Eyeworld

EW CATARACT 22 January 2015 by Maxine Lipner EyeWorld Senior Contributing Writer ration for intracameral injection would ultimately increase the safety of cataract surgery by providing better endophthalmitis prophylaxis with reduced risk for TASS or toxici- ty," Dr. Braga-Mele said. She views the take-home mes- sage as pointing out the need for practitioners to be educated on the use of intracameral antibiotics. "It has been proven in some prospective studies to be efficacious in the prevention of endophthalmi- tis; however, it is still not deemed a necessary step in cataract surgery," she said. "But if one wishes to take this step then one needs to under- stand the spectrum of use and how to appropriately dose it for intracameral use either by using a validated compounding pharmacy or in the case of intracameral Vigamox [moxifloxacin, Alcon, Fort Worth, Texas], by having a proper 'recipe' for mixing it in the operating room." EW Reference Braga-Mele R, Chang DF, Henderson BA, et al. Intracameral antibiotics: Safety, efficacy, and preparation. J Cataract Refract Surg. 2014; 40(12):2134–2142. Editors' note: Dr. Braga-Mele has financial interests with Alcon and Allergan (Irvine, Calif.). Contact information Braga-Mele: rbragamele@rogers.com an ease of delivery, she said. Another advantage was that because these target a higher drug concentration at the requisite site, they could potentially eliminate the need for topical drops, which could help with compliance issues. Cost was also considered in some cases. "There was a Spanish study showing that cefuroxime was efficacious and a cost analysis showing that it was cost effective as well in Spain," Dr. Braga-Mele said. This is not the only possible agent, however. "The peer-review litera- ture generally supports the safety of using intracameral preparations of vancomycin, moxifloxacin, and sev- eral of the cephalosporins," she said. Weighing complications One issue with intracameral agents is that they are not available for intracameral use commercially and must be compounded, bringing with them the risk of complications, she said. "It's not a huge concern, but it can be a devastating outcome if you get TASS," Dr. Braga-Mele said. "Also, because intracameral anti- biotics, other than the approved Aprokam [cefuroxime, Thea Group, Clermont-Ferrand, France] in Eu- rope, need to be mixed, diluted, or prepared, you could have dilutional errors." This could result in side effects such as macular edema from an inflammatory process and possibly even retinal infarction. "We concluded that an ap- proved commercial antibiotic prepa- used and have been shown in papers to be effective." They hoped this review would give their readership the ability to decide whether they want to use an intracameral antibiotic to help potentially prevent endophthalmi- tis. In addition, the review provides practitioners information on the underlying pharmacology, dosage, and preparation schedules of the 3 most readily available antibiotics, Dr. Braga-Mele said. "The biggest problem with self-preparations or compounding pharmacies has been TASS risks," she said, adding that besides under- scoring the benefits, they hoped to help practitioners better understand such potential risks with the use of these medications. Considering the medications All of the reviewers sifted through the current literature. "We each took a section to review, be it an antibiotic itself, the basic pharmacology of the antibi- otics, the spectrum of activity of the antibiotics, or the dosage and preparation, and we reviewed papers on that," Dr. Braga-Mele said. This review, which included 78 references, was an extensive one. The aim was not necessarily to determine the best intracameral antibiotic but rather to help prac- titioners select the best medication for their patient population and to consider which might be the easiest for them to get compounded or to mix themselves in their operating rooms, Dr. Braga-Mele explained. "The purpose of the paper is not to advocate the use of intracameral antibiotics," she said. "It is to inform and educate on the use of intraca- meral antibiotics if someone should decide to use them." When investigators considered the intracameral agents, they found that only one, intracameral cefuroxime, had truly proven its efficaciousness, in the ESCRS prospective, randomized study. "[The study] showed that intra- cameral cefuroxime did help in the prevention of endophthalmitis," she said. "What we found was that there are some potential advantages to the use of intracameral antibiotics after cataract surgery." Some of the intracameral medications were found to have Review helps physicians navigate intracameral agent waters Scoping out the latest on intracameral antibiotics W hen it comes to the use of intracameral antibiotics, practi- tioners these days must sift through a plethora of information to deter- mine if the drugs are the best option for their practices. A new review published in the Dec. 2014 issue of the Journal of Cataract & Refractive Surgery, conducted by physicians for the ASCRS Cataract Clinical Committee, aims to clarify what is available in the intracameral sphere, according to Rosa Braga-Mele, MD, professor of ophthalmology, Univer- sity of Toronto. Dr. Braga-Mele along with David F. Chang, MD, Bonnie An Henderson, MD, Nick Mamalis, MD, Audrey Talley-Rostov, MD, and Abhay Vasavada, MD, were involved in the review. The reason for pursuing the review, titled "Intracameral antibi- otics: Safety, efficacy, and prepara- tion," was because there are cur- rently so many schools of thought on whether or not to use intraca- meral antibiotics, Dr. Braga-Mele explained. "We have some very good pro- spective studies that have been done that show efficacy and safety with certain formulations, but in Canada and the U.S. there are currently no FDA- or Health Canada-approved formulations that are premade and easy to use," she said. "We wanted to review the literature and discuss the currently available intracameral antibiotics that are An example of endophthalmitis 2 days after uncomplicated phaco Source: Sonia Yoo, MD

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