|Year : 2022 | Volume
| Issue : 2 | Page : 115-122
Outcome of cataract surgery with 1 h of preoperative antibiotic regimen: A strategy during COVID-19 Pandemic: Study from a tertiary eye care hospital
Sasikala Elizabeth Anilkumar1, Navaneeth Saggam2, Madhuri Thotakura2, Ram Rammohan3, Kalpana Narendran4
1 Department of Paediatric Ophthalmology and Strabismus, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Coimbatore, Tamil Nadu, India
2 Department of IOL and Cataract Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Coimbatore, Tamil Nadu, India
3 Department of Lab Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Coimbatore, Tamil Nadu, India
4 Department of Paediatric Ophthalmology and Strabismus; Department of IOL and Cataract Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Coimbatore, Tamil Nadu, India
|Date of Submission||07-Sep-2021|
|Date of Decision||04-May-2022|
|Date of Acceptance||10-Jul-2022|
|Date of Web Publication||30-Aug-2022|
Dr. Sasikala Elizabeth Anilkumar
Department of Paediatric Ophthalmology and Strabismus, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Coimbatore - 641 014, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Purpose: This study aims to describe the visual and surgical outcomes of 810 eyes of 805 patients who underwent unilateral cataract surgery on the same day with 1 h of preoperative antibiotic regimen. Setting: Tertiary Care Ophthalmic Hospital. Design: Retrospective, descriptive study. Methods: This study comprised of consecutive adult patients who underwent preoperative cataract work up, received 1 h of preoperative antibiotic regimen, and underwent cataract surgery on the same day of consultation with a minimum 3-week follow-up period. This study describes the demographic profile, preoperative, intraoperative details, postoperative (PO) best-corrected visual acuity (BCVA), and surgical outcomes of these patients. Results: 810 eyes of 805 patients with a mean age of 61.0 ± 9.7 years, 50% had systemic and 9% had ocular comorbidities. The mean preoperative BCVA was 0.8 ± 0.7 LogMAR. Phacoemulsification was performed in 90.1%. Intraoperative complications had occurred in 8 (1%) eyes. The mean PO BCVA of the study group on PO day 1 (POD1) and PO 3 weeks was 0.13 ± 0.3 LogMAR and 0.07 ± 0.3 LogMAR, respectively. Our study showed that 95.68% had improvement in vision, while 96.8% achieved BCVA 6/18 or better. None had PO endophthalmitis. Comparison between preoperative and both POD 1 day and PO 3-week BCVA showed statistically significant improvement (P < 0.001). Conclusion: Our study results satisfied the benchmark set by the World Health Organization (WHO) for PO BCVA with good surgical outcome. Preoperative antibiotic applied 1 h before cataract surgery provided safety and comfort and with low risk for endophthalmitis. This strategy can be adopted to tackle the backlog of cataract surgeries due to COVID-19 (or any other emergency situation) in developing countries.
