NEWS & OPINION 36 EWAP DECEMBER 2022 which 56,551 surgeries were in Group 1, and 29,011 were in Group 2. The study found that 3 eyes (0.005%) in Group 1 and 2 eyes (0.006%) in Group 2 developed postoperative endophthalmitis (P =0.77). The endophthalmitis rate in this study is consistent with a prior study at AECS of 335,000 consecutive phacoemulsification cases (0.01%).4 There was no difference in proportions of phacoemulsification and manual small incision surgery (MSICS) between the two groups, with Groups 1 and 2 having 29,097 (51%) and 12,950 (48%) MSICS cases and 27,454 (49%) and 15,061 (52%) phacoemulsification cases, respectively (P =0.77). The rates of posterior capsular rupture and zonular dialysis were <1.5%, without a difference between the two groups. The study’s findings demonstrate that adopting the four Western OR protocols did not lower endophthalmitis rates following cataract surgery as compared to AECS’ standard protocols. Importantly, despite having multiple patients in the room and reusing of surgical instruments, phacoemulsification tubing, and surgical gowns, postoperative endophthalmitis rates at AECS (0.006%) were lower than the rate reported in the U.S. by the Intelligent Research in Sight (IRIS) Registry (0.04%).8 AECS regularly monitors intraoperative and postoperative surgical outcomes through its electronic clinical registry. By critically evaluating the impact of each step of its surgical protocols and the necessity of each item in the OR, AECS can offer cost-effective ophthalmic surgery without jeopardizing patient safety. Of note, all patients in this study received intracameral moxifloxacin prophylaxis. The findings from this study and others 7,9,10 demonstrate the effectiveness surgery. EWAP References 1. Eckelman MJ, Sherman J. Environmental impacts of the U.S. health care system and effects on public health. PLoS One. 2016;11:e0157014. 2. Freeman W. 2020 Cataract Surgical Equipment Market Report. 2020:55. Table 11. Market Scope. July 2020. Accessed April 15, 2021. staging. market-scope.com/files/prod-ucts/ brochures/196/2020%20 Cataract%20 Equipment%20 Report%20Brochure.pdf 3. Chang DF, Thiel CL, Ophthalmic Instrument Cleaning and Sterilization Task Force. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste. J Cataract Refract Surg. 2020;46:933–940. 4. Haripriya A, et al. Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from 2 million consecutive cataract surgeries. J Cataract Refract Surg. 2019;45:1226–1233. 5. Haripriya A, et al. Complication rates of phacoemulsification and manual small-incision cataract surgery at Aravind Eye Hospital. J Cataract Refract Surg. 2012;38:1360–1369. 6. Thiel CL, et al. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43:1391–1398. 7. Haripriya A, et al. Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery. Br J Ophthalmol. 2022. Online ahead of print. 8. Pershing S, et al. Endophthalmitis after cataract surgery in the United States: A report from the Intelligent Research in Sight Registry, 2013–2017. Ophthalmology. 2020;127:151–158. 9. Ravindran RD, et al. Incidence of post-cataract endophthalmitis at Aravind Eye Hospital: outcomes of more than 42,000 consecutive cases using standardized sterilization and prophylaxis protocols. J Cataract Refract Surg. 2009;35:629–636. 10. Haripriya A, et al. Endophthalmitis reduction with intracameral moxifloxacin prophylaxis: Analysis of 600000 surgeries. Ophthalmology. 2017;124:768–775. Editors’ note: Dr. Shukla is chair of the EyeSustain Editorial Board. Dr. Chang is chair of the EyeSustain Medical Advisory Board. of intracameral antibiotics even in the setting of routinely reusing supplies, medications, surgical devices, and OR attire. In the U.S., we are strictly prohibited from reusing surgical gowns and gloves, or from having more than one patient in the operating room. The risk of microbial cross-contamination is considered high enough that repeatedly violating these policies would lead to closure of the surgical facility. Our study, involving more than 85,000 consecutive patients, found no difference in endophthalmitis rate with or without taking these precautions. This challenges the necessity of our zero-tolerance prohibition of these four OR policies routinely employed at AECS. Because of the substantial economic and environmental cost of needless surgical waste, we should continue to study other OR policies and regulations that may be unnecessary for ophthalmic Table 2. Comparison of postoperative endophthalmitis (POE) by both group and type of cataract surgery. Source (all): Aakriti G. Shukla, MD, and David F. Chang, MD
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