Postoperative endophthalmitis, a rare but potentially devastating infection inside the eye, fell by 64.4% after a hospital introduced a comprehensive surgical safety culture program, according to a real-world study published in Eye Discovery. The condition can emerge after intraocular surgery when microorganisms enter the eye, triggering intense inflammation that may rapidly damage delicate retinal tissues and threaten permanent vision loss. While prevention has traditionally emphasized antibiotics, antiseptic preparation, and surgical technique, the new findings suggest that coordinated staff behavior and continuous process monitoring may also have a measurable effect on infection risk.
Researchers from the Eye & ENT Hospital of Fudan University, the Eye Institute of Fudan University, and collaborating institutions examined medical records from 191,657 patients who underwent inpatient ophthalmic surgery between January 2017 and December 2023. The investigators compared the incidence of acute-onset postoperative endophthalmitis before and after a multifaceted safety intervention introduced in late 2019. Acute-onset cases were defined as infections in which signs and symptoms appeared within six weeks of surgery. Patients who had undergone an intraocular procedure during the preceding two months were excluded to reduce the possibility that an earlier operation had contributed to the infection.
During the three-year pre-intervention period, 27 cases of postoperative endophthalmitis occurred among 71,978 ophthalmic inpatients, corresponding to an average incidence of 0.038%. In the four years following implementation, 16 cases were recorded among 119,679 patients, reducing the average incidence to 0.013%. The difference was statistically significant. A Poisson regression analysis, a statistical method commonly used to evaluate the frequency of relatively rare events, also identified a significant downward trend in annual infection rates as the intervention continued.
The most striking annual result appeared in 2023, when only one case was reported among 40,782 ophthalmic inpatients. That represented an incidence of approximately 0.002%. Because a single event in one year can be strongly influenced by chance, the researchers cautioned against interpreting the figure in isolation. However, the 2023 result occurred within a broader multiyear decline, suggesting that the intervention may have supported sustained improvement rather than producing only a short-term reduction.
The safety program was designed to influence the entire surgical system rather than a single clinical procedure. It involved visual reminders placed in surgical areas, recurring training sessions and educational meetings, tighter regulation of surgical instruments, microbial sampling of operating-room surfaces, and video-based reviews of staff performance. The program included surgeons, nurses, anesthetists, operating-theatre managers, sanitation workers, and sterile-services personnel. By involving every group that interacts with the surgical environment, the hospital sought to reduce small inconsistencies that can accumulate across instrument handling, room preparation, cleaning, and intraoperative workflow.
The intervention’s apparent effect was particularly clear in cataract and crystalline lens surgery, the ophthalmic subspecialty with the highest overall infection rate. Across the entire study period, the incidence in this group was 0.055%. After the safety program began, the rate fell from 0.132% to 0.021%, representing a reduction of more than sixfold. This was the clearest statistically significant subspecialty-specific change. Vitreoretinal surgery showed a downward trend that did not reach conventional statistical significance, while other subspecialties had too few events to support firm conclusions.
The findings are notable because the hospital did not substantially increase antibiotic use or introduce a new antimicrobial regimen during the observation period. Its perioperative infection-prevention practices remained relatively consistent and included irrigation of the lacrimal drainage system, povidone-iodine disinfection, conjunctival sac irrigation, and routine intracameral cefuroxime at the end of cataract surgery. Surgical techniques, staffing patterns, and the distribution of patients among subspecialties were also described as relatively stable. This allowed the researchers to examine whether behavioral and organizational changes could contribute additional protection on top of established medical safeguards.
Microbiological results provided further context. Pathogen testing was performed in 88.37% of postoperative endophthalmitis cases, and 68.42% of tested cases produced a positive culture. The study found no significant before-and-after differences in pathogen detection, the proportion of culture-negative cases, or the distribution of identified microorganisms. This pattern suggests that the intervention may not have changed which organisms were present or exerted the selective pressure associated with heavier antibiotic exposure. Instead, its benefit may have resulted from reducing opportunities for contamination through more consistent environmental control, instrument management, and staff behavior.
The researchers emphasized that the study cannot prove that the safety culture program alone caused the decline. It was a single-center observational analysis involving hospitalized patients, while many ophthalmic procedures take place in outpatient settings. Unmeasured changes in patient characteristics, clinical practice, or hospital operations may also have influenced the results. Nevertheless, the large patient population, the sustained follow-up period, and the consistency of the decline provide a strong basis for further investigation. Multicenter studies will be needed to determine whether similar interventions work across different hospitals, surgical environments, and ophthalmic procedures.
The study points to a broader lesson in infection prevention: safer surgery may depend as much on reliable systems as on powerful drugs or advanced technologies. Endophthalmitis is rare, which makes it difficult for any single hospital to detect meaningful changes quickly, but small improvements in preparation, communication, equipment handling, environmental hygiene, and feedback may collectively reduce risk. By embedding these behaviors into everyday practice, surgical teams may improve patient safety without increasing antibiotic exposure. The findings position safety culture as a practical, non-antibiotic strategy that could complement established infection-control measures in ophthalmology and potentially other highly coordinated surgical specialties.
Subject of Research: People
Article Title: Surgical safety culture and postoperative endophthalmitis: A real-world study
News Publication Date: 10-Aug-2026
Web References: https://doi.org/10.1016/j.edisc.2026.100051; https://www.sciencedirect.com/journal/eye-discovery
References: Eye Discovery, 2026, 2:100051. DOI: 10.1016/j.edisc.2026.100051
Image Credits: Biyun Zhan
Keywords: postoperative endophthalmitis, ophthalmic surgery, surgical safety culture, cataract surgery, infection prevention, patient safety, operating-room hygiene, antibiotic stewardship, ophthalmology, healthcare quality improvement
