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EW CATARACT 31 May 2016 by Rich Daly EyeWorld Contributing Writer unknown long-term toxicity im- pacts, the approach also includes a range of advantages beyond clinical efficacy. "If you have a patient popula- tion that is strapped financially and compliance is an issue, that might sway the balance over to intracamer- al medications," Dr. Mah said. EW References 1. Haripriya A, et al. Efficacy of intracameral moxifloxacin endophthalmitis prophylaxis at Aravind Eye Hospital. Ophthalmology. 2016;123:302–308. 2. Chang DF, et al. Antibiotic prophylaxis of postoperative endophthalmitis after cata- ract surgery: Results of the 2014 ASCRS member survey. J Cataract Refract Surg. 2015;41:1300–1305. 3. Lane SS, et al. Evaluation of the safety of prophylactic intracameral moxifloxacin in cataract surgery. J Cataract Refract Surg. 2008;34:1451–9. 4. Arbisser LB. Safety of intracameral moxi- floxacin for prophylaxis of endophthalmitis after cataract surgery. J Cataract Refract Surg. 2008;34:1114–20. 5. Shorstein NH, et al. Decreased postoper- ative endophthalmitis rate after institution of intracameral antibiotics in a Northern Califor- nia eye department. J Cataract Refract Surg. 2013;39:8–14. Editors' note: Drs. Chang and Stiverson have no financial interests related to their comments. Dr. Mah has financial interests with Alcon, Allergan, and Bausch + Lomb (Bridgewater, New Jersey). Contact information Chang: dceye@earthlink.net Mah: mah.francis@scrippshealth.org Stiverson: richard.stiverson@kp.org He plans to continue to use vanco- mycin on unilateral cases as infor- mation about hemorrhagic occlusive retinal vasculitis (HORV) evolves, although those concerns have led him to switch to moxifloxacin for sequential bilateral cases. Dr. Chang is a member of a joint task force of ASCRS and the American Society of Retina Special- ists that formed following the initial report of HORV. Based on almost 30 total cases, "the association with vancomycin is very convincing and is probably due to a rare, delayed type III hypersensitivity," Dr. Chang said. "Because the retinal vasculitis and visual loss is delayed, many of these patients are bilaterally blind after receiving vancomycin in both eyes following cataract surgery." Although Dr. Chang used intracameral vancomycin without any known complications for many years, he switched to intracameral moxifloxacin because of the emer- gence of increasing numbers of cases linking postop HORV to vancomy- cin. Dr. Chang uses compounded moxifloxacin (1 mg/0.1 ml) from a Food and Drug Administration (FDA)-registered compounding pharmacy, which requires it to meet stringent manufacturing criteria set by the FDA. Dr. Chang noted that it is not possible to sterilize a bottle of Vigamox, and it is not manufac- tured with the intent of intracameral injection. The growing body of evidence led Dr. Mah to switch to intracamer- al antibiotic injections. Although possible concerns with intracameral injections include evidence for U.S. surgeons, several surgeons said. "It does add to the overall evi- dence that intracameral medications seem to prevent—or at least lower the rates of—endophthalmitis," said Francis Mah, MD, director of the cornea service, and co-director of the refractive surgery service, Scripps Clinic, La Jolla, California. "This is another paper to add to the evidence specifically on moxifloxacin." The study published in the February issue of Ophthalmology also found no adverse events attributed to the intracameral moxifloxacin use. 1 "The size of the Aravind study leaves little doubt as to the effi- cacy of prophylactic intracameral moxifloxacin," said Richard Kent Stiverson, MD, Lakewood, Colo- rado. "There is much to like about moxifloxacin. Perhaps this will be the study that gets more U.S. sur- geons to adopt routine intracameral use." Existing use The findings may be particularly rel- evant to the 50% of surgeons using intracameral antibiotics, as found in the 2014 ASCRS survey. 2 Specifically, among those surgeons using intraca- meral antibiotics, vancomycin was used by 37% overall and 52% of U.S. surgeons, while moxifloxacin was used by 33% overall and 31% of U.S. surgeons. Most using intracameral moxifloxacin were injecting un- preserved topical Vigamox (moxi- floxacin, Alcon, Fort Worth, Texas) by a 7:1 margin over compounded moxifloxacin. Although off-label, several pub- lished studies have supported the safety of using topical Vigamox, Dr. Chang said. 3,4 Also, one U.S. retro- spective study suggested efficacy of intracameral moxifloxacin in a small population of 1,890 eyes. 5 The findings also fit the ex- perience of Kaiser Permanente in Colorado, which has not had an endophthalmitis case in 42,000 eyes since adopting intracameral antibi- otics, Dr. Stiverson said. HORV update Dr. Stiverson adds vancomycin to the balanced salt solution irrigating solution and uses the solution for stromal hydration of the incisions. Routine intracameral moxifloxacin prophylaxis in a large number of cataract patients provided a significant reduction in postop endophthalmitis I ntracameral moxifloxacin pro- phylaxis after cataract surgery reduces endophthalmitis rates to below those of eyes treated only with topical antibiotics, according to a recently published paper reporting on the largest number of eyes to date. The study was conducted on cataract patients at the Aravind Eye Hospital system in southern India using manual, sutureless, small incision cataract surgery (MSICS). The retrospective study com- pared postop outcomes among 3 groups of cataract patients during a 14-month study period: 37,777 eyes of charity patients who did not receive intracameral moxifloxacin, 38,160 eyes of charity patients who received intracameral moxifloxacin prophylaxis, and 40,777 eyes of private patients who did not receive intracameral moxifloxacin. Nearly all of the charity patients received MSICS, while 80% of the private patients had phaco. The postop endophthalmitis rate was 0.08% among the topical- ly treated charity eyes and 0.07% among the topically treated private eyes. In comparison, the intraca- merally injected charity eyes had a 0.02% endophthalmitis rate, or one- fourth that of other charity patients. "In the developing world, limit- ed health care resources means that cost containment is paramount to increased access to cataract surgery," said David Chang, MD, clinical professor, University of California, San Francisco, one of the study's authors. "So this is a phenomenal finding—inexpensive intracameral antibiotic prophylaxis can reduce endophthalmitis to less than 2 per 10,000, despite numerous cost-re- ducing operating room practices that we do not allow in the United States." Despite the surgical technique and patient-risk differences between the study and common U.S. experi- ence, the findings present relevant Four-fold reduction in endophthalmitis with intracameral injections Auromox is formulated for intracameral injection and is commercially available in India. It was used at Aravind Hospital for the study. Source: Aurolab

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