Eyeworld

EW CATARACT 48 November 2017 All the doctors interviewed for this article said they have not personally had any complications they think were related to intracam- eral antibiotic use, but Dr. Swan said given his training at the Moran Eye Center, which he called a referral center for cases of toxic anterior segment syndrome, he was "well-in- formed of many of the issues." Dr. Swan also said a lot of complications arise from dilution errors made by compounding pharmacies, which is why he likes the products by Imprimis Pharmaceuticals, which he noted has 503B status under the Drug Quality and Security Act as an outsourcing facility and must meet certain requirements. Dr. Greenwood said that some of his patients will experience a little subconjunctival hemorrhage, but it's self-resolving. There's also always the poten- tial for the patient to experience an allergic reaction, though that's rare, Dr. Mamalis said. "I can't talk about intracameral antibiotics without bringing up the HORV issue," Dr. Mamalis said of hemorrhagic occlusive retinal vascu- litis (HORV), which has been associ- ated with intracameral vancomycin. 5 "Vancomycin has a very long track record of being an antibiotic used intracamerally with tens of thou- sands of uses without a problem, showing a decrease in endophthal- mitis. Unfortunately, there's the issue of HORV, an immune type reaction to vancomycin, which [can cause] very serious damage to the retina and the eye itself." ASCRS and American Society of Retina Specialists formed a joint Task Force in 2016 to investigate intraca- meral vancomycin and HORV. The Task Force offered considerations regarding intraocular vancomy- cin, which included weighing the potential risk of HORV associated with vancomycin against the risk of endophthalmitis, reconsidering using vancomycin in close sequen- tial bilateral cataract surgery due to the delayed onset of HORV, and considering alternative intracameral antibiotics. Dr. Mamalis said he teaches those in training to hydrate the wound and the stab incision, mak- ing sure they are water tight. He added, however, that you don't want the eye to be completely firm be- cause you need enough space for the 0.1 mL injection of the antibiotic. Given that most residents are already performing anti-VEGF injec- tions through the pars plana, mak- ing the transition to intracameral antibiotics into the vitreous is pretty easy, Dr. Greenwood. In fact, he said the latter is done in an even more controlled environment under the microscope and with a well-prepped, sedated patient. Dr. Swan said he will speak with patients about intracameral antibiot- ics preoperatively. "I usually say, 'At the time of surgery we'll be doing an injection of antibiotic and steroid that's going to help in the healing process, and it also means that you must be on one drop a day after surgery, which is nice,'" Dr. Swan said, adding that he also explains its role in endophthal- mitis prevention. Still off-label, but moving forward Dr. Mamalis reiterated the fact that there are no approved antibiotics for intracameral use in the U.S. That's why it's important to know and trust the pharmacy where you are receiving a compounded antibiotic for injection. The ASCRS Cataract Clinical Committee published a paper about the safety, efficacy, and preparation of intracameral antibiot- ics in 2014. 6 "I have no issues with it not being FDA approved; the body of literature to support it is so strong, and so many things that we do in ophthalmology are off-label. Anti- biotics after cataract surgery in drop form are off-label," Dr. Swan said. "Would it be nice to have some- thing? Absolutely. ASCRS and other organizations have worked tireless- ly to get the FDA to recognize the European data and data from other countries because it's fairly unlikely that a drug company is going to do a study with that many eyes because it's going to be too cost prohibitive." ASCRS formed the ASCRS Re- search Council, chaired by Doug- las Rhee, MD, in 2016 to develop research trials, one of which, Dr. Mamalis, a member of the council, said will be to compare intracameral antibiotics to topicals. This research, Dr. Mamalis said, could lead to FDA approval of an intracameral antibi- otic, if it showed a difference or at least equivalence between the two with intracamerals having a lower rate of endophthalmitis. This would "take away all of the issues of trying to mix it up, draw it up. If we could get an approved, single-use sterile container from a company where you just draw it up and inject it, that would be the ideal solution to this problem," Dr. Mamalis said. EW References 1. Herrinton LJ, et al. Comparative effec- tiveness of antibiotic prophylaxis in cataract surgery. Ophthalmology. 2016;123:287–94. 2. Haripriya A, et al. Endophthalmitis reduction with intracameral moxifloxacin prophylaxis: Analysis of 600,000 surgeries. Ophthalmology. 2017;124:768–775. 3. 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;32:407–10. 4. Grzybowski A, et al. Endophthalmitis prophylaxis in cataract surgery: Overview of current practice patterns around the world. Curr Pharm Des. 2017;23:565–73. 5. Witkin AJ, et al. Vancomycin-associated hemorrhagic occlusive retinal vasculitis: Clini- cal characteristics of 36 eyes. Ophthalmology. 2017;124:583–95. 6. Braga-Mele R, et al. Intracameral anti- biotics: Safety, efficacy, and preparation. J Cataract Refract Surg. 2014;40:2134–42. Editors' note: The physicians have no financial interests related to their comments. Contact information Greenwood: michael.greenwood@vancethompsonvision. com Mamalis: nick.mamalis@hsc.utah.edu Swan: russell.swan@vancethompsonvision.com Considering continued from page 47 Dr. Greenwood switched from Tri-Moxi as an intracameral antibiotic (shown here as a cloudy suspension) to Dex-Moxi-Ketor because it is clear and patients don't experience floaters. Source: Michael Greenwood, MD Scan EWAR code to view video

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