Eyeworld

49 EW FEATURE Various choices For surgeons who use topical anti- biotics, there are numerous choices commercially available; in the U.S. the majority use topical moxifloxa- cin or gatifloxacin perioperatively. Third-generation quinolones are showing "some significant resis- tance, especially in the Staph bacteria," he said, adding that he encourages surgeons to use fourth-generation drugs with less (although ever-increasing) resistance issues. There is no such clear-cut ma- jority when it comes to intracameral antibiotics. However, moxifloxa- cin (directly injected from topical Vigamox) and vancomycin are most commonly used. "I'm surprised there are still a lot of people who use vancomycin added to the balanced salt solution infusion bottle (15%)," Dr. Mamalis said. Treatment differences Because neither the U.S. nor Canada has an approved intracameral anti- biotic, "there may be some reformu- lation issues with preparation that prevent surgeons from including intracameral antibiotics in their surgical routine," Dr. Braga-Mele said. In Canada, most surgeons use an antibiotic "at least a day prior to surgery or starting on the day of the surgery, but 3 days prior is falling out of favor," she said. A patient's insurance coverage may also play a role in the choice of antibiotics, Dr. Mamalis said, noting it is not un- usual for the center's postop nurse to note a specific fourth-generation fluoroquinolone is not covered by insurance. Surgeons are then left with the option of choosing another drug, another drug class, or an ear- lier generation of fluoroquinolones, he said. But if postoperative antibiotics are not being used, it is possible that surgeons are opting for intracameral use or instilling a drop themselves at the end of surgery, Dr. Braga-Mele said. "I think we should raise the question that perhaps those who are starting their postoperative topical antibiotic on day 1 are instilling a drop at the end of the case or using an intracameral antibiotic," she said. "The other thing is they might be the doctors who patch their pa- tients, and patches aren't removed until day 1 postop. That's when they have their patients start the drops." Dr. Braga-Mele said she does not use intracameral antibiotics because her rate of endophthalmitis "is al- most non-existent," and a review of 16,000 cases in Canada found such a low rate of endophthalmitis that she is not swayed by the literature that exists. Some may be using moxi- floxacin (either in direct injection mixed from the topical solution or compounded for direct injec- tion) because it's not preserved and EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put EW Pulse in the subject line. Poll size: 238 The survey asked "When do you start preoperative topical antibiotic?" continued on page 50 Of the respondents who said they do not inject intracameral antibiotics, almost 50% said they are not convinced of the need. Source: ASCRS January 2015 Intracameral antibiotics

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