Incidence of endophthalmitis after phacoemulsification cataract surgery: a meta-analysis

Authors: Shi SL, Yu XN, Cui YL, Zheng SF, Shentu XC

Geographical coverage: Sweden, United Kingdom, Canada, Japan, Australia, Spain, Thailand, USA, India, Germany, Singapore, France, Norway, China, Saudi Arabia, Colombia, South Korea, Malaysia.

Sector: Burden of Disease

Sub-sector: Epidemiology, incidence of endophthalmitis, prevention

Equity focus: Not reported

Study population: Patients with cataracts

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Not applicable

Background:

Cataract surgery is one of the most commonly performed intraocular operations worldwide, with phacoemulsification gradually replacing extracapsular extraction as the main technique. While generally safe, postoperative endophthalmitis remains a serious complication. This infection arises from microbial contamination during or after surgery and is influenced by several risk factors. Although its incidence is relatively low (0.013%–0.7%), the consequences are significant. Previous meta-analyses have not focused specifically on phacoemulsification.

Objective:

To assess the incidence of endophthalmitis and the effectiveness of prophylactic measures following phacoemulsification cataract surgery (PCS).

Main findings:

The authors reviewed 39 studies (totaling 5,878,114 eyes) from multiple regions. The overall pooled incidence of endophthalmitis was 0.107%, reduced to 0.092% after excluding an outlier. Incidence declined over time: 0.097% (pre-2000), 0.089% (2000–2010), 0.063% (post-2010).

Topical povidone-iodine: 0.178%
Subconjunctival antibiotics: 0.047%
Intracameral antibiotics: 0.045%
Relative risk of intracameral vs. no intracameral antibiotics: 7.942
Specific antibiotic results:
– Cefuroxime: 0.053%
– Cefazolin: 0.049%
– Moxifloxacin: 0.01%

Methodology: 

Two reviewers searched PubMed and Web of Science (up to 30 April 2021) for prospective or retrospective studies assessing endophthalmitis incidence post-phacoemulsification. Non-English articles, reviews, experimental studies, small samples (<1000), and non-relevant formats were excluded.

Data extraction covered study details and endophthalmitis incidence. Quality was assessed using the Newcastle–Ottawa Scale. Meta-analyses used random- or fixed-effects models depending on heterogeneity. Subgroup and sensitivity analyses, along with publication bias tests, were performed.

Applicability/external validity:

The findings are applicable across global settings and support the adoption of intracameral antibiotics to prevent endophthalmitis. Regional variations in antibiotic use were noted, providing insights for public health policy and surgical guidelines.

Geographic focus:

Studies were conducted across 18 countries including Sweden, the UK, Canada, Japan, and others.

Summary of quality assessment:

There is low confidence in the review’s conclusions due to unclear study selection process, exclusion of non-English studies, and no risk of bias analysis.