Higher Endophthalmitis Risk After Open Globe Repair, and Pediatric Cataract Surgery Carries More Risk Than Adult Surgery
Highlights
Endophthalmitis remained an uncommon complication across ophthalmic surgery, but its incidence differed markedly by procedure.
Open globe repair had the highest 30-day rate in both adults and children, underscoring the infectious risk associated with traumatic ocular injury and urgent repair.
Pediatric cataract surgery carried a significantly higher risk than adult cataract surgery, while MIGS procedures had infection rates similar to standard cataract surgery.
Background
Postoperative endophthalmitis is one of the most feared complications in eye surgery because even a rare case can lead to profound vision loss. Although modern aseptic technique, perioperative antibiotics, and improved surgical workflows have reduced risk, the true incidence varies by procedure, patient age, and underlying ocular pathology. Cataract surgery has historically dominated endophthalmitis surveillance because of its high volume, but other operations such as vitreoretinal surgery, glaucoma procedures, strabismus repair, and traumatic open globe repair also carry important infectious risk.
Large registry studies are especially valuable in this setting because randomized trials are generally too small to measure rare events like endophthalmitis. The IRIS® Registry, maintained by the American Academy of Ophthalmology, provides a national-scale view of real-world ophthalmic care and can reveal procedure-specific patterns that are difficult to observe in single-center studies.
Study Design
This retrospective clinical cohort study examined adult and pediatric patients in the American Academy of Ophthalmology IRIS® Registry who underwent ophthalmic surgery from 2016 to 2024. The primary outcome was acute endophthalmitis diagnosed within 30 days after surgery. The analysis included 17,457,881 procedures, making this one of the largest datasets to date evaluating postoperative endophthalmitis across multiple ophthalmic procedures.
The study compared infection incidence across procedure categories, including open globe repair, vitrectomy for retinal detachment, trabeculectomy, tube shunts, scleral buckle surgery, cataract surgery, standalone MIGS, goniotomy, and strabismus surgery. A key comparison was pediatric versus adult cataract surgery. The investigators also evaluated whether same-day cataract and glaucoma surgery differed in infection risk from glaucoma surgery alone.
Key Findings
The headline result is that postoperative endophthalmitis was rare overall but not uniform across procedures. In adults, the highest incidence occurred after open globe repair at 0.94%, or roughly 1 case per 106 procedures. This is clinically intuitive: open globe injuries are often contaminated, emergent, and accompanied by tissue disruption, all of which can increase infection risk.
Among adult posterior-segment and glaucoma procedures, incidence was 0.097% after vitrectomy for retinal detachment, 0.1% after trabeculectomy, 0.075% after tube shunt surgery, and 0.068% after scleral buckle surgery. Cataract surgery, the most common ophthalmic procedure, had a lower infection incidence of 0.038%, or approximately 1 case per 2,652 surgeries. Standalone MIGS procedures showed a similar rate at 0.039%, suggesting that these minimally invasive glaucoma procedures do not appear to carry an infection burden meaningfully higher than routine cataract surgery. Goniotomy was even lower at 0.02%, and strabismus surgery had the lowest reported adult incidence at 0.011%.
In pediatric patients, the same general pattern held, but the absolute and relative risks differed. Open globe repair again showed the highest incidence at 0.87%, or about 1 case per 115 procedures. Other notable pediatric rates included 0.415% after scleral buckle surgery, 0.11% after cataract surgery, 0.084% after vitrectomy for retinal detachment, and 0.0072% after strabismus surgery. The finding that pediatric cataract surgery had a significantly higher rate of endophthalmitis than adult cataract surgery (P = 0.014) is clinically important and likely reflects differences in ocular anatomy, underlying disease, surgical complexity, postoperative care adherence, and the feasibility of postoperative drop administration and follow-up in younger children.
The comparison of same-day cataract and glaucoma surgery versus glaucoma surgery alone did not show a significant difference in endophthalmitis rates. That result is reassuring for surgeons considering combined procedures when otherwise clinically appropriate, though the rarity of the event means small absolute differences may still be difficult to detect reliably.
Several broader clinical patterns emerge from the data. First, trauma-related surgery is consistently the highest-risk category, which emphasizes the need for rapid repair, careful intraoperative decontamination, and vigilant postoperative surveillance. Second, infection risk after modern cataract and MIGS procedures is low in absolute terms. Third, pediatric eyes appear to require special attention, particularly for cataract surgery, where the risk appears higher than in adults.
Expert Commentary
These findings should be interpreted in the context of the strengths and limitations of registry research. The major strength is scale: more than 17 million procedures provide enough power to estimate rare outcomes and to compare multiple surgery types. The IRIS Registry also reflects real-world practice across diverse settings, making the results highly relevant to clinical care and quality improvement.
At the same time, registry-based analyses depend on accurate coding and complete documentation. Endophthalmitis identified within 30 days may miss delayed presentations, and diagnosis codes may not always distinguish culture-proven endophthalmitis from presumed cases. The dataset may also lack granular information on important risk modifiers such as intraoperative complications, wound construction, antibiotic prophylaxis choice, case complexity, surgical duration, lens status, postoperative medication adherence, or microbiologic findings. These unmeasured variables could partly explain procedure-specific differences.
Even with those limitations, the results align with established clinical expectations. Open globe repair is inherently high risk because the eye has already been breached, and contamination may precede surgery. Cataract surgery remains low risk overall, but pediatric cataract cases are often more complex than adult cases and require different perioperative management. The finding that MIGS infection rates were comparable to cataract surgery is reassuring as minimally invasive glaucoma techniques continue to expand.
From a practice standpoint, these data can support informed consent, perioperative counseling, and institutional quality benchmarks. For high-risk procedures, especially open globe repair and certain pediatric cases, clinicians may consider more intensive postoperative monitoring and a low threshold for evaluation if pain, vision loss, hypopyon, or inflammation occurs.
Conclusion
This IRIS Registry analysis shows that postoperative endophthalmitis is uncommon but highly procedure dependent. Open globe repair carries the greatest risk, and pediatric cataract surgery appears riskier than adult cataract surgery. In contrast, MIGS procedures do not appear to confer a higher infection risk than standard cataract surgery. The study reinforces the value of registry-scale surveillance for rare but vision-threatening complications and provides useful benchmarks for surgical counseling and quality improvement.
Funding and ClinicalTrials.gov
This was a retrospective registry-based cohort study using the AAO IRIS® Registry. No clinical trial registration is applicable.
References
1. Chaaya C, Goldberg EA, Ross CJ, et al. Comparative Endophthalmitis Rates in Adult and Pediatric Patients Across Various Ophthalmic Procedures: An IRIS® Registry Analysis. Ophthalmology. 2026-04-13. PMID: 41985695.
2. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study. Arch Ophthalmol. 1995;113(12):1479-1496.
3. American Academy of Ophthalmology. IRIS® Registry. Clinical and quality improvement resource for ophthalmology outcomes research.
