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Purpose: To report the incidence of acute postoperative endophthalmitis (POE) after macular surgery in France between 2006 and 2016 and to identify associated factors., Methods: This retrospective database study included all hospital discharge records involving a surgical procedure for an epiretinal membrane or a macular hole in France from January 2006 to October 2016. Acute POE was identified by two codes in the tenth edition of the International Classification of Diseases within 42 days of a macular surgical procedure in the French national administrative database., Results: In France, 152 034 macular surgical procedures for epiretinal membranes or macular holes were recorded from 1 January 2006 to 31 October 2016. Suspected acute POE was reported in 381 cases. The incidence of POE was 0.25% overall, 0.30% for epiretinal membrane surgery and 0.14% for macular hole surgery. In multivariable Poisson regression analysis, epiretinal membrane surgery was associated with POE [incidence rate ratio (IRR), 2.24; 95% CI, 1.62-3.11; p < 0.001]. For epiretinal membrane surgery, the 2010-2011 period was significantly associated with a higher risk of POE (IRR, 1.66; 95% CI, 1.13-2.42; p = 0.03)., Conclusion: The incidence of POE after macular surgery was 0.25% overall in France between 2006 and 2016 and twice higher for epiretinal membrane surgery than for macular hole surgery. For epiretinal surgery only, the incidence of POE was higher in 2010-2011 (period of the switch to transconjunctival vitrectomy) than in the rest of the study period., (© 2019 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: To assess the incidence of acute postoperative endophthalmitis (POE) after cataract surgery combined with corneal, glaucoma or vitreoretinal surgical procedures from 2005 to 2014 in France., Methods: In this cohort study, acute POE occurring within 6 weeks after surgery was identified by means of billing codes recorded in a national database in patients operated for cataract extraction with phacoemulsification, or corneal, glaucoma or vitreoretinal surgical procedures, either combined or stand-alone., Results: From January 2005 to December 2014, up to 6 260 477 eyes underwent phacoemulsification cataract surgery as a single procedure and 115 468 eyes underwent phacoemulsification combined with corneal, glaucoma or vitreoretinal surgical procedures. The crude incidence of acute POE after stand-alone or combined cataract surgery was 0.102% and 0.149%, respectively. In multivariate Poisson analysis, combined surgery taken as a whole was at higher risk than cataract stand-alone surgery, with an adjusted incidence rate ratio (IRR) (95% CI) of 1.38 (1.11 to 1.70; p=0.0054). Glaucoma surgeries were associated with a lower acute POE incidence compared with phacoemulsification, conversely to vitreoretinal surgical procedures: IRR 0.63 (0.47 to 0.85; p<0.001) and IRR 1.78 (1.58 to 2.01; p<0.001), respectively., Conclusion: A higher incidence of acute POE after combined cataract surgery than after cataract surgery done as a stand-alone procedure was observed based on the French nationwide medical-administrative database. The incidence of acute POE after combined surgery was related to the type of surgery performed simultaneously with cataract extraction., Competing Interests: Competing interests: EB, ASM and CQ have nothing to disclose. VD reports personal fees and non-financial support from Bayer, Novartis, Alcon, Horus and Thea outside the submitted work. JFK reports personal fees from Alcon, Allergan, Alimera, Bayer, Novartis, Roche, Thea and Zeiss outside the submitted work. AMB reports personal fees from Allergan and Bausch Lomb, grants from Horus, personal fees from Thea and Zeiss outside the submitted work. CPCG reports grants and personal fees from Allergan, Bayer, Novartis, Horus and Thea outside the submitted work., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: The number of patients affected by retinal diseases treated with intravitreal injections (IVTs) has resulted in a rapidly growing number of procedures. One of the worst complications after these injections is endophthalmitis., Objective: To evaluate the incidence of acute endophthalmitis after IVTs of corticosteroids or anti-vascular endothelial growth factor (anti-VEGF) agents., Design, Setting, and Participants: This population-based cohort study included patients undergoing IVTs from January 1, 2012, through December 31, 2015, in France. Data were acquired from the French medical-administrative database (Système National d'Information Inter-Régime de l'Assurance Maladie), which collects hospitalization discharge abstracts and out-of-hospital care information for the whole country. Data were analyzed