Postoperative endophthalmitis is a rare but severe complication of intraocular surgery. It can threaten vision and, in some cases, lead to permanent visual loss. Traditionally, efforts to reduce this risk have focused on antibiotic prophylaxis, preoperative antisepsis, surgical technique optimization, and new surgical materials. However, surgical safety depends not only on drugs and techniques, but also on the daily behaviors, risk awareness, and continuous improvement practices of healthcare teams.
A real-world study published in Eye Discovery provides new evidence from the perspective of surgical safety culture. Researchers from the Eye & ENT Hospital of Fudan University, the Eye Institute of Fudan University, and collaborators analyzed data from 191,657 patients who underwent inpatient ophthalmic surgery between January 1, 2017 and December 31, 2023. The study evaluated changes in the incidence of postoperative endophthalmitis before and after the implementation of a multifaceted surgical safety culture intervention. After the intervention was implemented, the rate of postoperative endophthalmitis decreased from 0.038% to 0.013%, representing a 64.4% reduction.
The study focused on acute-onset postoperative endophthalmitis, defined as the onset of signs and symptoms within six weeks after surgery. Patients who underwent inpatient ophthalmic surgery during the study period were included, while those who had undergone an intraocular procedure within two months before admission were excluded to reduce the potential influence of previous surgery. The researchers defined 2017 to 2019 as the pre-intervention period and 2020 to 2023 as the post-intervention period.
The intervention was established at the study hospital in late 2019 and continued thereafter. It applied to all personnel involved in ophthalmic surgery, including surgeons, nurses, anesthetists, operating theatre managers, sanitation workers, and sterile services staff. Unlike a single technical measure, the intervention consisted of five components: surgical safety visual cues, periodic training and educational meetings, regulation of surgical instruments, surface microbial sampling in the operating theatre, and video-based performance review. Through these measures, the research team aimed to standardize key safety behaviors and gradually embed a sustainable culture of surgical safety.
Before the intervention, 27 cases of postoperative endophthalmitis occurred among 71,978 ophthalmic inpatients, with an average incidence of 0.038%. After implementation, 16 cases occurred among 119,679 patients, with an average incidence of 0.013%. The difference was statistically significant. Further Poisson regression analysis also showed a significant downward trend in annual postoperative endophthalmitis incidence with sustained implementation. In 2023, the hospital recorded 1 case of postoperative endophthalmitis among 40,782 ophthalmic inpatients, corresponding to an annual incidence of 0.002%. This single-year figure should not be overinterpreted on its own, but together with the overall trend, it suggests that sustained safety culture intervention may have long-term value for quality improvement.
Across ophthalmic subspecialties, patients undergoing cataract and crystalline lens surgery had the highest incidence of postoperative endophthalmitis. Over the full study period, the incidence in this subspecialty was 0.055%. After the intervention, the rate of postoperative endophthalmitis after cataract and crystalline lens surgery decreased from 0.132% to 0.021%, a more than six-fold reduction, with statistical significance. In the subspecialty analysis, this was the clearest reduction and the one that reached statistical significance. By contrast, vitreoretinal surgery also showed a downward trend, but it did not reach conventional statistical significance. In other subspecialties, event numbers were small or no postoperative endophthalmitis cases were observed, so the results should be interpreted with caution.
An important feature of this study is that it did not focus on increasing antibiotic use or changing surgical techniques. Throughout the observation period, the study hospital maintained a relatively consistent perioperative infection prophylaxis regimen, including preoperative lacrimal drainage system irrigation, povidone-iodine disinfection, conjunctival sac irrigation, and routine intracameral cefuroxime at the conclusion of cataract surgery. Against this background of stable infection prophylaxis protocols, surgical techniques, surgical staffing, and patient distribution across subspecialties, the researchers considered that the decline in postoperative endophthalmitis was likely related to standardized processes, behavioral feedback, environmental monitoring, and team education under the surgical safety culture intervention.
From the perspective of hospital quality improvement, this finding is particularly noteworthy. Current discussions about preventing postoperative endophthalmitis often focus on antibiotic regimens, but antibiotic use may raise concerns about antimicrobial resistance, cost, and potential adverse events. In contrast, surgical safety culture intervention is a non-antibiotic strategy. It does not directly alter microbial ecology, nor does it require hospitals to immediately change surgical techniques or introduce complex equipment. Through continuous training, on-site visual reminders, instrument management, environmental sampling, and video-based review, hospitals may identify risks within existing workflows, correct unsafe behaviors, and integrate safety awareness into routine surgical practice.
Microbiological findings also supported this interpretation. Across the study period, the pathogen testing rate among postoperative endophthalmitis cases was 88.37%, and the positive culture rate was 68.42%. There were no significant differences before and after the intervention in pathogen detection rate, culture-negative rate, or pathogen distribution. The researchers suggested that this may be related to the non-antibiotic nature of the intervention, whose effect is more likely to come from reducing opportunities for contamination rather than altering pathogen profiles through antimicrobial pressure.
The study also has several boundaries. First, it was a single-center real-world study, and the study population was limited to hospitalized ophthalmic surgery patients, whereas a substantial proportion of ophthalmic surgeries are performed in outpatient settings. Second, the study was restricted to ophthalmology, so extrapolation to other surgical specialties should be made with caution. Third, although perioperative prophylaxis protocols, surgical teams, and patient distribution across subspecialties remained relatively stable during the study period, residual confounding from unmeasured factors cannot be fully excluded in an observational study. Future multicenter studies are needed to further evaluate the applicability of this framework across different hospitals, ophthalmic procedure types, and other surgical settings.
Overall, this study suggests that reducing the risk of severe postoperative infection does not necessarily depend only on stronger drugs or newer technologies. In highly process-driven and team-based clinical settings such as ophthalmic surgery, safety culture itself may serve as an important tool for quality improvement. By integrating behavioral standards, environmental monitoring, and feedback mechanisms into a sustainable intervention framework, hospitals may further improve surgical safety without increasing the antibiotic burden.
Article information:
Surgical safety culture and postoperative endophthalmitis: A real-world study .
Eye Discovery , 2026, 2:100051.
Article link: https://doi.org/10.1016/j.edisc.2026.100051
About Eye Discovery
Eye Discovery is an open-access, peer-reviewed international academic journal, with ISSN 3117-4167. It is published quarterly by Elsevier and serves as the official journal of Eye & ENT Hospital of Fudan University, China.
Eye Discovery is dedicated to creating a high-end platform for ophthalmologists, scientists, and scholars worldwide to focus on innovative achievements in ophthalmology and interdisciplinary fields, and to promote academic dissemination and exchange.
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Surgical safety culture and postoperative endophthalmitis: A real-world study
10-Aug-2026