Keywords: 1 hr preoperative antibiotic regimen, cataract surgery, COVID-19 pandemic, surgical outcome, visual outcome
|How to cite this article:|
Anilkumar SE, Saggam N, Thotakura M, Rammohan R, Narendran K. Outcome of cataract surgery with 1 h of preoperative antibiotic regimen: A strategy during COVID-19 Pandemic: Study from a tertiary eye care hospital. Kerala J Ophthalmol 2022;34:115-22
|How to cite this URL:|
Anilkumar SE, Saggam N, Thotakura M, Rammohan R, Narendran K. Outcome of cataract surgery with 1 h of preoperative antibiotic regimen: A strategy during COVID-19 Pandemic: Study from a tertiary eye care hospital. Kerala J Ophthalmol [serial online] 2022 [cited 2022 Dec 4];34:115-22. Available from: http://www.kjophthal.com/text.asp?2022/34/2/115/355045
| Introduction|| |
The leading cause of blindness globally is cataract (17.01 million). Cataract surgery is the second most common surgical procedure after cesarean section. The global median cataract surgical rate was 1700 per million population per year during the past decade. India has achieved high cataract surgical coverage of nearly 6.5 million surgeries every year with an average rate of more than 5000 surgeries per million population per year. It is known that the majority of cataract surgeries are being performed by the nongovernmental sector. Yet, the backlog of cataract surgery in India is enormous. In 2019, the blindness in population aged ≥50 years in India due to untreated cataract was reported to be 62.2%. The “Lancet Global Health Commission on Global Eye Health: Vision beyond 2020” had estimated, worldwide, 596 million people with distance vision impairment, of whom 43 million were blind and a large proportion of those affected (39.62 million; 91.75%) live in low-income and middle-income countries. Furthermore, the largest number of blind people lived in South Asia.,
Over the years, cataract surgical service in a developing country such as India has undergone a dramatic adaptation to provide patient convenience. At present, the standard approach to treat cataracts is “Delayed Sequential Bilateral Cataract Surgery.” There is a wide variability in the antibiotic agents used (fluoroquinolone versus aminoglycoside, or cephalosporin, or chloramphenicol), the administration routes (topical, intraocular, subconjunctival, or oral), and the timing (preoperative, intraoperative, or postoperative [PO]). The rationale behind their use is that antibiotic levels exceeding the minimal inhibitory concentrations required to inhibit bacterial growth in the aqueous humor would lower the risk of intraocular contamination either intraoperatively or postoperatively.
The vast majority of respondents in the survey carried out among the ophthalmologist members of the All India Ophthalmological Society, 90% (n = 1109), used perioperative topical antibiotics for cataract surgery. In clinical practice, topical antibiotics are commonly used 1 or 3 days before cataract surgery., The ESCRS published guidelines recommend the use of a topical quinolone four times a day for 24 or 48 h before surgery and additional instillations of one drop, 1 h and 0.5 h before operation.
Since the beginning of COVID-19 pandemic in India, there has been a drastic reduction in elective cataract surgeries., Lockdown measures led to a poor health-seeking behavior. The evolving guidelines provided by the Government of India in the mid-2020 regarding the performance of safe cataract surgery (focused on the safety for the operating teams and patients) led to the restarting of cataract surgeries., In comparison to the corresponding period of the previous year, the number of cataract surgeries had declined drastically by 99.7%. To tackle the huge surge in the number of patients presenting to the hospitals after lifting of the lockdown, it was recommended to change the functioning of hospitals to prevent crumbling of the health-care system., Unlike other surgical disciplines that might be more reliant on expansive resources such as intensive care and inpatient hospitalization, it might be possible to ramp-up operations in ophthalmology due to the predominantly outpatient nature of surgeries.
To handle the critical situation during the COVID-19 pandemic at our tertiary care center, one of the strategies proposed was to perform same-day unilateral cataract surgery with 1 h of preoperative antibiotics. These was planned without compromising on the preoperative preparation, intraoperative, or PO patient care. This study aims to describe the visual and surgical outcomes of such patients.
| Methods|| |
This is a retrospective, descriptive study done among 810 eyes of 805 consecutive eligible adult patients. Eligible patients were defined as those who underwent cataract evaluation, preoperative preparation, received preoperative antibiotics and applied it for a duration of 1 h before surgery, underwent cataract surgery on the same day and were discharged either on the same day or the next day morning. Patients who had uncontrolled systemic ailments requiring specialist evaluation and requiring anticoagulants to be stopped before cataract surgery were not advised to undergo cataract surgery on the same day. The study was approved by the institutional Ethics Committee and has adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all patients.
Preoperative cataract surgery evaluation
All patients underwent vision, retinoscopy, slit-lamp biomicroscopy, intraocular pressure (IOP) (using noncontact tonometry method), fundus evaluation or ultrasonogram B-scan (hazy media due to dense cataract), and biometry. Eligible patients were identified and a dedicated team that included a doctor, clinical manager, ophthalmic technician, counselor, and nurse was responsible for fast tracking these patients to avoid delay or breach in protocol. Patients underwent counseling for selection of the intraocular lens. Systemic evaluation including random blood sugar, blood pressure measurement, body temperature, blood oxygen saturation, and electrocardiogram (for needed patients) was performed.
