The edition · Ophthalmology
One endophthalmitis in 106 open globes, and a marker that says who to watch closely
Seventeen million procedures give per-operation infection rates worth quoting at consent; microvasculature dropout separates preperimetric eyes that will convert from those that will not; and melanoma carries six times the uveitis risk of lung cancer on checkpoint inhibitors.
The edition in brief
A registry analysis of 17,457,881 ophthalmic procedures between 2016 and 2024 gives 30-day endophthalmitis incidence by operation. In adults the highest was open globe repair at 0.94% - one in 106 - followed by vitrectomy for retinal detachment (0.097%), trabeculectomy (0.1%), tube shunts (0.075%), scleral buckle (0.068%), cataract surgery (0.038%), standalone minimally invasive glaucoma surgery (0.039%), goniotomy (0.02%) and strabismus surgery (0.011%). Children had higher rates after cataract surgery than adults (0.11% against 0.038%, P=0.014) and after scleral buckle (0.415%). A 4.9-year prospective cohort of 93 preperimetric glaucoma eyes found that those with baseline microvasculature dropout lost circumpapillary capillary density faster (-0.88 %/year against -0.23) and developed visual field loss far more often (62.5% against 26.2%, P<0.001), while retinal nerve fibre layer loss did not differ. A propensity-matched cohort of 16,834 melanoma and 16,834 lung cancer patients on immune checkpoint inhibitors found non-infectious uveitis in 1.10% against 0.18% (relative risk 6.17, 95% CI 4.20-9.08), persisting after excluding ipilimumab and nivolumab. A meta-analysis of 23 studies and 1,482 eyes put glaucoma events after Boston type 1 keratoprosthesis at 25.6% overall, with de novo glaucoma in 31.1% and progression of pre-existing disease in 37.7%. And a 12-year series of 27 eyes found secondary inferomedial wall decompression after fat decompression in Graves' orbitopathy reduced proptosis by 4.5 mm and improved acuity in dysthyroid optic neuropathy, with diplopia in 70%.
Melanoma patients on checkpoint inhibitors had six times the uveitis risk of lung cancer patients
In a patient on a checkpoint inhibitor with new visual symptoms, the primary tumour matters - melanoma carries roughly six times the uveitis risk of lung cancer, and it is not explained by combination therapy.
Microvasculature dropout picked out the preperimetric eyes that went on to lose field
In preperimetric glaucoma, baseline microvasculature dropout marks eyes that converted to field loss in 62.5% of cases against 26.2% - use it to set the follow-up interval, not to start treatment.
A quarter to a third of keratoprosthesis eyes developed or progressed glaucoma
Treat glaucoma as an expected sequel of keratoprosthesis rather than a complication - plan the monitoring method before surgery, and consider drainage surgery in eyes that already have it.
Secondary bony decompression rescued proptosis and vision after fat decompression alone
Secondary bony decompression after an inadequate fat decompression works - but consent for it must lead with a 70% rate of diplopia, and a plan for squint surgery afterwards.
Say the number, not the word, when consenting for infection risk
Quote infection risk as a frequency for the specific operation and write the number down - 'a small risk' covers an eightyfold range and documents nothing.
Seventeen million procedures give an endophthalmitis rate for every operation you do
Replace 'a small risk of infection' with the number for the operation in front of you, and raise it for children having cataract surgery, whose rate was about three times the adult one.
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