from March through July 2017., Exposures: Intravitreal injections of corticosteroid or anti-VEGF agents., Main Outcomes and Measures: Incidence of acute endophthalmitis within 6 weeks after IVT by means of billing codes from a national database., Results: During the study period, 1 811 977 IVTs of corticosteroids or anti-VEGF agents performed on 254 927 patients (60.4% female; median age, 79 years [interquartile range, 70-85 years]) were analyzed. A total of 444 acute endophthalmitis cases (crude incidence, 0.0245%) were recorded. In multivariable analysis, which did not include adjustment for when the endophthalmitis occurred during the study period, the risk of endophthalmitis was lower in male patients (incidence rate ratio [IRR], 0.78; 95% CI, 0.63-0.96; P = .02), higher for corticosteroids than for anti-VEGF agents (IRR, 3.21; 95% CI, 2.33-4.44; P < .001), and higher for nonprefilled syringes of anti-VEGF medications than prefilled syringes for ranibizumab (IRR, 1.63; 95% CI, 1.15-2.30) and aflibercept (IRR, 1.82; 95% CI, 1.25-2.66; P < .001)., Conclusions and Relevance: The findings from this study of a nationwide database appear to have confirmed the low incidence rate of acute endophthalmitis after IVTs of corticosteroids or anti-VEGF agents. Although an association may not necessarily indicate a cause and effect, the risk for acute endophthalmitis after IVTs appeared to be higher for corticosteroids compared with anti-VEGF agents, while a lower risk of endophthalmitis appeared to be found with prefilled syringes of anti-VEGF medications.

Purpose: To evaluate epidemiology, diagnostic and therapeutic management strategies and visual outcomes of cases of bacterial and fungal endogenous endophthalmitis managed in the Nice University Medical Center between January 2000 and June 2015., Methods: Three hundred twenty-three charts of patients with endophthalmitis treated at the Nice University Medical Center over this period were retrospectively reviewed to select the ones with endogenous endophthalmitis. Demographic characteristics, medical history, clinical presentation, diagnostic and therapeutic management, microbiology, and final outcomes were analyzed., Results: Twenty-two eyes of 20 patients were selected, constituting 6.20% of all cases of endophthalmitis. The mean age was 69years, and 75% of patients were male. The most common risk factors were diabetes, malignancies and cardiac diseases. Bacterial isolates were found in 16 cases (80%), fungal isolates in 3 (15%) and co-infection in 1 case. Gram-positive organisms accounted for 70.6% of cases (mostly Staphylococcus aureus [25%], Streptococcus agalactiae [25%] and Streptococcus pneumoniae [16.7%]). Candida albicans was the most common fungal organism. There was one bacterial and fungal co-infection. Two patients died, 4 eyes were enucleated or eviscerated (20%), and 4 patients (20%) attained a final visual acuity of 1/10 or better., Conclusion: Endogenous endophthalmitis is a rare and serious condition with a poor prognosis. Gram-positive microorganisms, mostly S. aureus, were the main causative pathogens found., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Purpose: To report the incidence and characteristics of endophthalmitis after intravitreal injections of anti-vascular endothelial growth factor agents or corticosteroids and to describe the clinical and bacteriologic characteristics, management, and outcome of these eyes with acute endophthalmitis in France., Design: Retrospective, nationwide multicenter case series., Methods: From January 2, 2008 to June 30, 2013, a total of 316,576 intravitreal injections from 25 French ophthalmic centers were included. For each center, the number of intravitreal injections was determined using billing codes and the injection protocol was recorded. A registry and hospital records were reviewed to identify patients treated for endophthalmitis after injection during the same time period. The main outcome measures were the incidence of clinical endophthalmitis and visual acuity of endophthalmitis cases., Results: During the study period, 65 cases of presumed endophthalmitis were found, giving an overall incidence of 0.021% (2.1 in 10,000 injections) (95% confidence interval [CI], 0.016%-0.026%). The median number of days from injection to presentation was 4 [1-26] days. The most common symptom was vision loss. Bacterial identification was achieved in 43.4%. The most frequent pathogens were gram-positive bacteria (91.3%), including coagulase-negative Staphylococcus in 78.3%. Neither the interval between injection and presentation for endophthalmitis nor the clinical signs differentiated culture-positive from culture-negative cases. In multivariate analysis, the use of a disposable conjunctival mould