Preoperative cataract surgery preparation
All patients received preoperative antibiotic eye drop (E/D) ofloxacin 0.3% (Auroflox, Aurolab, India) 1 h before cataract surgery, applied 6 times every 10 min. Just before the surgery, E/D povidone–iodine 5% (Aurodone, Aurolab, India) was applied in the conjunctival cul-de-sac in the Block Room, and also on the operating table before preparation for surgery, and at the end of surgery before placing the eye patch. Periocular skin disinfection on the operating side was done with 10% povidone-iodine (Aurodone-DS, Aurolab, India) once in the Block Room and once again on the table before draping the patient's face. At the end of surgery, all patients received injection of 0.1 cc of intracameral (IC) moxifloxacin (Auromox, Aurolab, India). Cleaning, disinfection protocols, personal protective equipment usage for the patients' health-care providers and for the operating team were followed as per the guidelines. Separate operating team with sterilized instruments, operating sets, linen, and surgical material were used for these patients. All patients were discharged immediately after their surgery (except for admitted patients who needed overnight hospital stay, for whom next day PO vision and a slit-lamp biomicroscopy was performed before discharge). The daycare patients (those who were discharged on the same day of surgery) were reviewed the next morning and evaluated similarly on an outpatient basis. Patients were started on PO medications which included E/D ofloxacin 0.3% (Auroflox, Aurolab, India) four times a day for 1 week and E/D dexamethasone sodium phosphate 0.1% (Dexa, Aurolab, India) four times a day for 1 week, tapered over 4 weeks. Patients were reviewed after 3 weeks. During the PO 3 weeks (PO 3 weeks) visit vision, retinoscopy, IOP, slit-lamp biomicroscopy, and dilated fundus evaluation were performed.
The details of 810 eyes of 805 patients fulfilling the selection criteria were retrospectively collected from the electronic medical records of the institution database. The patient demographic details such as age, sex, locality, comorbidities, preoperative evaluation details including preoperative best-corrected visual acuity (BCVA), type of cataract, biometry details (axial length and keratometry), and IOP were recorded. The intraoperative parameters included were the type of anesthesia, type of cataract surgery performed, intraoperative complications, IOL power and design implanted for the patient, and the BCVA on PO day 1 (POD1), PO 3 weeks. The WHO definition was used to categorize BCVA: blindness was defined as VA <3/60, 5/60–3/60 as severe visual impairment, 6/24–6/60 as visual impairment, and 6/6–6/18 as NORMAL vision. PO details including the incidence of endophthalmitis on POD1 and PO 3 weeks were noted.
Inclusion and exclusion criteria for the study
All adult patients aged between 18 and 85 years undergoing cataract surgery with IOL implantation on the same day between October 2020 and January 2021 with a minimum 3-week follow-up were included, while patients with insufficient follow-up were excluded.
Data were entered using Google Forms, stored in excel, and were analyzed using STATA 14.0 (StataCorp, USA). Numerical data were presented with mean ± standard deviation and range, whereas categorical data were presented as count and percentage. To compare between preoperative and PO data, a Chi-square test was used for categorical; whereas to compare between mean values, paired sample t-test was used. A P < 0.05 was considered statistically significant.
