Combined Cataract Surgery Ups Postop Endophthalmitis Risk

Veronica Hackethal, MD

July 05, 2018

Patients who undergo combined cataract surgery, or removal of cataracts combined with treatment of other eye disorders during the same procedure, have higher incidence of acute postoperative endophthalmitis (acute POE) compared with those who have cataract surgery alone, results of a French nationwide database show.

Acute POE, a relatively rare complication of ocular surgery, refers to infection and inflammation of the anterior and posterior segments of the eye. Acute POE can cause vision loss in severe cases. 

The study, published online June 20 in the British Journal of Ophthalmology, also suggests that the incidence of acute POE after combined surgery may depend on the type of procedure performed, with higher rates linked to vitreoretinal procedures.

"[U]sing big data, we were able to identify combined cataract surgery as a risk factor for acute POE when compared with phacoemulsification as a stand-alone procedure.

This only applied to vitreoretinal surgeries combined with phacoemulsification. These new findings should be taken into consideration to provide fair information to patients," write Catherine Creuzot-Garcher, MD, PhD, from the Centre des Sciences du Goût et de l'Alimentation and Université Bourgogne Franche-Comté, Dijon, France, and colleagues.

About 20% of patients with cataracts also have glaucoma. One advantage of combined surgery is that it avoids a second hospitalization for later surgery among patients with concomitant glaucoma or other eye conditions. Yet despite recent technical advances, concerns remain about the safety and effectiveness of combined surgeries.

To gain a more complete picture of the risk for acute POE with combined cataract surgery, researchers analyzed billing codes from a national database covering 1546 public and private hospitals in France. The analysis included 6,260,477 eyes that underwent standalone phacoemulsification cataract surgery and 115,468 eyes that underwent phacoemulsification combined with corneal, glaucoma, or vitreoretinal surgery between 2005 and 2014. Researchers evaluated the rate of acute POE occurring within 6 weeks of these procedures. 

The rate of combined cataract surgeries increased by 57.2% from 2005 to 2014. Rates of standalone phacoemulsification increased by about the same percentage (52.7%).  

The overall rate of acute POE was 0.102% in eyes that underwent cataract surgery alone or and 0.149% in those that underwent combined surgery.

During the study, the incidence of acute POE after phacoemulsification alone declined significantly, dropping from 0.144% in 2005 to 0.050% in 2014 (P < .0001). In contrast, the incidence of acute POE after combined surgery showed a nonsignificant trend toward a decline, going from 0.128% in 2005 to 0.118% in 2014 (P = .92).

Combined surgery as a whole carried a 38% higher risk for acute POE than standalone surgery (incidence rate ratio [IRR], 1.38; 95% confidence interval [CI], 1.11 - 1.70; P = .0054). Results were similar after adjustment for type of surgery (adjusted IRR, 1.27; 95% CI, 1.01 - 1.60; P = .042).

However, glaucoma surgeries, alone or combined, had a lower risk for acute POE than phacoemulsification alone (IRR, 0.63; 95% CI, 0.47 - 0.85; P < .001). By contrast, the POE risk was 78% higher with vitreoretinal procedures (IRR, 1.78; 95% CI, 1.58 - 2.01; P < .001), regardless of whether they were combined with cataract surgery.

Women had a 30% lower risk for acute POE than men (adjusted IRR, 0.70; 95% CI, 0.65 - 0.75; P < .001).

The authors mentioned several potential limitations, including inherent drawbacks of administrative database studies. Results may not generalize to other countries with different practices for preventing postoperative eye infections. Also, eyes that underwent combined procedures may have had more severe disease, which could have biased results.

One or more authors reports personal fees, nonfinancial support, and/or grants from one or more of the following: Bayer, Novartis, Alcon, Horus, Thea, Allergan, Alimera, Bayer, Novartis, Roche, Zeiss, Bausch + Lomb, and Horus.

Br J Ophthalmol. 2018;0:1-5. Abstract

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