Author: Marko Popovic (Canada)
Co-authors: Jeff Park, Michael Balas, Sherif El-Defrawy, Ravin Alaei, Peter Kertes
Purpose
Intraocular transmission of exogenous pathogens in cataract surgery can lead to devastating consequences like endophthalmitis. The aim of this study is to systematically evaluate the features of published clusters of infectious endophthalmitis secondary to pathogen transmission in cataract surgery.
Setting/Venue
Systematic review.
Methods
A search strategy was employed using Ovid MEDLINE, EMBASE, and Cochrane CENTRAL (January 1990 to August 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, sample and source microbiology, the plausible route of transmission and recommendations for prevention of pathogen transmission were recorded. Risk of bias assessment was performed using a modified observational study risk of bias tool.
Results
From 4735 identified articles, a total of 268 eyes from 24 studies across 15 countries were included. A contaminated intraocular solution (i.e. irrigation solution, viscoelastic, or diluted antibiotic) was the most commonly involved source of transmission identified in ten studies, followed by a contaminated phacoemulsification machine identified in five studies. The mean time to presentation with infectious features was 13.4 days (range: 1.3-46.3) with a baseline logMAR visual acuity (VA) of 1.89 (range: 1.35-2.58; VA: ~counting fingers]. Visual acuity at last follow-up for the entire cohort was 1.39 (range: 0.04-3.00; Snellen: ~20/490). Diabetic patients had worse outcomes [logMAR 1.86 (range: 0.18-3.00; VA: ~counting fingers)] at final follow-up when compared to non-diabetics [logMAR 0.98 (range: 0.00-2.75; Snellen: ~20/190)]. The most frequently isolated pathogen responsible for post-cataract endophthalmitis clusters was Pseudomonas sp. Practical strategies to minimize risk of transmission and optimize pathogen detection included improving the cleaning protocol, refraining from reusing surgical instruments, practicing caution against possible breach of presterilized products, implementing control measures to scrutinize disinfection practices, using molecular biology techniques for accurate detection of causative pathogens, and obtaining statistical data on hospital infections to inform future preventative strategies. All included studies were assessed to have a low risk of bias.
Conlusions
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.
Financial Disclosure
MMP: Financial support (to institution) - PSI Foundation. PJK: Advisory board – Novartis, Alcon, Bayer, Allergan; Financial support (to institution) – Allergan, Bayer, Roche, Novartis; Financial support – Novartis, Bayer, Zeiss; Scientific Advisory Board – Novelty Nobility; Equity owner – ArcticDx. RHM: Advisory board- Bayer, Novartis, Allergan, Roche; Financial Support (to institution)- Bayer, Novartis.
Comments
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