Eyeworld

EW FEATURE 38 Intracameral antibiotics January 2015 by Maxine Lipner EyeWorld Senior Contributing Writer the Swedes used the intracameral ap- proach before anyone else. "I think that Per Montan and coworkers at St. Eriks in Stockholm are the father figures of intracameral antibiotic prophylaxis," 4 he said, adding that Spanish ophthalmologists, who started a survey of the use of intra- cameral cefazolin back in 2002, also had an important role in this. Currently the only intracameral drug for which there is an evidence base is intracameral cefuroxime, Dr. Barry said. The French product Aprokam (cefuroxime, Thea Group, Clermont-Ferrand, France) is ap- proved by the European Medicines Agency, he noted. In a recent ESCRS survey published in the January 2014 issue of JCRS, which Dr. Barry authored, cefuroxime was the overwhelming choice. 5 "In Europe, of the 74% of people in the survey who use intracameral antibiotics, 82% of those use cefuroxime," Dr. Barry said. "The number using vancomy- cin or moxifloxacin is fairly small." European preference In Europe, many physicians are convinced that the intracameral approach is the way to go based on the evidence of the studies, even be- yond the landmark ESCRS trial, Dr. Barry said. "There have been many studies done in France and Spain where institutions have made the decision to switch and have record- ed their results," he said. "In every study you read from Europe or elsewhere around the world where the intracameral ap- proach was adopted, when endoph- thalmitis rates were high, they got very low and when they were low they got even lower," Dr. Barry said. He credits the ESCRS trial with spurring additional work in the area, which ultimately led to a change in European practice patterns. "I think it would be wrong to give the ESCRS study entire credit, but I think that it was the overwhelming driving force, and it resulted in a large vol- ume of studies being conducted in Spain, France, and other European countries," Dr. Barry said. However, Likewise, Peter Barry, MD, consultant, Royal Victoria Eye and Ear Hospital, and St. Vincent's University Hospital, Dublin, is con- vinced that the intracameral method is superior in staving off endoph- thalmitis. He also views the ESCRS study, in which he was lead author, as a pivotal one. While a concern with the study was that the back- ground rate of endophthalmitis was too high, Dr. Barry argues that this is not so. "The Shorstein study from northern California last year had a 0.35% rate that they were running when they decided to switch to the intracameral route, which is exactly the same as the control group in the ESCRS study," he said. In addition, a Swedish national study, which was also published in the January 2013 issue of JCRS, looked at 1 million consecutive patients in their database. 3 In this study endophthalmitis rates rose to the 0.3% mark without the intraca- meral antibiotics, Dr. Barry said. AT A GLANCE • One prospective study shows a 5-fold decrease in endophthalmitis with the intracameral approach. • In Europe the intracameral approach is favored in many countries, with studies from the region bolstering support for this. • While the literature also backs use of topical antibiotics, with retrospective and surrogate evidence, so far there has been no prospective support. Intracameral antibiotics versus topical Best practices: What is the evidence? F or practitioners performing cataract surgery, keeping endophthalmitis at bay is on everyone's mind. However, while some swear by intracameral antibiotics, others continue using the topical approach. EyeWorld is honing in on just what the scientific evidence supports. Audrey Talley Rostov, MD, Northwest Eye Surgeons, Seattle, thinks the evidence clearly shows that the intracameral approach is superior. She views the ESCRS prospective, randomized study, published in March 2006 in the Journal of Cataract & Refractive Surgery (JCRS), as a landmark trial. 1 Patients in the study were placed in one of 4 groups to receive topical medica- tion, intracameral antibiotics, both antibiotics, or no antibiotics. With the intracameral approach, patients had a 5-fold decrease in endophthal- mitis, she said. Meanwhile, the first large-scale U.S. study, conducted by Neal Shorstein, MD, and published in the January 2013 issue of JCRS, also favored the intracameral approach, she said. 2 "There was a 2.2-fold decline in endophthalmitis during the first 2 years of the 5-year retrospective study following the introduction of intracameral cefuroxime," she said. "A further 10-fold decrease was observed during the next 2 years of the study when all patients received either intracameral cefuroxime, moxifloxacin, or vancomycin." To stave off endophthalmitis cases such as this one, many are weighing the evidence on whether an intracameral approach is better than a topical one. Source: Francis Mah, MD

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