Eyeworld

EW NEWS & OPINION 22 October 2017 by Ellen Stodola EyeWorld Senior Staff Writer moxifloxacin in those patients who were taking topical drops in addi- tion to the injection, the cefuroxime group had the highest confidence in reduction of endophthalmitis, Dr. Shorstein said. The moxifloxacin group had a slightly higher rate, but the confidence interval was wider. It would take tens of thousands of patients and years of study to make a better comparison, he said. In summary, Dr. Shorstein said "intracamerals appear to reduce endophthalmitis incidence." Topical drops don't appear to add benefit to intracamerals, but more study is needed. Intracameral injection alone may be sufficient, but again, Dr. Shorstein stressed that more study is needed. Dr. Chang highlighted specifics about intracameral moxifloxacin prophylaxis, discussing its use and results from the Aravind Eye Hospi- tal study. Published this past June in Ophthalmology, the study sought to compare the rate of postoperative endophthalmitis before and after using intracameral moxifloxacin prophylaxis for phaco and suture- less manual small incision cataract surgery, as well as in patients with posterior capsular rupture. More than 600,000 consecutive cataract surgeries were included in the study, which concluded that routine intra- cameral moxifloxacin prophylaxis reduced the overall endophthalmitis rate by 3.5-fold. Dr. Chang shared additional new data on nearly 1.1 million consecutive cataract sur- geries from January 2013 through March 2017 at Aravind, which showed the same 3.5-fold reduction with intracameral antibiotic. Sweden published in the Journal of Cataract & Refractive Surgery (JCRS) in 2002 and a large randomized control trial by the European Society of Cat- aract & Refractive Surgeons (ESCRS), which was initiated in 2003 with results published in JCRS in 2007. Dr. Shorstein discussed his per- sonal experience at Kaiser Perma- nente. In 2007, they noticed a slight increase in endophthalmitis. They began to use cefuroxime in 2007 and later between 2009 and 2011 added moxifloxacin and vancomy- cin. The 2007 endophthalmitis rate was similar to the baseline rate of the ESCRS study, he said, noting that his group saw a 22-fold decrease in endophthalmitis from the beginning of the study to the end. There were about 2,000 eyes that received an intracameral injection alone with no perioperative or postoperative drops prescribed. After this, Dr. Shorstein said a National Eye Institute (NEI) grant prompted further study of larger groups in the region, which resulted in an in-depth look at 315,246 eyes with 250 surgeons. He noted three take-home messages. Looking at the topical alone group compared to those with an added intracameral injection, there was a 42% reduction in endophthalmitis in the injection group, which was statistically significant. Patients who received no antibiotic (e.g., forget- ting to fill the prescription) had nearly a two-fold increase in the risk of endophthalmitis compared to the topical group. The question remains whether topical drops provide any additional benefit when intracamer- al antibiotic is injected. Finally, com- paring intracameral cefuroxime and require chemo prophylaxis. One is the reduction of endogenous surface organisms using either antiseptic or topical antibiotic, and the other is eradication of pathogens that gain entry into the ocular tissues using an antibiotic, Dr. Mah said. As far as eliminating endoge- nous surface organisms, povidone iodine is effective, he said, adding that physicians should leave povi- done iodine in the eye for at least 5 minutes of contact time. The landmark study showed significant reduction of endophthalmitis rates with use of povidone iodine, Dr. Mah added. There was a 75–80% reduction in endophthalmitis with povidone iodine. What do physicians know about topical antibiotic prophylaxis? One of the first studies was in 1964, Dr. Mah said. There were 22 infections in 20,000 cataract extractions. A later follow-up study in 36,000 consecutive retrospective operations found that switching antibiotics could help. Dr. Mah said there is in vivo animal data from a study at the University of Pittsburgh that found that using an agent was better than saline, and using it preop and postop was better than one or the other. There are problems with top- ical drops, Dr. Mah noted, includ- ing compliance, manual dexterity, ocular surface toxicity, penetration into the eye, and cost. In terms of educating patients, Dr. Mah said that a study from Canada showed that upward of 92% of patients were incorrectly putting drops in follow- ing routine cataract surgery. When using topical antibiotics in the U.S., most physicians begin use about 1–3 days prior to surgery, with frequent dosing the day of surgery. Dr. Mah added that mostly there is no postoperative tapering, and antibiotics are often used at least 7 days postoperatively. In summary, he said that topical antibiotics are widespread and entrenched in the U.S., postopera- tive use is greater than preoperative use, retrospective studies suggest efficacy, and surrogate evidence suggests efficacy. However, he noted that efficacy of topical antibiotics is unproven in a placebo-controlled prospective study. Dr. Shorstein gave a brief history of intracamerals, referencing several studies. He discussed a study from Experts discussed considerations for antibiotic prophylaxis in cataract surgery A recent webinar sponsored by the ASCRS Cataract Clinical Committee examined the topic of antibiotic prophylaxis for cataract surgery. Faculty weighed in on intracameral and topical antibiotics and factors to consider. Speakers included Richard Kent Stiverson, MD, Denver, Colorado, Neal Shorstein, MD, Walnut Creek, California, David F. Chang, MD, Los Altos, California, and Francis Mah, MD, La Jolla, California. Dr. Mah presented on current trends in infectious endophthalmitis and touched on topical antibiotics, which he noted are the majority of what U.S. ophthalmologists are using. There is no FDA-approved antibiotic currently on the market for prophylaxis in cataract surgery, he said. Dr. Mah then shared data on topical antibiotics and post-surgical endophthalmitis rates. "In general, we're not doing too bad in terms of infectious endophthalmitis fol- lowing cataract surgery," he said, with the accepted rate of about 1 in 1,000. But what's causing it? Dr. Mah said there was a landmark prospective study looking at this, which showed that 60% of patients with bacterial endophthalmitis were culture-positive. Dr. Mah went on to discuss the prognosis for these patients. After endophthalmitis, about 43% of pa- tients have vision of 20/40 or better but 34% have 20/200 or worse after treatment. The prognosis is bad if initial vision is poor, Dr. Mah said. We know that there are some relatively established risks for endophthalmitis. Posterior capsule rupture, preexisting periocular in- fections, and immunocompromised status are risk factors. However, Dr. Mah noted that it is multifactorial. Prophylaxis is one area that physicians can potentially manage, Dr. Mah said, adding that the source of the organism is endogenous. The lids, lashes, and lacrimal system harbor the organisms that cause the majority of endophthalmitis. There are two approaches that Antibiotic prophylaxis covered in webinar Webinar reporter Post-surgical endophthalmitis rates listed by country and year Source: Francis Mah, MD

• Blank Page
• Blank Page (1)