Reply
Authors: Sarah Hilkert Rodriguez, Lindsay Chun, Chuanhong Liao
Journal: Ophthalmology (2023)

We thank Liu et al for their insightful comments regarding the association between aphakia and endophthalmitis after pediatric cataract surgery. We agree that these issues require further scrutiny, and we are grateful for the opportunity to expand on these important points. Liu et al noted the myriad confounding factors that could potentially contribute to the observed higher incidence of endophthalmitis when comparing children to adults: differences in surgical techniques, underlying ocular conditions in children, and systemic disparities in health care. One difference in surgical techniques is the handling of the posterior capsule. As adult studies have reported an association between posterior capsular tears and endophthalmitis,1Hatch W.V. Cernat G. Wong D. et al.Risk factors for acute endophthalmitis after cataract surgery: a population-based study.Ophthalmology. 2009; 116: 425-430Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar we also used codes for same day anterior vitrectomy as a proxy for opening the posterior capsule. The absence of an association with anterior vitrectomy in this database may reflect one such difference in surgical techniques. The opening of the posterior capsule in children is often a planned step in pediatric cataract surgery rather than a complication. In considering other surgical techniques, incisions are typically smaller for children who are left aphakic than for children in whom intraocular lenses (IOLs) are placed. We had originally hypothesized that placing an IOL in very young children might increase the risk of endophthalmitis owing to potential wound leaks. To the contrary, we found that wound revision was associated with aphakia. Other more subtle differences in surgical techniques may not be captured with Current Procedural Terminology codes, although incision closure and posterior capsular management represent two of the more common differences. With regard to underlying systemic conditions, baseline factors among children that preclude IOL implantation could certainly confound the association between aphakia and endophthalmitis. Some potential factors include age, gender, trauma, Marfan syndrome, lens displacement, juvenile idiopathic arthritis, other types of uveitis, developmental delay, trisomy 21, or an immune compromised status. In this particular analysis, we explored trauma as a potential confounder, and neither excluding cases with trauma nor controlling for trauma changed the significance of the association. We later reported that none of these factors explained the association between aphakia and endophthalmitis among children, although we did find that developmental delay may represent an additional independent risk factor.2Chun L. Tanenbaum R. Liao C. et al.The association between developmental delay and endophthalmitis after pediatric cataract surgery using an insurance claims database.J AAPOS. 2023 Oct 26; 10.1016/j.jaapos.2023.09.003Abstract Full Text Full Text PDF Scopus (1) Google Scholar We also considered the possibility that higher complexity cataract surgeries might confound the relationship between aphakia and endophthalmitis. Indeed, retinal detachment (RD) and vitreous hemorrhage (VH) were both associated with aphakia. However, among the 33 cases of suspected endophthalmitis, RD and VH were not associated with IOL status. Because most cases of RD or VH were present before surgery rather than between the surgery and the endophthalmitis diagnosis, we agree that more complex baseline ocular conditions that preclude IOL placement, rather than a protective effect of the IOL per se, could explain the observed findings. These data show association but not causation. Importantly, Liu et al also emphasized the role of antibiotics. We used J-codes to evaluate for intraoperative antibiotics, but only 3% of all surgeries included J-codes. There was no difference in the proportion of patients who received antibiotics by IOL status (2.8% vs 3.3%; P = 0.43). Although the data from this study are insufficient to address this important variable, we advocate for the use of intracameral antibiotics in all pediatric cataract cases, especially if the child may have an aversion to drop instillation. Regarding systemic disparities in care, claims data fall short of capturing many social determinants of health. Marketscan includes children whose parents have employer-sponsored private health insurance; race, ethnicity, and socioeconomic data are lacking. We repeated the analysis among 12 794 children covered by Medicaid insurance with similar results.3Chun L. Liao C. Rodriguez S.H. Evaluating endophthalmitis after pediatric cataract surgery using the CMS Medicaid claims database.Women in Ophthalmology Meeting, Carlsbad, California. August 25–28, 2022; Google Scholar However, our data use agreements prohibited combining datasets. Finally, errors in coding are possible, although in a large database, errors would not be expected to have a differential impact on patients based on IOL status. To avoid misinterpreting Current Procedural Terminology codes, we individually reviewed claims for all endophthalmitis cases. Overall, Liu et al highlighted some important drawbacks to claims data: limited patient-specific information, surgical details, and postoperative care protocols. Nonetheless, these data offer the most comprehensive and highly powered study of potential risk factors of postcataract surgery–related endophthalmitis in a pediatric population to date. We thank the authors for their thoughtful comments, and we welcome additional studies. Re: Rodriguez et al.: Association between aphakia and endophthalmitis after pediatric cataract surgery (Ophthalmology. 2023;130:551–553)OphthalmologyVol. 131Issue 3PreviewThe recent report by Rodriguez et al1 undeniably stimulates thought on several vital issues, while at the same time putting forth a number of propositions that warrant further scrutiny. Full-Text PDF