The Incidence of Endophthalmitis after Cataract Surgery among the U.S. Medicare Population Increased between 1994 and 2001

doi:10.1016/j.ophtha.2005.02.028

Ophthalmology

Volume 112, Issue 8, August 2005, Pages 1388-1394

https://doi.org/10.1016/j.ophtha.2005.02.028 Get rights and content

Objective

To estimate the annual incidence rate of presumed endophthalmitis after cataract surgery, evaluate any changes in this rate over time, and examine demographic risk factors for endophthalmitis after cataract surgery.

Design

Population-based review of Medicare beneficiary claims data.

Data Source

Medicare 5% sample beneficiary data files for inpatient and outpatient claims from 1994 through 2001 were examined to identify all cataract surgeries and subsequent cases of presumed endophthalmitis after cataract surgery.

Methods

All cataract surgery and presumed endophthalmitis cases after cataract surgery were identified based on claims submitted. The annual rate of presumed endophthalmitis after cataract surgery was calculated, and demographic risk factors for endophthalmitis were examined using multivariate models.

Main Outcome Measures

Incidence rate of endophthalmitis after cataract surgery and prevalence of demographic risk factors for endophthalmitis over an 8-year period.

Results

One thousand twenty-six cases of presumed endophthalmitis occurred after 477 627 cataract surgeries, yielding an incidence rate of 2.15 per 1000 for this 8-year period. Rates of endophthalmitis adjusted for age, gender, and race were significantly higher in 1998 to 2001 than in earlier years (relative risk [RR], 1.41; 95% confidence interval [CI], 1.24–1.60). Older age and black race also were associated with increased risk of endophthalmitis (RR, 1.83; 95% CI, 1.19–2.81; age, ≥90 years, and RR, 1.30; 95% CI, 1.02–1.65, respectively).

Conclusions

Analysis of Medicare claims data suggests that the incidence of endophthalmitis after cataract surgery has been increasing, but does not provide an explanation for this occurrence. An increase in the incidence of endophthalmitis after cataract surgery is of concern, because cataract surgery is the most commonly performed operation in the United States, and the number of cataract surgeries performed annually will likely increase substantially over the coming decades due to the aging of the U.S. population.

Section snippets

Materials and Methods

Data for this project were derived from Medicare beneficiary claims files. All years of data that were available at the time of writing were used for our analyses. Data were available in 2 forms: research identifiable files (RIFs) and beneficiary encrypted files (BEFs). These 2 databases are very similar, with 2 exceptions: the degree of information regarding the date of service and the level of patient identifiers. The RIFs contain the exact date of billing and complete identifying

Results

The BEF and RIF datasets provided similar rates of endophthalmitis (Table 2), and as expected because of the increased number of days included, the 2-quarter rate was slightly higher than the 1-quarter rate for a given year. Among years with date-specific data available, 90-day postsurgery endophthalmitis rates ranged from 1.60 cases per 1000 surgeries in 1997 to 2.29 per 1000 in 2001 (Table 2). For years where BEFs and RIFs were both available, endophthalmitis rates did not differ

Discussion

The findings from this study suggest that endophthalmitis rates after cataract surgery increased in the U.S. between 1994 and 2001. Due to the lag in the availability of Medicare data for such analyses, we cannot comment on whether the endophthalmitis rate after cataract surgery has since stabilized or continued to increase. We report an endophthalmitis rate of 1.79 cases per 1000 in 1994 and a rate of 2.47 cases per 1000 in 2001, a 37% increase over this 8-year period. Two additional

Acknowledgments

The authors gratefully acknowledge the assistance of Gerry Anderson and Robert Herbert in providing de-identified datasets for analyses.

