SEP 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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66 EW CORNEA September 2013 Preventing endophthalmitis by Michelle Dalton EyeWorld Contributing Writer Some argue intracameral injections are best, while others are using topical drops instead would have the best risk-to-reward ratio." Dr. Shorstein's group looked at more than 16,000 patients; the most striking revelation was that the people who developed infections were those who were not administered intracameral cefuroxime either because of allergy or because the group was initially afraid to inject it in cases of posterior capsular rupture. "When we added moxifloxacin for those allergic patients and injected in all patients, especially in the complicated cases, we found a truly significant decline in infection," he said. W ith seemingly overwhelming evidence from large cohort studies that intracameral injections can help deter endophthalmitis in the postop cataract patient, more and more European surgeons are embracing the studies and using intracameral cefuroxime. Yet in the U.S., skepticism remains high. "There are no antibiotics currently approved for intracameral use in the U.S. But there are also no topical antibiotics approved for postcataract surgery prophylaxis either. I'm not sure why there is so much resistance to intracameral, especially considering the strong data," said Christina Rapp Prescott, MD, PhD, assistant professor of ophthalmology, Division of Cornea, Cataract, and External Diseases, Wilmer Eye Institute, Baltimore. Prior ASCRS surveys cited two main reasons for the disinterest in the U.S.: "further study was needed and compounds were not commercially available," said Neal Shorstein, MD, Kaiser Permanente, Walnut Creek, Calif. "That said, if there was a commercially available product at a reasonable cost, 80% would use intracameral injections." Cefuroxime—the compound used in the ESCRS endophthalmitis study—has a two-part dilution, which adds to the discomfort level about potential errors, Dr. Shorstein said. John D. Sheppard, MD, president, Virginia Eye Consultants, Norfolk, Va., expanded the explanation, saying there is no consensus on More and more European surgeons are using intracameral cefuroxime to deter endophthalmitis (shown here), but in the U.S. skepticism remains high. Source: Nick Mamalis, MD patient selection and choice of medication in the U.S., and "these huge landmark clinical trials we rely upon are of necessity understandably flawed by design: the prospective ESCRS trial by a relatively high base incidence and delayed topical antibiotic administration until the first postoperative day, and the Shorstein study1 by a retrospective design with randomly chosen intracameral medications." Peter Barry, FRCS, head of the Department of Ophthalmology, St. Vincent's University Hospital, Dublin, and senior retinal surgeon, Royal Victoria Eye and Ear Hospital, Dublin, found the Shorstein study "impressive. Their endophthalmitis rates were around 0.3%, which was very similar to the ESCRS study." In that study,2 the base incidence at 0.35% "was higher than anticipated but we consider that it is a true rate that is supported by the Swedish Cataract Register." More impressively, once Kaiser Permanente began using intracameral injections, Treating continued from page 65 we can treat their issues, we cannot cure them." EW Editors' note: Dr. Epitropoulos has financial interests with Allergan (Irvine, Calif.) and Bausch + Lomb (Rochester, N.Y.). Dr. Talley-Rostov has financial interests with Allergan and Bausch + Lomb. Contact information Epitropoulos: aepitrop@columbus.rr.com Talley-Rostov: ATalleyRostov@nweyes.com "the rate of endophthalmitis was reduced more than 22-fold," he said. European acceptance, U.S. indifference? In Europe, "more than 200 surgeons across 30 European countries were surveyed and 74% use intracameral injections," Dr. Barry said. "That's a rather high acceptance rate." Although the majority of Europeans have converted to intracameral use, "we are still waiting for FDA approval in the U.S.," Dr. Prescott said. "There are issues related to offlabel use and potential toxicity with intracameral injections," but those same issues exist for topical antibiotics. "American surgeons may have more cost constraint issues with a much higher volume performed in private ASCs," Dr. Sheppard said. "I find that in the U.S., locations where malpractice is out of control tend to use intracameral injections more aggressively, as a defensive move and not purely a therapeutic choice. There should be concerns about dosage errors, but also antibiotic toxicity to the cornea, meshwork, and macula, and these targets have not been adequately addressed in the U.S. literature." Although he's not a proponent for intracameral use in "routine cases," Dr. Sheppard said the Shorstein article "clearly indicates advantages in targeting high-risk patients, particularly where their capsule has been broken; these cases Preferred route of administration Dr. Prescott said the low rates of endophthalmitis result in a doubleedged sword of sorts—"the low rates decrease the incentive for improvement," she said. "Based on the evidence, intracameral antibiotics should be the standard of care. There is not a clear winner for antibiotics, but I prefer moxifloxacin, since that eliminates the compounding issue and has an excellent safety profile. For topical antibiotics, I prefer Polytrim [trimethoprim/ polymyxin B ophthalmic, Allergan, Irvine, Calif.] since it has good broad coverage, especially for the most common bacteria, and is inexpensive." Dr. Sheppard prescribes a topical fluoroquinolone the day before surgery and for a full two weeks postop (noting some studies have shown delayed onset beyond seven days). "I prefer besifloxacin 0.6% because of its superior MICs and pharmacokinetics, which allow for twice-daily use," he said. He uses either moxifloxacin or cefuroxime intracamerally, but only in high-risk cases, he said, which account for less than 1% of his overall cases. These include secondary IOLs, transplants with vitrectomies, glaucoma procedures in aphakes, and routine cataract surgery with unexpected capsular rupture or vitreous prolapse. Dr. Barry believes intracameral antibiotics should be offered to all patients, not just those at high risk. Beginning in 2010, Dr. Shorstein's hospital began using an intracameral antibiotic on every cataract patient, "and the net effect has been a 22-fold reduction from

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