ASCRS White Paper: What is the association between clear corneal cataract incisions and postoperative endophthalmitis?

The relationship between unsutured clear corneal tunnel incisions and an increased incidence of infection after cataract surgery remains uncertain; however, there is a growing concern and body of evidence regarding a potential causal association. Although 2 large recent studies from the Bascom Palmer Eye Institute report no greater incidence of endophthalmitis with corneal incisions than with sclerocorneal tunnel incisions, the bulk of the recent literature suggests that post-cataract endophthalmitis is more likely with corneal incisions (Table 1). The concern is fueled by the clear evidence of an increased rate for post-cataract infections since 1994, the timeline for the widespread use of unsutured clear corneal cataract incisions. Indeed, laboratory models indicate that corneal tunnel incisions do not provide hermetic sealing under certain conditions. These investigations suggest that the incisions may be competent at physiologic levels of intraocular pressure (IOP) but fail when IOP is lowered. Critics of the reports, in which human cadaver eyes are used, raise the valid issue that post-mortem eyes lack the corneal endothelial pump mechanism thought to be partly responsible for maintaining incisional self-sealing. Nonetheless, there is a genuine concern regarding the relationship between clear corneal incisions (CCIs) and rates of postoperative infection, suggesting that we carefully evaluate the potential. A recent report in this journal revealed that all cases of endophthalmitis at the Moran Eye Center at the University of Utah from 1996 through 2002 were associated with unsutured clear corneal incisions. During this