Eyeworld

EW CATARACT 38 November 2017 by Maxine Lipner EyeWorld Senior Contributing Writer Pharmaceutical focus Nick Mamalis, MD, professor of ophthalmology, John A. Moran Eye Center, University of Utah, Salt Lake City, likewise begins his endophthal- mitis prevention with povidone-io- dine (betadine). This has been shown in a number of studies to be the most effective way of sterilizing the surface of the conjunctiva for cataract surgery, he said. When you put these drops in is also important. "A lot of physicians use lidocaine gel to numb the surface of the eye prior to surgery," Dr. Mamalis said. "It's very important that the povi- done-iodine drops be put in prior to the gel." Otherwise, the gel coats the eye and the betadine doesn't get in contact with the surface. "When the patient is in the operating room and we're doing the preparation for the eye, we do the betadine skin prep, but we also make sure that there is a drop of 5% betadine on the surface of the eye at that time," Dr. Mamalis said. At the conclusion of the case, Dr. Mamalis will give a drop of fourth-generation fluoroquinolone topical antibiotic. "We'll have pa- tients use that every 2 hours for the first day and then four times a day for 7 days postop," he said. In some cases, Dr. Mamalis also uses an intracameral antibiotic. Dr. Mamalis will use this approach for cases at the veterans' hospital where he sometimes works, especially with complicated cases or ones involving surgery done by residents. He thinks that the extra protection is helpful and is planning on doing this in all of his cases going forward. As part of this intracameral approach, he relies on moxifloxacin to forestall endophthalmitis, which he uses for two reasons. "The first reason is that it has very good cover- age, especially for the gram-positive bacteria in a high dose, which you get intracamerally with an injec- tion," Dr. Mamalis said, adding that the second reason is it's commer- cially available in a preservative-free formulation. A second agent that was used in the European Society of Cataract & Refractive Surgeons (ESCRS) en- dophthalmitis study is cefuroxime. "In Europe, they have an available single-use cefuroxime for intracam- eral injection, and all you do is mix it up with fluid and inject it," Dr. preceding surgery, and I tell wom- en not to wear eye makeup during those 3 days," he said. "We do the povidone-iodine prep in the oper- ating room, and we try to drape in such a way as to hide the lid margin and the eyelashes from the surgical field." Currently, for endophthalmi- tis prophylaxis he uses Vigamox (moxifloxacin, Novartis, Basel, Switzerland) four times a day for 1 week. Dr. Miller starts patients on this postoperatively. "If you do these drops before surgery, you end up growing out the bacteria that are re- sistant to the drops," he said, adding that postoperatively you can end up with more resilient bugs as a result. Dr. Miller currently avoids injecting medications to prevent en- dophthalmitis. "I'm in a university where we have a pharmaceutical stu- dent or a pharmacist mixing this up, and dilution errors are all too com- mon," he said. "If someone mistakes micrograms for nanograms or mil- ligrams, you can have a 1,000-fold dilution error." Then practitioners find themselves dealing with a toxic anterior segment syndrome (TASS) problem. "Rather than having a 1 in 2,000 incidence of endophthalmitis, you have a 1 in 700 incidence of TASS," he said, adding that this is not a trade-off he's willing to make. Kevin M. Miller, MD, professor of clinical ophthalmology, Universi- ty of California, Los Angeles, point- ed out that the use of intracameral cefuroxime was found in a trial to be beneficial in preventing endoph- thalmitis. Likewise, studies looking at moxifloxacin have shown that patients using this have a reduced incidence. Dr. Miller encourages his pa- tients to keep their lids and lashes as clean as possible prior to surgery. "I tell them to scrub for the 2 to 3 days A closer look at what cataract surgeons are using to keep endophthalmitis at bay W hile cataract surgeons agree that it is vital to keep endophthalmitis away, practitioners have a variety of modes for going about this. Here's a closer look at what some practi- tioners are doing. Edging out endophthalmitis Dr. Lee injects intracameral moxifloxacin at the conclusion of a case. Source: Bryan Lee, MD, JD Intracameral antibiotics and HORV David Chang, MD, discusses intracameral antibiotics and the risk of HORV.

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