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Bacterial endophthalmitis is a blinding infectious disease typically acquired during ocular surgery. We previously reported significant alterations in retinal metabolism during Staphylococcus (S) aureus endophthalmitis. However, the changes in retinal lipid composition during endophthalmitis are unknown. Here, using a mouse model of S. aureus endophthalmitis and an untargeted lipidomic approach, we comprehensively analyzed temporal alterations in total lipids and oxylipin in retina. Our data showed a time-dependent increase in the levels of lipid classes, sphingolipids, glycerolipids, sterols, and non-esterified fatty acids, whereas levels of phospholipids decreased. Among lipid subclasses, phosphatidylcholine decreased over time. The oxylipin analysis revealed increased prostaglandin-E2, hydroxyeicosatetraenoic acids, docosahexaenoic acid, eicosapentaenoic acid, and α-linolenic acid. In-vitro studies using mouse bone marrow-derived macrophages showed increased lipid droplets and lipid-peroxide formation in response to S. aureus infection. Collectively, these findings suggest that S. aureus-infection alters the retinal lipid profile, which may contribute to the pathogenesis of bacterial endophthalmitis.
Cost-Effectiveness of Preoperative Topical Antibiotic Prophylaxis for Endophthalmitis Following Cataract Surgery
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To determine the cost-effectiveness of preoperative topical antibiotic prophylaxis for the prevention of endophthalmitis following cataract surgery.
Cost-effectiveness analysis using a decision-analytic microsimulation model.
Preoperative topical antibiotic prophylaxis vs no-prophylaxis costs and effects were projected over a life-time horizon for a simulated cohort of 500 000 adult patients (≥18 years old) requiring cataract surgery in theoretical surgical centers in the United States. Efficacy and cost (2021 US dollars) values were obtained from the literature and discounted at 3% per year.
Based on inputted parameters, the mean incidence of endophthalmitis following cataract surgery for preoperative topical antibiotic prophylaxis vs no-prophylaxis was 0.034% (95% CI 0%-0.2%) and 0.042% (95% CI 0%-0.3%), respectively—an absolute risk reduction of 0.008%. The mean life-time costs for cataract surgery with prophylaxis and no-prophylaxis were $2486.67 (95% CI $2193.61-$2802.44) and $2409.03 (95% CI $2129.94-$2706.69), respectively. The quality-adjusted life-years (QALYs) associated with prophylaxis and no-prophylaxis were 10.33495 (95% CI 7.81629-12.38158) and 10.33498 (95% CI 7.81284-12.38316), respectively. Assuming a cost-effectiveness criterion of ≤$50 000 per QALY gained, the threshold analyses indicated that prophylaxis would be cost-effective if the incidence of endophthalmitis after cataract surgery was greater than 5.5% or if the price of the preoperative topical antibiotic prophylaxis was less than $0.75.
General use of preoperative topical antibiotic prophylaxis is not cost-effective compared with no-prophylaxis for the prevention of endophthalmitis following cataract surgery. Preoperative topical antibiotic prophylaxis, however, would be cost-effective at a higher incidence of endophthalmitis and/or a substantially lower price for prophylaxis.
Disparities in Vision Health and Eye Care
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Endophthalmitis Rates among Medicare Beneficiaries Undergoing Cataract Surgery between 2011 and 2019
2022, Ophthalmology
To determine national incidence and risk factors associated with developing endophthalmitis after cataract surgery in the United States.
Retrospective, cross-sectional analysis.
Medicare beneficiaries aged ≥65 years undergoing cataract surgery between 2011 and 2019.
Medicare claims were used to identify all patients who underwent ≥1 cataract surgery between 2011 and 2019. Endophthalmitis cases within 90 days of the cataract surgery were identified using diagnostic codes. Patients with a history of endophthalmitis 12 months before their cataract surgery procedure were excluded. Annual and aggregate 9-year incidences were determined for all cataract surgeries and for stand-alone cataract procedures. A stepwise multivariable logistic regression model using generalized estimating equations was used to evaluate factors associated with occurrence of postoperative endophthalmitis.
The 90-day postoperative endophthalmitis rate and patient risk factors associated with onset of endophthalmitis after cataract surgery.
A total of 14 396 438 cataract surgeries were performed among Medicare beneficiaries between 2011 and 2019. The overall 90-day postoperative endophthalmitis rate was 1.36 per 1000 cataract surgeries for all cataract procedures and 1.30 per 1000 cataract surgeries for stand-alone cataract procedures. A decreasing trend was noted for postoperative endophthalmitis rates during the 9-year study period. On multivariable analysis, the risk of endophthalmitis after cataract surgery was increased for cases performed among those aged ≥75 years versus those aged <75 years (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.11–1.18), Blacks (OR, 1.13; 95% CI, 1.07–1.20), Native Americans (OR, 1.43; 95% CI, 1.19–1.73), and eyes with any history of invasive glaucoma surgery (OR, 1.40; 95% CI, 1.18–1.65). Cataract cases combined with retinal surgery (OR, 2.60; 95% CI, 2.15–3.16) and those performed when the Charlson Comorbidity Index (CCI) was greater than 0 also had an increased likelihood of developing endophthalmitis. The risk of endophthalmitis was lower for cases performed on women versus men (OR, 0.89; 95% CI, 0.86–0.92).
The overall 90-day postoperative endophthalmitis rate after cataract surgery was 1.36 per 1000 cataract surgeries between 2011 and 2019. Patient age, gender, race, and CCI were associated with risk of endophthalmitis.
Endophthalmitis Rate in Immediately Sequential versus Delayed Sequential Bilateral Cataract Surgery within the Intelligent Research in Sight (IRIS®) Registry Data
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To compare the rate of postoperative endophthalmitis after immediately sequential bilateral cataract surgery (ISBCS) versus delayed sequential bilateral cataract surgery (DSBCS) using the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry database.
Retrospective cohort study.
Patients in the IRIS Registry who underwent cataract surgery from 2013 through 2018.
Patients who underwent cataract surgery were divided into 2 groups: (1) ISBCS and (2) DSBCS (second-eye surgery ≥1 day after the first-eye surgery) or unilateral surgery. Postoperative endophthalmitis was defined as endophthalmitis occurring within 4 weeks of surgery by International Classification of Diseases (ICD) code and ICD code with additional clinical criteria.
Rate of postoperative endophthalmitis.
Of 5 573 639 IRIS Registry patients who underwent cataract extraction, 165 609 underwent ISBCS, and 5 408 030 underwent DSBCS or unilateral surgery (3 695 440 DSBCS, 1 712 590 unilateral surgery only). A total of 3102 participants (0.056%) met study criteria of postoperative endophthalmitis with supporting clinical findings. The rates of endophthalmitis in either surgery eye between the 2 surgery groups were similar (0.059% in the ISBCS group vs. 0.056% in the DSBCS or unilateral group; P = 0.53). Although the incidence of endophthalmitis was slightly higher in the ISBCS group compared with the DSBCS or unilateral group, the odds ratio did not reach statistical significance (1.08; 95% confidence interval, 0.87–1.31; P = 0.47) after adjusting for age, sex, race, insurance status, and comorbid eye disease. Seven cases of bilateral endophthalmitis with supporting clinical data in the DSBCS group and no cases in the ISBCS group were identified.
Risk of postoperative endophthalmitis was not statistically significantly different between patients who underwent ISBCS and DSBCS or unilateral cataract surgery.

