Title: Reply : Reducing the risk of endophthalmitis after cataract surgery
Abstract: Our finding that subconjunctival antibiotics reduced the risk for postoperative endophthalmitis by half is consistent with the finding in other studies,1–4 including the pooled results from 2 randomized controlled trials conducted in the 1960s.5 Unlike in the United States, in other countries the use of prophylactic subconjunctival antibiotics is more widespread.1 We previously found that 44% of Australian and New Zealand ophthalmologists routinely used perioperative subconjunctival antibiotics.1 Respondents to our survey1 who routinely used subconjunctival antibiotics had half the self-reported incidence of postoperative endophthalmitis than nonusers—a result remarkably similar to our case-control study. A recent study from the United Kingdom found no change in the incidence of postoperative endophthalmitis.6 This was similar to our previous population-based study of endophthalmitis after cataract surgery in Western Australia over 2 decades.7–10 These results contrast with the apparent increasing rate in the U.S.11 Given that subconjunctival antibiotics are now less commonly used in the U.S. than in Australia and the United Kingdom, the changing pattern of prophylaxis rather than wound location (as others have suggested) may account for the U.S.'s increasing endophthalmitis rate.1 This may also be a side-effect of using topical anesthesia for cataract surgery.1,12 The large randomized trial from the European Society of Cataract & Refractive Surgeons13 provides the best available evidence to support chemoprophylaxis using intracameral cefuroxime. However, this found no benefit using topical levofloxacin. Given the cost and size of any randomized controlled trial to investigate the type and route of administering an agent to prevent endophthalmitis, it is unlikely there will be a trial to investigate the use of subconjunctival antibiotics. To best prevent endophthalmitis after cataract surgery, ophthalmologists should use conjunctival antiseptic preparation preoperatively and administer intracameral antibiotics at the end of surgery. For those concerned about intracameral antibiotic use, we believe that subconjunctival antibiotics are also a suitable chemoprophylaxis option.14