Eyeworld

73 EW RESIDENTS March 2019 facilitate the implementation of IC moxifloxacin. IC moxifloxacin has been shown to have a broad spec- trum of coverage with long-term stability and ease of preparation. 9 These factors may motivate clini- cians to reconsider the importance of IC antibiotics at the conclusion of phacoemulsification, especially in the academic setting with resident surgeons. Limitations of the study include partial blinding, lack of a sham injection, use of resident surgeons alone, and the low incidence (37.5%) of culture-proven POE, rais- ing the possibility of confounding cases of sterile vitritis or toxic ante- rior segment syndrome rather than infectious POE. Unfortunately, poly- merase chain reaction (PCR) was unavailable for the detection and identification of bacterial contam- inants. Additionally, surgeons and residents were not masked to the treatment, which may have intro- duced bias in postoperative assess- ments. However, the retina surgeons consulted to evaluate and treat the potential cases of POE were masked to the use of IC moxifloxacin. Surgery for all patients in this study was performed by ophthalmology residents, and the authors noted a slightly increased baseline incidence of POE in their population. Thus, there may be limited applicability to other practice settings in which resident surgeons are not employed. Finally, a sham injection would have improved the study by pro- viding blinding of the surgeon and by being more comparable to the treatment group as any additional instrument introduced into the eye adds a potential risk for infection. Overall, this rigorous study proves significant benefit to use of IC moxifloxacin in reducing the incidence of POE. In the future, assessment of specific infectious agents responsible for presumed POE will further clarify antibiotic ef- fectivity. With its safety, widespread availability, and clear reduction in infection risk, IC moxifloxacin may be regarded as the next step in the evolution of cataract surgery. EW References 1. Olson RJ, et al. Cataract in the Adult Eye Preferred Practice Pattern. Ophthalmology. 2017;124:P1–P119. (p=0.035) without any notable effect on additional ocular parameters including BCVA, endothelial cell count, intraocular pressure, and cen- tral corneal thickness by postopera- tive week 6. This result is consistent with previous randomized trials and large retrospective analyses, which have demonstrated reduced rates of POE following injection of IC antibiotics. 2–6 In total, there were eight cases of POE reported in this study. Only one case of POE occurred in the group treated with IC moxifloxacin, in which cultures grew methicillin- resistant Staphylococcus aureus sen- sitive only to vancomycin. Two of the remaining cases of POE, in the control group, were culture-positive for fluoroquinolone-sensitive organ- isms, suggesting that IC moxifloxa- cin provides additional prophylaxis against POE beyond the standard postop fluoroquinolone drop regimen. While most cases of POE present within the first few weeks of treatment, further follow up beyond 6 weeks would have provided rates of subacute or chronic POE, which have clinically significant implica- tions. Although intraoperative compli- cations, especially posterior capsule rupture, are known to be significant risk factors for POE, in only one case of POE in this study was there an intraoperative complication. Despite the high rate of posterior capsule rupture in this study (approximately 8% in both groups), intraoperative complications did not appear to influence the development of POE. Accordingly, some reporting from the authors about postop factors or complications that could have af- fected the POE rate would have been beneficial. Although the rates of pos- terior capsule rupture may not reflect those in every practice setting, they make this study particularly rele- vant to residency training programs, which have higher rates than private practice settings. 7,8 Future studies could analyze data from combined private practice and academic cen- ters, as well as control for surgeon experience and baseline levels of intraoperative complications. Since moxifloxacin has wid- er commercial availability than some of the other IC preparations that have been studied, the lack of toxicity noted in this study could 2. ESCRS Endophthalmitis Study Group. Pro- phylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33:978–88. 3. Barry P. Adoption of intracameral antibiotic prophylaxis of endophthalmitis following cataract surgery: update on the ESCRS En- dophthalmitis Study. J Cataract Refract Surg. 2014;40:138–42. 4. Au CP, et al. Efficacy and cost-effectiveness of intracameral vancomycin in reducing postoperative endophthalmitis incidence in Australia. Clin Exp Ophthalmol. 2016;44:803– 811. 5. Witkin AJ, et al. Vancomycin-associated hemorrhagic occlusive retinal vasculitis: clinical characteristics of 36 eyes. Ophthal- mology. 2017;124:583–595. 6. Haripriya A, et al. Endophthalmitis reduction with intracameral moxifloxacin prophylaxis: analysis of 600,000 surgeries. Ophthalmology. 2017;124:768–775. 7. Nguyen ET, Shorstein NH. Preparation of in- tracameral antibiotics for injection. J Cataract Refract Surg. 2013;39:1778–9. 8. Pingree MF, et al. Cataract surgery compli- cations in 1 year at an academic institution. J Cataract Refract Surg.1999;25:705–8. 9. Hollander DA, et al. Bacterial endophthalmi- tis after resident-performed cataract surgery. Am J Ophthalmol. 2006;141:949–51. Contact information Mieler: wmieler@uic.edu intracameral moxifloxacin for prevention randomized controlled clinical trial" Safety and efficacy of intracameral moxifloxacin for prevention of post-cataract endophthalmitis: a randomized controlled clinical trial Mathias Melega, MD, Monica Alves, PhD, Rodrigo Pessoa Cavalcanti Lira, PhD, Iuri Cardoso da Silva, MD, Bruna Gil Ferreira, MD, Hermano Assis Filho, MD, Fernando Rodrigo Pedreira Chaves, PhD, Alexandre Martini, MD, Livia Maria Dias Freire, MD, Roberto dos Reis, MD, Carlos Eduardo Leite Arieta, PhD J Cataract Refract Surg. 2019;45(3):343–350. Purpose: To evaluate the safety and efficacy of intracameral (IC) 0.5% moxifloxacin in the prevention of post-cataract endophthalmitis. Setting: University of Campinas, Campinas, Sao Paulo, Brazil Design: Prospective, randomized, partially masked, single-site clinical trial Methods: A total of 3,640 eyes from 3,640 patients who underwent phacoemulsification were randomized into two groups in block sizes of 4. Group A consisted of 1,818 patients who received an IC injection of 0.03 mL (150 µg) of undiluted 0.5% moxifloxacin at the end of surgery. Group B consisted of 1,822 patients who received no IC medication. The postoperative prescription for both groups consisted of 0.5% moxifloxacin and 0.1% dexamethasone. Patients were monitored for 6 weeks after surgery. The primary outcome was the incidence of acute endophthalmitis in each group. Secondary outcomes were best corrected visual acuity (BCVA), endothelial cell density (ECD), intraocular pressure (IOP), and central corneal thickness (CCT). Results: The incidence of endophthalmitis within 6 weeks of follow up was 1 out of 1,818 eyes (0.05%) in the moxifloxacin group and 7 out of 1,822 eyes (0.38%) in the control group (p=0.035). There was no significant difference in BCVA (p=0.202), ECD (p=0.482), IOP (p=0.105), or CCT (p=0.558). No ocular or systemic study-related adverse events were observed. Conclusions: The IC injection of undiluted 0.5% moxifloxacin can be safely applied as the last step of phacoemulsification. It was found to be effective in reducing the risk of endophthalmitis. This study represents the first controlled randomized clinical trial to evaluate the safety and efficacy of IC moxifloxacin in the prevention of post-cataract endophthalmitis.

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