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Manuscript no. 2004-19.

Supported in part by the National Eye Institute, Bethesda, Maryland (grant no.: NEI K2400395), and the Grossman Fund for Preventive Ophthalmology, Baltimore, Maryland.

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Original ArticleThe Incidence of Endophthalmitis after Cataract Surgery among the U.S. Medicare Population Increased between 1994 and 2001

Objective

Design

Data Source

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

Can J Ophthalmol

Ophthalmology

J Cataract Refract Surg

Am J Ophthalmol

J Cataract Refract Surg

J Cataract Refract Surg

Ophthalmology

Surv Ophthalmol

Am J Ophthalmol

J Cataract Refract Surg

Adv Ren Replace Ther

Ophthalmology

Ophthalmology

Prospective evaluation of early visual and refractive effects with small clear corneal incision for cataract surgery

J Cataract Refract Surg

Acute-onset postoperative endophthalmitisreview of incidence and visual outcomes (1995–2001)

Ophthalmic Surg Lasers

Extracapsular extraction of the crystalline lens

Oftalmologia

A 10 year retrospective survey of cataract surgery and endophthalmitis in a single eye unitinjectable lenses lower the incidence of endophthalmitis

Br J Ophthalmol

Original Article
The Incidence of Endophthalmitis after Cataract Surgery among the U.S. Medicare Population Increased between 1994 and 2001