Postoperative endophthalmitis (POE) remains one of the most feared complications of intraocular surgery. Although incidence has fallen dramatically over time, prevention strategies have traditionally focused on technical measures, including antimicrobial prophylaxis, antisepsis, and refinements in surgical technique. Now, a new real-world study from Fudan University Eye and ENT Hospital asks whether another lever deserves more attention: surgical safety culture.
In late 2019, the hospital introduced a multifaceted safety intervention for all staff involved in ophthalmic surgery. The program combined visual safety cues, biweekly training and educational meetings, standardized regulation of surgical instruments, routine surface microbial sampling, and video-based review of staff performance. Surgeons, nurses, anesthetists, theatre managers, sanitation workers, and sterile-services personnel were all included in the program.
The researchers compared POE rates among 191,657 patients undergoing inpatient ophthalmic surgery at the hospital between 2017 and 2023. Before the intervention, 27 cases occurred among 71,978 patients, giving an incidence of 0.038 percent. After implementation, 16 cases occurred among 119,679 patients (an incident rate of 0.013 percent), corresponding to a 64.4 percent reduction when compared with the pre-intervention period. Poisson regression also showed a significant continued decline in annual incidence during sustained implementation.
The effect was particularly striking in cataract and crystalline lens surgery: POE fell from 0.132 percent before the intervention to 0.021 percent afterward, a greater than six-fold reduction. By contrast, reductions in other subspecialties did not reach statistical significance, possibly reflecting lower event rates or a greater contribution from procedure-specific technical risks.
The authors note that the hospital’s perioperative infection prophylaxis regimen remained unchanged throughout the study, including povidone-iodine preparation and routine intracameral cefuroxime after cataract surgery. The authors therefore argue that the decline was most plausibly associated with the behavioral and organizational intervention rather than a change in antibiotic practice.
The study does have some limitations: it was single-center, included only hospitalized patients, and cannot exclude residual confounding over the seven-year observation period. Even so, its findings suggest that surgical safety may be shaped as much by repeated behaviors, feedback, and shared expectations as by drugs and devices. For ophthalmic units looking for scalable quality-improvement strategies, culture itself may be an intervention worth prescribing.
