Eyeworld

49 EW FEATURE June 2016 • Controversies in ophthalmology 2. Barry P, et al. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study. J Cataract Refract Surg. 2006;32:407–410. Editors' note: Dr. Liegner has financial interests with Imprimis Pharmaceuti- cals (San Diego). Dr. Myers has finan- cial interests with Leiter's Compound- ing Pharmacy. Drs. Chang, Miller, and Shorstein have no financial interests related to their comments. Contact information Chang: dceye@earthlink.net Liegner: liegner@embarqmail.com Miller: kmiller@ucla.edu Myers: wmyers2020@gmail.com Shorstein: nshorstein@eyeonsight.org prophylaxis in 2014. 1 Approximately half of the respondents were using intracameral antibiotic prophylax- is—an increase from 30% in the 2007 ASCRS survey. "Of those not using intracameral antibiotics, half cited concerns about mixing or compounding errors," Dr. Chang said. "Two-thirds said that they were not convinced of the need, and 19% cited cost as a factor." Having an FDA-approved commercial antibiotic formulation would dramatically change practice patterns in the U.S., according to Dr. Chang. In the 2014 survey, 75% of respondents said that it was import- ant to have an approved commer- cial formulation for intracameral injection, compared to 54% in 2007. "Eighty-four percent said that they would use a commercially approved intracameral antibiotic if this were available at a reasonable cost," he said. "It is a shame that American patients don't have access to such a product, when commercially formulated cefuroxime is available in roughly 2 dozen EU countries and has been used in more than 3 million eyes." Other issues Some surgeons have also worried about allergic reactions to intracam- eral antibiotics. But Dr. Myers said allergies are rarely seen in intraocu- lar injections. "Perhaps the blood aqueous bar- rier is a factor in minimizing reac- tions," Dr. Myers said. "I still would avoid any of the antibiotics in cases where anaphylactic reactions have occurred previously." Amid ongoing concerns about endophthalmitis that are driving much of the focus on the promise of intracameral antibiotics, Dr. Miller underscored the good news for U.S. cataract surgeons. Even though endophthalmitis rates remain about the same in the microincision cata- ract surgery era as they were during the extracapsular era, U.S. rates, overall, are lower than those found among European cataract patients treated with intracameral antibiotics in a European Society of Cataract & Refractive Surgeons (ESCRS) study. 2 "It speaks to the quality of sur- gery done over here," Dr. Miller said. On a separate point about the possibility for widespread intracam- eral antibiotic use to fuel antibiotic resistance, Dr. Shorstein noted that despite some absorption of the intra- cameral agent into the bloodstream, the few available studies show that the serum concentration remains much lower than oral administra- tion of the drug. Delivery methods Jeffrey Liegner, MD, clinical in- structor, Rutgers New Jersey Medical School, Newark, New Jersey, prefers a transzonular intravitreal delivery of a combination injection that includes vancomycin using a 27- or 30-gauge cannula, placed after IOL positioning and under viscoelastic. That approach is used by 70% of sur- geons who use the combined prod- uct, according to Dr. Liegner, while 30% use a pars plana injection. "It's more familiar to them be- cause of anti-VEGF experience," Dr. Liegner said. Dr. Liegner said he thinks a transzonular approach is safer than injection into the sclera across the choroids. Dr. Miller and other surgeons agreed that placement of the antibi- otics in the vitreous cavity is most effective because that is the location where infections usually start. A future option in early stage clinical trials involves coating intraocular lenses with antibiotics, which could eliminate the need for injections. EW References 1. 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. " The general sentiment is that every U.S. ophthalmologist would inject an antibiotic if it was FDA approved and commercially prepared and there was no question that there was going to be a dilution error. " –Kevin M. Miller, MD

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