Postoperative Endophthalmitis Rates Notably Declined Over 20 Years

Postoperative endophthalmitis rates have notably decreased in the past two decades in the US, with similar declines in vitrectomy as a first-line treatment for the complication, according to a new cohort study in JAMA Ophthalmology.¹

Between 2000 and 2022, endophthalmitis rates decreased by 75%, with an adjusted average decrease of 2.7% per year, even after accounting for procedures that typically exhibit low complication rates. In the same period, the rate of vitrectomy for endophthalmitis decreased by 3.8% per year.

“In a study covering 22 years of observation from across the US and more than 5.8 million intraocular procedures, the rate of endophthalmitis varied dramatically, starting at 0.2% initially in 2000 and decreasing by 75% to a low of 0.05% in 2022,” wrote the investigative team, led by Brian VanderBeek, MD, MPH, Scheie Eye Institute, University of Pennsylvania.

Endophthalmitis is a concerning, sight-threatening postoperative complication, with substantial efforts made to reduce its incidence.² Owing to the invention of modern sterilization, rates of postsurgical endophthalmitis in the mid-20th century were close to 1%, with decreases sustained until the turn of the century.

Long-term trends on overall endophthalmitis rates and treatment patterns are lacking – it is unknown if the deviation from Endophthalmitis Vitrectomy Study (EVS) recommendations toward the decreased use of vitrectomy is linked to varying vision outcomes.³

In this analysis, VanderBeek and colleagues used the Optum Clinformatics Data Mart database, involving more than 20 years of data, to evaluate endophthalmitis rates after intraocular procedures and measure the frequency of prompt vitrectomy as its primary treatment.¹

Cohorts were created by searching for various intraocular procedures between 2000 and 2002, including intravitreal injections and surgery for cataract removal, glaucoma, retinal conditions, and corneal transplants. Eligibility criteria necessitated ≥6 months of data before and 6 weeks after the intraocular procedure.

Primary outcomes for the analysis included the incidence rate of post-intraocular procedure endophthalmitis, with secondary outcomes including the rate of prompt vitrectomy as the primary treatment for endophthalmitis, compared with an injection of antibiotics alone or a tap-and-inject (TAP) procedure.

After applying the eligibility criteria, 5,827,809 intraocular procedures from 2,124,964 patients were included for analysis. During the study period, 4305 cases of endophthalmitis were identified, for an overall rate of 0.07%.

Yearly rates of endophthalmitis tended to decline from a high of 7 cases per 3502 procedures (0.20%) in 2000 to a low of 163 cases per 332,159 procedures (0.05%) in 2022, a decrease of 75% (P <.001). Cases treated with prompt vitrectomy also experienced a decrease over time, from a high of 17 of 35 (48.6%) in 2003 to a low of 60 of 515 (11.6%) in 2021.

Upon multivariable analysis, the incidence rate ratio (IRR) of endophthalmitis showed a 2.7% per-year decrease (IRR, 0.97; 95% CI, 0.97–0.98; P <.001) during the study period. Further analysis revealed the IRR of prompt surgical treatment decreased by 3.8% per year (IRR, 0.96; 95% CI, 0.95 – 0.97; P <.001).

In a linked editorial, Nicolas A. Yannuzzi, MD, department of ophthalmology, Bascom Palmer Eye Institute, University of Miami, indicated their institution continues to promote early treatment with antibiotics, delivered via vitreous tap or vitrectomy, as a cornerstone of endophthalmitis treatment.⁴

“We favor vitrectomy for highly severe initial presentations, eyes not responsive to tap and injection, or eyes with diagnostic uncertainty, but realize that treatment should be tailored to each patient,” Yannuzzi said.

Reference

1. _{VanderBeek BL, Chen Y, Tomaiuolo M, et al. Endophthalmitis Rates and Types of Treatments After Intraocular Procedures. JAMA Ophthalmol. Published online August 01, 2024. doi:10.1001/jamaophthalmol.2024.2749}
2. _{Eifrig CW, Flynn HW Jr, Scott IU, Newton J. Acute-onset postoperative endophthalmitis: review of incidence and visual outcomes (1995-2001) [published correction appears in Ophthalmic Surg Lasers. 2003 Jan-Feb;34(1):80.]. Ophthalmic Surg Lasers. 2002;33(5):373-378}
3. _{Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol. 1995;113(12):1479-1496}
4. _{Ghalibafan S, Flynn HW, Yannuzzi NA. Changes in Rates of Postprocedural Endophthalmitis and Treatments. JAMA Ophthalmol. Published online August 01, 2024. doi:10.1001/jamaophthalmol.2024.2805}