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KP Surgeons Dramatically Reduce Cataract Infections

In a new video, Kaiser Permanente researchers explain how the Walnut Creek ophthalmology department virtually eliminated a rare, surgery-related infection. With Division of Research colleagues, they published the results to wide acclaim.

When the rates of a rare complication of cataract surgery began to rise in Kaiser Permanente Northern California’s busy Walnut Creek ophthalmology offices, Neal H. Shorstein, MD, and colleagues began analyzing individual cases in an attempt to figure out what was going on.

“We couldn’t identify a specific cause or trend,” said Shorstein, a cataract surgeon for more than 20 years and associate chief of quality for Kaiser Permanente’s Diablo Service Area.

Cataracts cause cloudiness in the eye, and the Walnut Creek ophthalmology offices conduct more than 4,000 cataract surgeries per year to improve vision. While the vast majority of the 10- to 15-minute surgeries were successful, a rare but serious infection called endophthalmitis was occurring in about 3 out of 1,000 surgeries.

In addition to standardizing sterilization procedures, Shorstein recommended that the Walnut Creek cataract surgeons adopt a new practice described in a 2006 European study, which showed a five-fold decrease in endophthalmitis. He partnered with Lisa Herrinton, PhD, research scientist with the Kaiser Permanente Division of Research, who helped with the study design, statistical analysis, and interpretation of the results.

Antibiotic drops—applied during cataract surgery and for several weeks afterward—have long been the standard practice to prevent infection. In the European study, the antibiotics were injected directly into the eye at the end of surgery.

In addition to the usual course of eye drops, Shorstein and his colleagues administered the shots—using three different antibiotics—in 16,000 cataract surgeries performed between 2007 and 2011.

The results were outstanding. The rate of endophthalmitis dropped to about 1 in 7,000 cataract surgeries.

“The ability to improve the safety and outcome of cataract surgery with such a simple technique as an injection is very exciting,” Shorstein said. “Patients feel more secure undergoing the operation knowing that we’re able to significantly lower the risk of a devastating complication that can even lead to blindness in some cases.”

Shorstein and Herrinton’s next study will examine the full range of prophylactic practices in cataract surgery, including antibiotic eye drops, to measure their effectiveness, safety, and cost.

Cataract surgeons throughout the Northern California Region are committed to adopting post-operative antibiotic injections as their standard practice.

The results were published in the Journal of Cataract and Refractive Surgery, by Shorstein, Herrinton and Kevin L. Winthrop, MD, of Oregon Health and Science University.

An editorial in the journal noted, “Shorstein et al. are to be congratulated for their courage and integrity in promptly initiating their study in 2007, a study which will undoubtedly become the landmark American contribution to the debate on the efficacy and economics of intracameral antibiotics in the reduction of blindness from postoperative endophthalmitis worldwide.”

“This successful effort to reduce cataract surgery infections demonstrates how Kaiser Permanente clinicians, working in concert with their research colleagues, can innovate to substantially improve care for our members,” said Tracy A. Lieu, MD, MPH, director of the Kaiser Permanente Division of Research.

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