assist device and the use of prophylaxis with an antibiotic or antiseptic were significantly associated with an increased incidence of endophthalmitis (P = .001). The majority of patients had worse visual acuity after 3 months of follow-up when compared with acuity before endophthalmitis., Conclusions: The incidence of presumed endophthalmitis after intravitreal injections of anti-vascular endothelial growth factors or corticosteroids was low and the prognosis poor. Prevention and management remain challenging. It remains to be determined whether the findings of this study are relevant for other countries using different techniques for intravitreal injections., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To determine whether an intracameral injection of cefuroxime at the end of cataract surgery decreases the incidence of postoperative endophthalmitis., Setting: Dupuytren Hospital, Ophthalmology Department, Limoges, France., Design: Clinical trials., Methods: Patients having cataract surgery between April 2003 and June 2008 were included in a survey of operative-site infection. Intracameral cefuroxime injections started in June 2006. Preoperative data (beta-lactam allergy, a history of endophthalmitis, age, sex), intraoperative data (use of trypan blue, use of capsular ring or iris retractors, surgical time, senior or junior surgeon, corticosteroid injection, iris retractors), and the incidence of postoperative infections at 8 days and 1 month were prospectively collected., Results: During the inclusion period, 5115 patients had cataract surgery; 2289 received cefuroxime and 2826 did not. The incidence of endophthalmitis was 35 (1.238%) of 2826 patients without intracameral cefuroxime and 1 (0.044%) of 2289 patients with intracameral cefuroxime; the difference was statistically significant (P<.0001). No intraoperative factor was significantly associated with postoperative infection. No allergic reaction was reported., Conclusion: Intracameral cefuroxime injection at the end of cataract surgery was safe and significantly decreased the incidence of endophthalmitis., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Background: Endophthalmitis is a severe condition that requires hospitalization with at least day care. Information on the incidence rate, costs and consequences of endophthalmitis is scarce., Objective: To estimate the number of patients with endophthalmitis hospitalized in France, as well as the average costs and hospital budget consequences., Methods: French Programme de Médicalisation des Systèmes d'Information (PMSI) data for 2006, derived from the official DRG classification, were analysed. Data were extracted concerning the following primary diagnoses: 'purulent endophthalmitis', 'other endophthalmitis' and 'endophthalmitis associated with another disease'. Two durations of hospitalization were compared: the actual duration and a weighted DRG duration. The cost of hospitalization was weighted by the average DRG cost + daily hospital costs x the difference between the actual and weighted DRG days in hospital. All costs are presented in euro, year 2007 values., Results: A total of 1518 patients (mean age 68.7 years; 47.1% male) experienced 1725 hospitalizations for endophthalmitis, including 1416 cases (82.1%) admitted to public hospitals. The majority of patients (79.1%) were classified by DRG codes that did not specify endophthalmitis (DRG 02M03Z). Most patients (1342) were given a drug injection and 510 underwent vitrectomy. Four patients died in hospital and 75 were transferred to other hospitals. The actual duration of hospitalization for endophthalmitis in public hospitals was 8.1 days (mean), whereas the average weighted DRG duration was 5.1 days, which underestimated the actual duration by 3 days. The average hospital cost was 3688 euro per patient, totalling 6,361,119 euro per annum for all public and private hospitalizations in France, including 223,723 euro as day care. If hospital funding was wholly based on DRG tariffs, the budget for endophthalmitis would be severely underestimated. The DRG inclusion of 'severe acute ocular infections' as a proxy for endophthalmitis dramatically underestimated its true cost by approximately 30%., Conclusion: For health economic evaluations, it is inappropriate to use DRG classifications as proxies for endophthalmitis. Expressed more generally, hospitalization cost analyses should not be based on any specific DRG, but always on the clinically relevant primary diagnosis. The PMSI clustering algorithm underestimates the hospital budgets required for endophthalmitis. Lastly, the PMSI (exhaustively reporting all hospitalizations) is best suited to capturing yearly endophthalmitis incidence rates, average costs and national health expenditure.

