Eyeworld

EW CATARACT 69 March 2018 posterior injections that have been made from various compounding pharmacies," he said. "I think the jury is still out regarding those." Dr. Mamalis thinks more sur- geons are going to use intracameral antibiotics in their cataract surgery regimens going forward. "The evidence is clear that it prevents endophthalmitis," he said. One current shortcoming in the U.S., however, is the fact that there is no approved single-use injection for antibiotics. "An ASCRS coun- sel has been put together to try to coordinate large nationwide studies to look at questions like this," Dr. Mamalis said. "The first thing we are tackling is postoperative intracamer- al antibiotics versus topical antibiot- ics." He thinks this could be a game changer. "Then we would have an FDA-approved medication that can be used for intracameral injection that I think all surgeons would con- sider using," he said. EW References 1. Shorstein NH, et al. Comparative effec- tiveness of three prophylactic strategies to prevent clinical macular edema after phacoemulsification surgery. Ophthalmology. 2015;122:2450–6. 2. Wielders LHP, et al. Prevention of macular edema after cataract surgery. Curr Opin Ophthalmol. 2018;29:48–53. 3. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33:978–88. 4. Shorstein NH, et al. Decreased postoper- ative endophthalmitis rate after institution of intracameral antibiotics in a Northern California eye department. J Cataract Refract Surg. 2013;39:8–14. Editors' note: Dr. Talley Rostov has fi- nancial interests with Allergan, Bausch + Lomb, and Sun Pharmaceutical In- dustries (Mumbai, India). Dr. Mamalis and Dr. Shorstein have no financial interests related to their comments. Contact information Mamalis: nick.mamalis@hsc.utah.edu Shorstein: nshorstein@eyeonsight.org Talley Rostov: ATalleyRostov@nweyes.com If insurance permits, Dr. Mama- lis prefers to use Vigamox (moxiflox- acin, Alcon, Fort Worth, Texas) since he's using intracameral moxifloxa- cin, which is preservative-free, but he thinks that Zymaxid (gatifloxacin 0.5%, Allergan, Dublin, Ireland) is equally good. While Dr. Mamalis currently relies on this "belt and suspenders" approach, he hopes new studies will curtail the need for this. "We're in the process of initiating a study to look at intracameral antibiotics and topical antibiotics postoperatively," he said. "Hopefully that will give us some answers. "I also have them use a topical steroid, 1% prednisolone drop," Dr. Mamalis said, adding that in stan- dard cases he asks patients to use this four times a day for 2 weeks. For those who are diabetic, he will keep them on the drops longer before tapering. Finally, he will put patients on an NSAID to help prevent CME and to reestablish the blood/aqueous barrier. The one he chooses depends on the patient's insurance coverage. "Because I'm at a university, we get patients who don't have a lot of insurance coverage for medications, and most of the insurances will just cover generic NSAIDs such as a generic ketorolac," Dr. Mamalis said. "I know that it may burn a little, but that's what my patient base ends up using. Patients use this four times a day for 2 weeks in standard cases, then depending on their condition may use this longer." Currently, he limits his injec- tions to intracameral antibiotics. "There are various combinations that are being done through com- pounding pharmacies that will have an antibiotic and a steroid injected either through the zonules or more posteriorly rather than intracam- erally in the anterior chamber," Dr. Mamalis said. However, he still doesn't think there's good evi- dence that this approach has any distinct advantages over a simple intracameral injection of an anti- biotic. What's more, there can be a downside. "There have been some outbreaks of inflammation inside the eye from these transzonular or and I use that five times a day for 2 weeks afterward," Dr. Talley Rostov said. Nick Mamalis, MD, professor of ophthalmology, John A. Moran Eye Institute, University of Utah, Salt Lake City, starts his patients on preoperative drops when they come in for their surgery. In addition to standard dilating drops preopera- tively, his patients receive three sets of drops of a topical fluoroquino- lone antibiotic, as well as three drops of an NSAID prior to surgery. "As they're being prepared for sur- gery and they're starting an intrave- nous line, they'll receive these drops preoperatively," Dr. Mamalis said. He does not view it as necessary to have these drops on board earlier. While some studies have shown that having antibiotics on board for a day or three before surgery will kill more bacteria, this is by no means the consensus, he said. "There has been an equally good number of studies that have shown that as long as antibiotics are on board before they go back to the operating room, you should get a good treat- ment of any surface bacteria," Dr. Mamalis said. In addition, patients will receive 5% betadine as well as lidocaine gel. "It's important that the betadine drop goes in before the lidocaine gel," he said. Otherwise, lidocaine gel can keep the betadine from spreading out and totally cov- ering the surface of the eye. At the conclusion of the cat- aract case, Dr. Mamalis will inject 0.1 ml of a preservative-free 0.5% moxifloxacin. "After we remove the drapes and we're getting patients ready to go out of the OR, they'll receive a topical fourth-generation fluoroquinolone drop as well as a topical drop of a dilute betadine solution," he said. Although he uses the intraca- meral approach, in his view it's still important to include such postoper- ative drops. "I'm still having them use postoperative antibiotic drops," he said. "It's like a belt and suspend- ers." Currently, he has patients use a topical fourth-generation fluoro- quinolone drop every 2 hours the day of the surgery and four times a day for 7 days. cephalosporin. If the patient is aller- gic, Dr. Talley Rostov uses moxiflox- acin, which tends to be a bit more expensive. She currently has plans to move to a moxifloxacin dexa- methasone injection at the time of surgery. "In that case, I'm going to try to use the NSAID afterward," she said. Currently, in addition to an NSAID drop, she puts the patient on a drop of steroid. She places the patient on loteprednol twice daily for 1 month and bromfenac once daily for 1 month. Because she uses intracameral antibiotics, she does not think she needs to include a pre- or postop- erative antibiotic drop as well. Dr. Talley Rostov opts for the intraca- meral approach because of lower endophthalmitis rates found in the literature. "There are multiple stud- ies that show that you decrease the incidence of endophthalmitis with use of intracameral antibiotics," she said. "There was a landmark ESCRS study and a study by Shorstein et. al that showed a 22-fold decrease in the incidence of endophthalmi- tis following cataract surgery with intracameral antibiotics." 3,4 While Dr. Talley Rostov current- ly uses an intracameral antibiotic, she is moving over to a combina- tion moxifloxacin/dexamethasone product. However, she will continue with the intracameral approach. "All the colleagues that I had who start- ed doing that stopped," she said. "From reports, there were a number of different issues and concerns with going a transzonular route to begin with, then there was breakthrough inflammation." As a result, a num- ber of those who used this approach stopped. She decided to stay with the intracameral approach, which she liked. In diabetic patients, Dr. Talley Rostov alters her regimen some- what. She starts the patient on an NSAID 3 days beforehand and also uses an additional antibiotic drop postoperatively such as moxifloxa- cin or ofloxacin. "Also for patients who had a complicated cataract surgery or for cornea transplant patients, I put them on a topical an- tibiotic as well as the intracameral,

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