Eyeworld

EW FEATURE 48 Intracameral antibiotics January 2015 by Michelle Dalton EyeWorld Contributing Writer atic, Dr. Mamalis said, cautioning over interpretation of the results. They are good to show trends, but they are still only a sampling of practitioners. Studies from Europe and the U.S. do show that intracameral antibiotics can decrease the inci- dence of endophthalmitis. So why are more surgeons not adding them to their treatment regimens? Dr. Mamalis thinks it might be because in the U.S. "there is nothing commercially available," and a good sterile surgical technique coupled with using fourth-genera- tion fluoroquinolones has reduced the risk of endophthalmitis to their current low levels. What struck Rosa Braga-Mele MD, the most was that some surgeons "don't use any type of co-antibiotics," which would be worrisome unless those same sur- geons are just using intracameral, she said. Dr. Braga-Mele is professor of ophthalmology, University of Toronto, director of cataract surgery, Kensington Eye Institute, Toron- to, and director of professionalism and biomedical ethics, Department of Ophthalmology, University of Toronto. A small number of the respondents were outside the U.S., and drawing any definitive conclusion would be difficult, said Nick Mamalis, MD, professor of ophthalmology, director of the Intermountain Ocular Research Center, and director of ocular pathology, John Moran Eye Center, University of Utah, Salt Lake City. In the ESCRS study, the re- searchers chose cefuroxime as the intracameral antibiotic of choice; at the time the study was designed, fourth-generation fluoroquinolones were not commercially available. As such, when cefuroxime is discussed during the ASCRS survey, it is likely to be by the Europeans because neither Canada nor the U.S. has a commercially available formulation designed for ocular use. The overall risk of endophthalmitis is rather low—Dr. Mamalis estimates it at about 1:1500—and that may help explain the varied responses, he said. Of the ASCRS respondents who said that they do not inject intracameral antibiotics, almost 50% said they were not convinced of the need. "For me, I don't have enough evidence that using intracameral antibiotics will make a difference in my patient population," Dr. Braga- Mele said. Some surgeons will con- tinue to be cautious about introduc- ing another substance into the eye "with the possibility of introducing a different kind of problem such as toxic anterior segment syndrome (TASS) when the risk of endophthal- mitis is lower than the risk of TASS or at the equivalent level," she said. Extrapolating definitive state- ments from survey data is problem- AT A GLANCE • Intracameral antibiotics are used more outside the U.S. • Studies confirm intracameral antibiotic use reduces the risk of endophthalmitis. • U.S. requirements for safety and efficacy mean it is unlikely intracameral antibiotics will be approved for endophthalmitis prophylaxis. Trends in intracameral antibiotic use Monthly Pulse Keeping a Pulse on Ophthalmology Differences between U.S. and European surgeons analyzed Y ears after the ESCRS Endophthalmitis Study Group's study was present- ed and published, cataract surgeons are still debating the merits of intracameral antibiotic use as a prophylaxis for endophthal- mitis—and which agent would be best, when to initiate topical drop use, and how long to use antibiotics postoperatively. The ASCRS Cataract Clinical Committee developed "a brief one-time questionnaire to poll members about their current anti- biotic prophylaxis practices." Here, EyeWorld asked two of the commit- tee members to comment about the trends, the implications for surgeons and patients, and what may happen down the road with endophthalmi- tis prophylaxis. 65% of survey respondents were from the U.S. T he topic of this Monthly Pulse survey was "Intracameral antibiotics." We asked, "In your opinion, how important is intracameral antibiotic prophylaxis?" Almost half of the respondents said "Very important." However, the majority of respondents still do not inject intracameral antibiotics, and the top reasons cited were mixing/compounding risk and not convinced of the need. We asked, "If you use intracameral antibiotic, do you also use topical antibiotics postoperatively?" and the majority said yes. When asked about their intracameral antibiotic preference, the majority of respondents who do use them choose moxifloxacin.

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