalmics) have found a greater effectiveness of intracameral carbachol with respect to reduction of IOP after cataract extraction.[49,][50]
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Conclusion
As modern cataract surgery is accomplished with clear, corneal incisions, it is important that these wounds be constructed meticulously and consistently with the proper surface architecture. Creating a tightly sealed incision is perhaps the most important step that the surgeon can take in preventing, or at least reducing, the chances of a devastating infectious complication. Preoperative antibiotics have become routine practice and, in the near future, intracameral antibiotics may become the standard of care. However, it is important to weigh the benefits of antibiotic prophylaxis with the risks of engendering bacterial resistance. With every substance and every instrument that is placed into the eye, care must taken to ensure that it is free of toxic contaminants, as TASS is becoming an increasingly recognized problem. Since prevention is always better than cure, preoperative and operatives measures to reduce infection, inflammation and IOP elevations are essential to optimize outcomes after cataract surgery.
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