Purpose: To report results of the National French Observational Database for Endophthalmitis (Observatoire National Des Endophtalmies [ONDE])., Setting: Departments of ophthalmology at universities, general hospitals, and private clinics., Methods: In this multicenter national interventional case series, data were collected prospectively between March 1, 2003, and November 1, 2004, from French ophthalmologists who answered a standardized 175-item questionnaire. The data were from patients with acute-onset endophthalmitis after cataract surgery. Before surgery, all 105 patients had received an official information card from the French Ophthalmological Society and provided written informed consent., Results: The study comprised 105 patients. The median time from cataract extraction to endophthalmitis was 4 days (range 1 to 39 days). All but 1 patient had symptoms, with blurred vision being the most common. Initial visual acuity was 5/200 or better in 18.9% (18/95) of patients. Intraocular samples from 90.5% (95/105) of patients yielded 45 pathogens, of which 86.7% were gram positive. Treatments included intraocular antibiotic injections in 95.1% (98/103) of patients, intraocular steroid injections in 41.4% (41/99) of patients, and immediate vitrectomy in 14.0% (14/100) of patients. Visual acuity at 3 months was 20/100 in 64% of patients., Conclusions: The ONDE study disclosed important changes in French ophthalmic surgical practice 15 years after the first prospective endophthalmitis survey and 12 years after a United States study were published. Progress toward standardization of preventive methods (eg, patient information, increased systemic antibiotic efficacy, more frequent corticosteroid use) has contributed to fewer vitrectomies.

Under the aegis of the GEEP (Groupement d'Etudes Epidémiologiques et Prophylactiques) a prospective multicentre study concerning bacterial endophthalmitis was carried out over a period of one year long with the contribution of 64 metropolitan ophthalmologic hospital departments. During this survey 143 cases of post surgical endophthalmitis were recorded: 111 of them were secondary to elective surgery, 32 developed after a perforating eye injury. Twenty-four cases of endophthalmitis developed in the absence of surgery were therefore called "medical" endophthalmitis. The frequency of endophthalmitis after elective surgery was 0.32%, and 2.8% after penetrating eye injury. Intraocular samples were obtained in 61.5% of the cases of post surgical endophthalmitis. 53 bacteria were isolated from 50 cases of endophthalmitis. The bacterial nature of the endophthalmitis was proved in 35% of these cases of post surgical endophthalmitis. Bacteria isolated from these cases of post surgical endophthalmitis were gram positive in 86.7%, and gram negative in 13.3% of cases. 20 bacteria were isolated from pseudophakic eyes: 10 of them were Staphylococcus epidermidis. The visual prognosis of endophthalmitis depends on the strain: visual acuity was more than 1/10 in 68% of cases of Staphylococcus endophthalmitis infection, but in only in 7% of cases of Streptococcus endophthalmitis infection. Intraocular injections of antibiotics both in the anterior chamber and in the vitreous, and vitrectomy increased the quality of the visual result. Three months after post surgical endophthalmitis, 35% of those eyes who received systemic and periocular antibiotic therapy, combined with intraocular antibiotics, with or without vitrectomy, recovered a visual acuity of 4/10 or more, instead of only 18% in the group without any intraocular therapy.

Data from retrospective studies of endophthalmitis vary widely with respect to incidence and to the pathogens implicated. To see whether we could provide more accurate data, we have done a prospective multicentre national survey of endophthalmitis over one year in France. Records of 36,241 operations and 1148 cases of ocular trauma from 64 centres specialising in eye surgery were analysed. There were 167 cases of endophthalmitis; incidence of postoperative endophthalmitis was 0.31 per 100 operations, and the risk after penetrating ocular trauma was 2.8%. In contrast with most previous studies, Staphylococcus epidermidis was the most frequently isolated organism, with gram-negative organisms accounting for only a small proportion of cases. Patients infected with streptococci had the least favourable outcome. The survey confirms data from retrospective studies showing that the incidence of postoperative or post-injury endophthalmitis is low. The low frequency means that large numbers of patients would be required for a trial of antibiotic efficacy, but such a trial is worthwhile because there are now antibiotics with good ocular bioavailability that are effective against most of the bacteria that cause endophthalmitis.