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Per Montan receives Kiewiet de Jonge Award
Per Montan MD of St Erik's Eye Hospital in Stockholm, Sweden received the Kiewiet de Jonge award in recognition for his paper "Prophylactic intracameral cefuroxime: Efficacy in preventing endophthalmitis after cataract surgery" at the XXI Congress of the ESCRS. Dr Montan's paper appeared in the June 2002 issue of the Journal of Cataract and Refractive Surgery. It concerned a retrospective study indicating that an antibiotic regimen containing cefuroxime reduced the incidence of endophthalmitis to 0.06 % in a series of a 32,180 consecutive cataract patients. That compared to an incidence of up to 0.5 % reported at some centres. "Our trial sought to address the question of whether it is feasible to reduce the incidence of endopthalmitis to an acceptable level," Dr Montan said. The prophylactic regimen used in the trial has now been adopted by cataract surgeons throughout Sweden , which currently has the lowest incidence of endophthalmitis of any country in the world. In the years immediately prior to the study, 1990-1995, the incidence of the complication at St Erik's Eye Hospital had been 0.26 %. The Swedish team instilled the antibiotic solution, consisting of 1.0 mg cefuroxime in 0.1 ml saline 0.9%, in the capsular bag at the completion of the surgery. Their protocol also included rinsing of the conjunctiva with chlorhexidine solution 0.05% five minutes before surgery. Dr Montan and his associates based their selection of cefuroxime on the etiological spectrum of previous endophthalmitis cases occurring after cataract surgery in their centre. Of the 59 causative strains they identified, only four were resistant to cefuroxime. Cefuroxime is a second-generation bactericidal cephalosporin. It is active against the majority of bacteria implicated in endophthalmitis, including most staphylococci and streptococci, many Gram-negative organisms, p. acne and the diphteroids. "We felt that cefuroxime was an uncontroversial choice for an intracameral antibiotic. As regards safety it is not toxic to the endothelium or retina. It also remains in the anterior chamber for four-to-five hours. It is not omnipotent, it doesn't cover all possible species of infective organisms. Other centres have reported very good results with intraocular vancomycin, but in my opinion that antibiotic should be reserved for treatment rather than prevention." Of the 20 cases of postoperative endophthalmitis that occurred in the retrospective study, 13 were culture-positive. Of those, 12 were caused by cefuroxime-resistant organisms, including enterococci in five cases, Agrobacterium in three cases, Alcaligenes xylosoxidans in two cases, and pseudomonas mendocina in one case. The one case where a non-cefuroxime resistant organism caused endophathalmitis involved Staphylococcus aureus. Dr Montan and his coauthors noted that the use of intracameral cefuroxime seemed to increase the incidence of postoperative infections with resistant organisms. For example, in the five years prior to adopting their current antibiotic regime they only encountered two cases of enterococcal endopthalmitis. That compared to five cases in the subsequent five years. They suggested that supplementary antibiotics might be necessary should the trend continue. The findings of Dr Montan's study have formed the basis for the protocol of the recently commenced ESCRS endophthalmitis study. The randomised controlled trial will involve a total of 35,000 cataract patients undergoing phaco cataract surgery in 16 centres in eight European countries. It will be the largest prospective trial ever undertaken in Ophthalmology. Patients in the ESCRS study will be randomised into four groups. The first will receive placebo eye drops and no intracameral antibiotics; the second group will receive perioperative eye drops containing levofloxacin, a third-generation fluoroquinolone, and no intracameral injection; the third will receive placebo eye drops but will undergo an intracameral injection of cefuroxime - identical to that used in Dr Montan's study - at the end of surgery; and the fourth group will receive both the antibiotic eye drops and the intracameral injection. Levofloxacin is a quinolone which when used as an eye drop penetrates in sufficiently high concentrations into the anterior chamber to be effective against most organisms which cause endophthalmitis. It has only recently become available for topical ophthalmic use. All patients will also receive povidone iodine preoperatively, the only agent given a recommendation in a recently published overview by Ciulla et al on prophylactic measures in cataract surgery, and levofloxacin drops for the first postoperative week to prevent wound infection, Dr Montan noted.Should there come a point during the two-year trial when there is an indisputable treatment benefit in favour of the intracameral injection, the study's monitoring committee will break that component of the trial. The trial may then continue with all the study groups using intracameral cefuroxime and some using intensive topical antibiotics additionally."What our study and other similar studies have established is that we can reduce the incidence of endophthalmitis in a controlled manner but if you want the ultimate proof of concept you need evidence-based medicine. Hopefully this ESCRS trial will provide a definitive answer," Dr Montan added. The Kiewiet de Jonge award is given for the best European paper published in the Journal of Cataract and Refractive Surgery in the previous year. It commemorates Jan Kiewiet de Jonge MD, an ophthalmologist from Leiden , The Netherlands who together with Cornelius Binkhorst MD was co-founder of both the Netherlands Intraocular Implant Club (NIOIC) and the European Intraocular Implant Council (EIIC), which later became the ESCRS. Dr Kiewiet de Jonge was secretary of the EIIC until his death in 1981. For many years it has been the tradition that the president of the NIOIC presents the Kiewiet de Jonge award to the recipient during the annual congress of the ESCRS. Per Montan MD |
