Intraoperative Antimicrobial Prophylaxis In Elective Cataract Surgery Patients With Penicillin Allergy

The true prevalence of IgE-mediated allergy in those self-identifying as penicillin allergic sits at less than 1%. There is a lack of evidence for significant cross-reactivity of intracameral cefuroxime in penicillin allergic patients. This has led to significant variation in intraoperative antimicrobial prophylaxis for cataract surgery in this setting in the United Kingdom. In this study, we critically appraise published evidence to produce evidence-based recommendations on this varied area of practice.

Literature review to produce evidence-based, "Concise Practice Point" for the Royal College of Ophthalmologists, United Kingdom.

A literature search was conducted using PUBMED and the content identified was used to produce a set of evidence-based recommendations. The search was performed on all fields using the search terms, “penicillin”, “allergy”, “cataract surgery” and “cefuroxime” in August 2021. References of cited publications were examined to identify further relevant articles. 

6 key papers were identified and used to produce the following set of evidence-based recommendations on how to approach the penicillin allergic cataract surgery patient: "Take a thorough allergy history to determine whether or not the patient has a history of possible anaphylaxis", "If there is a confirmed or suspicion of possible anaphylaxis to penicillin, intracameral moxifloxacin 0.1ml of 0.5mg/0.1ml should be considered as an alternative" and finally, "If there is no confirmed or suspicion of possible anaphylaxis to penicillin, based on the evidence we have considered, we recommend proceeding with intracameral cefuroxime".

The most suitable intracameral antimicrobial alternative to intracameral cefuroxime is moxifloxacin, for which large retrospective studies from the Aravind Eye Care System and elsewhere provide strong support. This option has many appealing features for the patient with severe penicillin or cefuroxime allergy; it is molecularly distinct, can be injected undiluted from a commercial preparation, it is not toxic to the eye and it has proven efficacy in preventing endophthalmitis.