Eyeworld

EW CATARACT 39 November 2017 Dr. Swan pointed out that many have emphasized that it would be nice to have a commercially avail- able, FDA-approved injectable med- ication to forestall endophthalmitis. "I think everyone in ophthalmology wishes that the FDA would accept some of the European data to allow for a product to be approved in the U.S. without a company having to undertake a clinical study that would be required to show effica- cy," he said. Still, he thinks there is growing data to support use of injectable medication to forestall en- dophthalmitis. "I think if you have the opportunity to integrate it into a practice, you're doing your patients a favor," Dr. Swan said. EW Reference 1. Haripriya A, et al. Endophthalmitis reduction with intracameral moxifloxacin prophylaxis: Analysis of 600,000 surgeries. Ophthalmology. 2017;124:768–775. Editors' note: Dr. Miller has financial interests with Johnson & Johnson Vision (Santa Ana, California) and Alcon (Fort Worth, Texas). Dr. Lee, Dr. Mamalis, and Dr. Swan have no finan- cial interests related to their comments. Contact information Lee: bryan@bryanlee.pro Mamalis: nick.mamalis@hsc.utah.edu Miller: kmiller@ucla.edu Swan: Russell.swan@vancethompsonvision.com When it comes to contamina- tion, Dr. Lee acknowledged that this is a potential issue, but he thinks the benefits of intracameral antibiotics outweigh the risks. "Fortunately, I get moxifloxacin from a reputable compounding pharmacy," he said. In general, Dr. Lee prefers moxi- floxacin, which he pointed out has broader coverage than vancomycin or cefuroxime. "Personally, I think that even with HORV it still might be reasonable to use vancomycin, especially if you are making that de- cision based on your local flora and history of endophthalmitis. Howev- er, it is harder to justify because the FDA just issued a statement saying intraocular vancomycin is 'generally not recommended because of the risk of HORV,'" Dr. Lee said. If using vancomycin, it would be prudent to space the surgeries further apart to help ensure the second eye is not affected, and Dr. Lee encouraged practitioners to do a dilated exam postoperatively. Dr. Miller thinks that the risk of HORV is exceedingly low but needs to be heeded, especially when doing both eyes close together. People who do surgery less than 3 weeks apart may end up doing the second eye before signs of HORV appear. The second eye may respond even more strongly and deteriorate faster because of the repeated inoculation, he explained. using intracameral moxifloxacin alone is reasonable for preventing endophthalmitis. He cited a study published in the June 2017 issue of Ophthalmology that considered approximately 600,000 cataract cases, 300,000 of which had been given intracameral moxifloxacin. "They had a seven-fold decrease in the endophthalmitis rate," Dr. Swan said. "This went from .07 to .01 with just implementation of moxifloxa- cin." 1 Even though there are con- cerns about efficacy against MRSA and other things with moxifloxacin, there's strong evidence to support that it does decrease the risk of en- dophthalmitis. Postoperatively, Dr. Swan only prescribes an NSAID drop. Howev- er, he does have partners who give patients the same intravitreal injec- tion and also prescribe LessDrops (Imprimis) a combination antibiotic, steroid, and NSAID drop, on a once- a-day basis after surgery instead of a daily NSAID alone. "But with the ad- ministration of an intravitreal dose, I don't think it is necessary to have a topical antibiotic as well," he said. When incorporating intracam- eral antibiotics into a practice, TASS is one of the most critical consider- ations, Dr. Swan thinks, adding that there is a need to have a nurse who has policies and procedures in place to ensure that there are no dilution errors. For this reason, he favors the Imprimis product, which he said has a stringent 503A/B compounding designation. "I am comfortable with the end product testing that goes into every batch that they're putting out and am comfortable adminis- tering that into people's eyes," Dr. Swan said. Bryan Lee, MD, JD, in private practice, Los Altos, California, and assistant professor of ophthalmolo- gy, University of Washington, Seat- tle, preoperatively does a betadine prep and irrigates the surface with dilute betadine at the end of the case. In addition, he injects intraca- meral moxifloxacin. "I use moxiflox- acin because it has great coverage, and it is well tolerated in the eye," Dr. Lee said. He also prescribes a generic fluoroquinolone. "Normal- ly, it's ciprofloxacin twice a day, starting the day before surgery and continuing for 8 days," Dr. Lee said. Mamalis said. "That's not approved in the U.S., so in the U.S. we have to go through a complex, multistage process of diluting it and making it up for intracameral injection." As a result, Dr. Mamalis sees multiple areas where dilution errors could make conditions ripe for TASS. Since there have been some rare cases of macular toxicity with improperly dosed cefuroxime, Dr. Mamalis steers away from this and instead uses moxifloxacin. Russell Swan, MD, Vance Thompson Vision, Bozeman, Mon- tana, likewise advocates using povi- done-iodine prophylactically before surgery for endophthalmitis preven- tion. "My current approach is povi- done-iodine preoperatively, as well as immediately postoperatively," he said. "At the end of our surgery, we currently use Dex-Moxi-Ketor [dexa- methasone/moxifloxacin/ketorolac, Imprimis Pharmaceuticals, San Diego]." Dr. Swan gives this combi- nation via intravitreal injection. "In the past, I have used just intracam- eral moxifloxacin as an alternative, but right now having the addition of the NSAID and the steroid is nice from a compliance standpoint with other drops after surgery," he said. With this regimen, he has patients take a daily NSAID drop for a month after surgery because with the injected steroid they can some- times get rebound inflammation between 2 and 4 weeks if they don't have a drop on board, Dr. Swan said. Previously, Dr. Swan used Tri- Moxi-Vanc (triamcinolone/moxi- floxacin/vancomycin, Imprimis) intravitreally. "We transitioned from the triamcinolone to the dexameth- asone because it's clear and has less patient complaints afterward," he said. He also switched away from vancomycin. "The vancomycin has better coverage for bugs such as MRSA, but with the finding of hem- orrhagic occlusive retinal vasculitis [HORV] and the series of cases on that, we thought it was in the best interest to transition away from it," Dr. Swan said. Because Dr. Swan likes to in- clude a depot of anti-inflammatory medication as well as the antibiotic, using an intravitreal approach made sense. However, in terms of strictly antibiotic prophylaxis, Dr. Swan thinks there is strong evidence that " I think everyone in ophthalmology wishes that the FDA would accept some of the European data to allow for a product to be approved in the U.S. without a company having to undertake a clinical study that would be required to show efficacy. " —Russell Swan, MD

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