| Results|| |
During the study period, 5282 adult cataract patients were operated in our Paying section. Of them, a total of 850 (16%) had undergone unilateral cataract on the same day with 1 h preoperative antibiotic regimen. A total of 810 eyes of 805 patients who fulfilled the inclusion criteria were taken up for the study. Forty eyes (4.7%) were excluded from the study, due to inadequate follow-up. Although telephonic reminders were given, due to the second wave of COVID-19, most patients had postponed their review visits. Patients who were lost to follow-up and could not be contacted through telephone after 3 consecutive calls, were excluded from this study. The demographic characteristics are detailed in [Table 1]. Study group had five patients who had both eyes operated sequentially. Fifty-four percent (54%) patients were aged more than 60 years. The mean distance traveled by the patient to undergo surgery was 70.2 ± 69.4 km. The preoperative and intraoperative details are provided in [Table 2]. The mean preoperative BCVA was 0.8 ± 0.7 LogMAR. Polymethylmethacrylate IOL was implanted in 75 (9.3%) eyes and the rest had foldable IOLs implanted. Due to intraoperative challenge, there was inability to implant IOL in one eye. Eight hundred and two (802 = 99.0%) eyes had no intraoperative complications. Details of the 8 (1%) eyes who had intraoperative complications and the management are detailed in [Table 3]. The mean BCVA at PO 3 weeks among the patients with intraoperative complication was 0.16 ± 0.38 LogMAR. Fifty one (51 = 6.3%) had complications on POD 1, of which 33 had striate keratitis, 7 had iritis, and 11 had corneal edema. Nine (1.1%) had complications at PO 3 weeks which included 2 with striate keratitis, 5 with iritis, and 2 with corneal edema. Of the patients with PO iritis at 3-week PO, all the five had iritis at 1-day postoperative too. There were no cases of rebound iritis. Three out of five had mature cataract. Three of them had systemic comorbidities. Three out of five achieved final vision better than 6/12 the other two had ocular comorbidities (Advanced PDR, Retinochoroidal coloboma) contributing to suboptimal vision. All the patients were asymptomatic during the follow-up and regular PO medications were provided. None developed endophthalmitis in this study period.
The mean BCVA of the study group on POD 1 was 0.13 ± 0.3 Log MAR ranged from 0 to 2.6 Log MAR. Seven hundred and sixty seven (94.7%) achieved normal vision, 29 (3.6%) were categorized as visually impaired, 5 (0.6) as severe visual impairment, and 9 (1.1%) as blind. One hundred and twenty one (87.0%) out of 139 who had been preoperatively categorized as blind achieved normal visual acuity on POD1. Mean visual improvement from preoperative to POD1 was statistically significant (P = 0.000). The mean BCVA of the study group on PO 3 weeks was 0.07 ± 0.3 LogMAR ranged from 0 to 2.6 LogMAR. Comparison between preoperative BCVA and PO 3-week BCVA is provided in [Table 4]. Twelve (1.5%) eyes had PO 3-week CDVA <6/60 and their pre, intra, and PO details are provided in [Table 5]. Our study showed that in comparison to preoperative BCVA, at PO 3 weeks, 775 (95.68%) had improvement in vision and 32 (3.95%) had retained their preoperative vision. Three (0.37%) eyes had dropped vision by 1 line postoperatively and all these patients had preexisting systemic and ocular comorbidities. The mean preoperative BCVA was 0.83 ± 0.7 for all the 810 eyes. Compared to this, there was a significant improvement in POD1 mean BCVA (LogMAR) which was 0.13 ± 0.3 (P = 0.0000) and in PO, 3-week mean BCVA (LogMAR) was 0.07 ± 0.2 (P = 0.0000). A paired sample t-test was done to assess any significant changes between mean pre and PO BCVA. Compared to mean preoperative BCVA, there was a statistically significant improvement in the mean PO (both POD1 and PO 3 weeks) BCVA (P < 0.001).
|Table 4: Comparison between preoperative best-corrected visual acuity and postoperative 3-week best-corrected visual acuity|
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|Table 5: Pre, intra, and postoperative details of patients with postoperative 3-week best-corrected visual acuity worse than 6/60 (n=12)|
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| Discussion|| |
With the rising COVID-19 cases, the ophthalmic community is facing extraordinary challenges to safely perform cataract surgeries. Very few ophthalmologists prefer to operate for cataract on the same day during their first consultation. There are only few reported studies in the literature on the outcome of cataract surgery with 1–2 h preoperative antibiotic regimen such as the study by Li et al. and the clinical trial by Vasavada et al., The study by Zhuang et al. suggested that it is essential to optimize day-case cataract surgery to decrease expense and increase efficiency, providing clear evidence that the practice pattern for cataract surgery has been evolving to address the need of the hour.
