Eyeworld

World view Intracameral antibiotics: controversy and our catch-22 E very month, the EyeWorld section editors and I select a topic to explore in depth through multiple complementa- ry articles. Our January cover focus on intracameral antibiotic endophthalmi- tis prophylaxis nicely illustrates this approach through a collection of 7 different articles. Be- cause of the difficulty in conducting sufficiently large prospective randomized clinical trials, we lack both the comparative evidence and ap- proved commercial products outside of Europe. As a result, whether and which intracameral antibiotics to inject remain controversial topics. Whether we should inject an intracameral antibiotic is first discussed by Francis Mah, MD, Audrey Talley Rostov, MD, and Peter Barry, MD, who was the lead investigator for the ESCRS multicenter prospective study of intracameral cefuroxime. The largest retrospective study of intracameral antibiotics in the U.S. was performed at Kaiser. Kent Stiverson, MD, and Neil Shorstein, MD, provide the background behind this study and update us with the current practices at Kaiser. Rosa Braga-Mele, MD, summarizes the Cataract Clinical Committee's white paper published in the Journal of Cataract & Refractive Surgery (JCRS) last month, which reviews the safety, effi- cacy, and off-label preparation of intracameral antibiotics. 1 Abhay Vasavada, MD, and Bonnie An Henderson, MD, who are also co-authors of that white paper, join Jeffrey Liegner, MD, in debating which intracameral antibiotic is best. Francis Mah, MD, and Christopher Starr, MD, highlight the Cornea Clinical Committee's November 2014 JCRS white paper reviewing MRSA. 2 Finally, I present the results from the recent survey of ASCRS members regarding antibiotic prophylaxis, while Dr. Braga-Mele and Nick Mamalis, MD, provide their analysis of the results. Our survey clearly demonstrates that adoption and belief in the efficacy of intracameral antibiotic injection prophylaxis is increasing among ASCRS members. I personally side with them and concur that the evidence for antibiotic prophylaxis efficacy is strongest for the intracameral route. This creates a frustrating catch-22 for eye surgeons and our patients. The FDA was created to protect patients from unproven or unsafe drugs. Meanwhile, Aprokam (Thea Group, Clermont-Ferrand, France), the commercial intraca- meral cefuroxime formulation, is approved and available throughout Europe with a well-established safety record (>1.3 million doses sold). However, the FDA's requirement for controlled clinical trials that are deemed too large and expensive to conduct by drug manufacturers leaves American ophthal- mologists no choice but to use off-label preparations. The consensus of the survey's respondents is that this is less safe. That our patients are denied access to the same commercial antibiotic available throughout Europe is par- ticularly galling in the context of Medicare's many new ASC regulations (e.g., regarding eye instrument sterilization). Many of these are costly, unproven, and arbitrarily mandated by non-ophthalmologists as being necessary to reduce endophthalmitis risk. Ironically, most patients probably think that this much regulation is a good thing. Our editorial board joins me in wishing you a Happy New Year, and we hope you'll continue to look to EyeWorld for the most relevant news, information, and education in 2015. EW References 1. Braga-Mele R, Chang DF, Henderson BA, Mamalis N, Talley Rostov A, Vasavada A, for the ASCRS Cataract Clinical Committee. Intracameral antibiotics: Safety, efficacy, and preparation. J Cataract Refract Surg 2014; 40(12):2134–2142. 2. Mah FS, Davidson R, Holland EJ, Hovanesian J, John T, Kanellopoulos J, Shamie N, Starr C, Vroman D, Kim T, for the ASCRS Cornea Clinical Committee. Current knowledge about and recommendations for ocular methicillin-resistant Staphylococcus aureus. J Cataract Refract Surg 2014; 40(11):1894–1908. David F. Chang, MD, chief medical editor The official publication of the American Society of Cataract & Refractive Surgery A S C R S January 2015 Volume 20 • No. 1 Publisher Donald R. Long don@eyeworld.org Editorial Editor Erin L. Boyle erin@eyeworld.org Managing Editor Stacy Majewicz stacy@eyeworld.org Staff Writer Ellen Stodola ellen@eyeworld.org Staff Writer Lauren Lipuma lauren@eyeworld.org Production Graphic Designer Julio Guerrero julio@eyeworld.org Graphic Design Assistant Susan Steury susan@eyeworld.org Production Manager Cathy Stern cathy@eyeworld.org 703-383-5702 Production Assistant Carly Peterson carly@eyeworld.org Contributing Writers Vanessa Caceres Lakeland, Fla. 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