Co-Author: Dr. Olivia Li
Simultaneous bilateral endophthalmitis (SBE) is rightly a much
feared complication of immediately sequential bilateral cataract surgery (ISBCS),
and is the oft cited reason for reluctance to perform ISBCS. Given the many
benefits of ISBCS to the patient, clinician, and the ever-stretched healthcare
budget world-wide, there is an urgent need to assess this risk. We attempt to
quantify the risk of SBE as well as final bilateral visual loss following
bacterial endophthalmitis to enable both clinicians and patients to make
informed decisions about the risks involved when choosing ISBCS, and to have
realistic expectations of the eventual visual potential.
The role of routine ISBCS divides cataract surgeons worldwide.
Some countries have adopted it as routine whilst others financially penalise
surgeons who perform ISBCS. Much of the literature maligns ISBCS because of the
potential risk of SBE and the devastating outcome of bilateral blindness. In
times when practical and procedural advances are continually being made to
reduce complications from cataract surgery and as the numbers of ISBCS
performed grows, it is important for some estimation of the risk of SBE to be
calculated. In particular, this risk must be relevant to surgeons operating
today, taking the available and accepted measures applicable to all surgeries,
including intracameral antibiotics and full segregation of each procedure.
A literature search was performed through PubMed. Studies
reporting rates of endophthalmitis and visual outcomes following cataract
surgery related endophthalmitis mostly from the past 5 years were reviewed.
Recognising that practices will differ and there will be many limitations, we performed
a meta-analyses to estimate the risk of SBE following ISBCS. We also aim to
quantify the risk of having final vision in both eyes below that of the driving
standard in the United Kingdom SBE.
Fungal endophthalmitis were excluded, but we included cases
where no organisms were identified.
There have only been 4 cases of SBE ever published. All 4 cases
breached the aseptic protocol published by the International Society of
Bilateral Cataract Surgeons (iSBCS) and the Royal College of Ophthalmologists of
the United Kingdom. In 95606 ISBCS cases reported there have been no bilateral
In the most recent large published studies, the rate of
endophthalmitis with the use of prophylactic intracameral cephalosporin is less
than 0.05%, corroborating the findings of the European Society of Cataract and
Refractive Surgeons’ landmark 2006 trial.
Visual outcomes following bacterial endophthalmitis secondary to
phacoemulsification and IOL implantation was analysed. The use of intracameral
antibiotics varied, and the data collected came from multiple centres
world-wide, including Greece, Turkey, the United States, India, Nepal and
China. Of the 189 reported cases analysed with final BCVA published, 34% had
final best corrected visual acuity (BCVA) of 0.3 LogMAR or better, the minimum
level of vision required for driving in the United Kingdom. A further 30% had
vision between 0.3 logMar and 1.0 logMAR. 47% had count fingers, hand motion or
light perception vision. 9% had no perception of light, mostly through
Multiple large studies have shown that an endophthalmitis rate
of less than 0.05% following cataract surgery is achievable. If the iSBCS and
the UK Royal College of Ophthalmologists guidelines were to be followed to
ensure that bilateral surgeries are performed as completely separate
procedures, that is the risk of the two eyes becoming infected would be random
events, then it follows that the risk of SBE would could be roughly estimated
to be 0.05% multiplied by 0.05%, which would be a 0.000025% risk. In other
words, there would be one case of endophthalmitis for every 4 million iSBCS (i.e.
8 million eyes) performed. Moreover, if in a third of endophthalmitis cases we
can expect BCVA to be 0.3logMAR or better, then the chances of having bilateral
vision of worse than the minimum of driving standard vision following ISBCS
would be in the region of 1 in over 9 million.
If the true risk were in the region of those above it would seem
that ophthalmologists have a duty to consider ISBCS when assessing patients
with bilateral cataracts. There are other concerns regarding bilateral surgery
that still needs to be addressed, but it seems unreasonable to continue waving
the shroud of SBE in an attempt to deny patients ISBCS when much evidence so
far point to the contrary.
Therefore we would urge all cataract surgeons to look beyond the
rhetoric and consider the risks and merits of iSBCS. We encourage greater
familiarity with the recommended precautions for safe ISBCS. Finally we ask all
ophthalmologists to continue audit of local endophthalmitis rates and publish
both BCVA before any surgical intervention, and final BCVA. This will enable us
to better counsel patients on the risks and potential outcomes, as well as for
us all to continue to strive for better treatment of endophthalmitis. With the
increasingly widespread use of intracameral antibiotics, infection rates should
continue to fall, making the need to publish data and share practices more