Postoperative visual outcome
The longstanding WHO benchmark for a good outcome, following cataract surgery, is a presenting visual acuity of 6/18 or better. It is reported that with refraction, 85% had a BCVA of 6/18 or better. Among the study group, 96.8% achieved BCVA 6/18 or better at PO 3 weeks. All the patients achieving PO vision of 6/60 or worse had ocular or systemic comorbidities. Zhuang et al. in their study reported the average preoperative BCVA of 1 ± 1.3 LogMAR and average PO BCVA at 1 month were 0.1 ± 0.6 Log MAR, similar to our study report.
Retrospective cohort study by Haripriya et al. reported the intraoperative complication rate as 0.8% and a total of 0.04% of PO endophthalmitis. The BCVA was better than 6/12 in 96% after phacoemulsification complications and 89% after manual SICS complications. In our current study, intraoperative complications rate was 1%. A study from a private practice in Madrid, Spain, stated that 28.5% had prior ocular pathologies and majority of them with retinal pathologies that had compromised visual outcomes. The main reason for PO 3-week BCVA worse than 6/60 in the present study among 10 out of 12 patients were due to preexisting retinal pathology [Table 5]. Han et al. in a prospective cohort study reported an overall intraoperative complication rate of 3.0%, with no cases of PO endophthalmitis. It recommended cataract risk stratification approach to reduce the trend in frequency and severity of intraoperative complications.
Postoperative surgical outcome and Endophthalmitis prophylaxis
The optimum length of time, frequency, duration, drug of choice, and manner of antibiotic cover for perioperative topical antibiotic prophylaxis have been debated. Kelkar et al. in an online ophthalmologist survey reported that 37% started preoperative antibiotics 3 days before surgery, 37% started them on the day before surgery, and only 10% started them on arrival at the surgical center. Nearly 94% of respondents used topical povidone-iodine immediately before surgery. Eighty-five percent injected intracameral antibiotics. Kelkar concluded that intracameral antibiotic prophylaxis had sharply increased in India and had resulted in a reduction of self-reported endophthalmitis cases. The major risk expected with only 1 h preoperative antibiotic regimen is PO endophthalmitis. Li et al. in their prospective randomized study evaluated the efficacy of combination preoperative prophylactic topical antibiotic regimen given 1 h versus 1 day before surgery in addition to perioperative povidone-iodine disinfection. Their study proved the equal effectiveness in reducing the conjunctival bacterial load in both groups and the greatest safety effect was achieved by irrigating the conjunctival sac with povidone-iodine. Nentwich et al. and Tan et al., respectively, attributed the reason for the reduction in the rate of PO endophthalmitis to implementation of a preoperative prophylaxis protocol using copious povidone-iodine., Vasavada et al. compared two moxifloxacin regimens for preoperative cataract prophylaxis. Group A had moxifloxacin instilled 4 times a day, 1 day before surgery along with 1 drop 2 h before surgery, while Group B had moxifloxacin instilled 2 h before surgery and then every 15 min for 1 h. They found that both the regimens achieved significant higher aqueous concentrations and reduced the amount of conjunctival bacterial flora.,
Intracameral antibiotics for endophthalmitis prophylaxis
The mode of antibiotic administration ranged widely from topical administration preoperatively to intraocular injections during surgery. Tan et al. also reported that there was a significant reduction in the rate of endophthalmitis with the use of intracameral cefazolin. Several multicentric trials and studies have also recommended intracameral antibiotic (s) at the end of surgery to reduce the occurrence of PO endophthalmitis.,,, Haripriya et al. proved that a routine intracameral moxifloxacin prophylaxis reduced the overall endophthalmitis rate by 3.5 fold and also reduced the PO endophthalmitis rate in eyes with PCR.,, In a review of the incidence of acute postcataract surgery endophthalmitis in India, it was reported between 0.04% and 0.15%. In our study, patients received preoperative antibiotic E/D ofloxacin 0.3% (Auroflox, Aurolab, India), 1 h before cataract surgery, applied for 6 times every 10 min, followed by perioperative povidone-iodine usage in the conjunctival sac and intracameral moxifloxacin. During the study period, there was no reported case of endophthalmitis. None of previous studies have reported on the visual and surgical outcomes, especially on the endophthalmitis rates with 1–2 h of preoperative antibiotics regimen.,, However, in our descriptive study, both the PO BCVA and the surgical complications (including endophthalmitis rates) were analyzed.
Since India is in the postsecond COVID-19 wave, there will be an increase in the outpatient visits and consultation for elective procedures upon return to near normalcy. It has been reported that the pandemic will probably lead to deterioration in the social determinants of eye health for many, through increased poverty and reduced access to services mainly in developing countries. Strategies suggested to cope with the backlog of cataract surgery include the adoption of telemedicine, artificial intelligence-assisted platforms, modification of face-to-face encounters, better theater organization, moving the FEMTO laser to the operating room or alternatives to laser-assisted capsulotomy such as zepto and miLoop for dense cataract and immediate sequential bilateral cataract surgery (ISBCS).,, Although globally, there is an ongoing debate on ISBCS. This approach has been adopted as a practice pattern among ophthalmologists from the developed world and has been suggested as a strategy to tackle surgery backlogs.,,, Due to the concern of the dreadful bilateral endophthalmitis with ISBCS and surgical surprises, such practice is less prevalent in India.
Despite the existence of the knowledge regarding the safety of cataract surgery with same-day preoperative antibiotic, there exists an hesitance in adopting this into their current practice by many clinicians., Therefore, along with the suggested strategies, adopting the Delayed Sequential Bilateral Cataract Surgery with 1 h of antibiotic regimen would be appropriate to tackle the cataract surgery backlog in India. This study has proven this to be a safe strategy. Many more institutions and practitioners are encouraged to adopt the strategy. Nevertheless, a sterile operative field has to be achieved by adopting routine prophylaxis protocols, disinfecting the skin in the periorbital region, and irrigating the conjunctiva using topical povidone–iodine.,
Although a case–control study would have been ideal, this was not feasible during the period of the ongoing pandemic. However, the study used historical rates to test the hypothesis. Another limitation was a follow-up of 3-week duration. The long-term PO effects are being currently followed up. In 3-week duration, it clearly indicated an excellent surgical and visual outcome, minimized the number of visits, reduced the hospital stay days, reduced the number of attendees exposing themselves to the hospital environment, and minimized exposure for the hospital staff. However, our recommended protocol for same-day antibiotics depends on a dedicated team work, adequate manpower, and stringent sterilization protocols, as well periodic monitoring, to achieve safe surgical and medium-term PO visual outcomes.
| Conclusion|| |
COVID-19 pandemic has resulted in the worsening of the backlog of cataract surgeries. Modified approaches are required to tackle the situation. Our strategy has successfully proven that same-day evaluation, with 1 h of preoperative antibiotic regimen along with intraoperative povidone-iodine and intracameral moxifloxacin, provides safety against PO endophthalmitis with good visual and surgical outcomes. This strategy significantly reduces the number of hospital visits and increases patient compliance and comfort. We suggest clinicians in developing countries to adopt the above approach which will benefit the patients, as well as effectively tackle the backlog of cataract surgeries during exigent times.
The authors thank Mrs. A. Padmavathi, Biostatistician, for her assistance in statistical analysis and Dr. R.S. Premkumar, Research Consultant for his help in the manuscript preparation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]