ENDOPHTHALMITIS PROPHYLAXIS

Luis Cordoves, MD

An increasing number of cataract surgeons around the world, particularly in Europe, are now using intracameral antibiotics for endophthalmitis prophylaxis, reported Luis Cordoves MD, Hospital Universitario de Canarias, Spain, at the 19th ESCRS Winter Meeting in Istanbul, Turkey.

Dr Cordoves noted that it was Gholam Peyman MD who first introduced the use of intracameral injections of antibiotics after cataract surgery in 1977 when he described their use in India Eye camps. Per Montan MD in Sweden picked up on the idea in 1996 and data from the Swedish Register showed that the rate of endophthalmitis fell from 0.35 per cent to 0.048 per cent following the almost universal adoption in the country of intracameral antibiotics.

Wide adoption of the practice across Europe followed the publication of the randomised controlled ESCRS Endophthalmitis Study, which yielded almost identical results to those of the Swedish Cataract Register.

A European Observatory of Cataract Surgery survey carried out in 2014, and involving 490 surgeons from nine European countries, indicated that in many European countries the use of intracameral cefuroxime is almost universal. Overall, 71 per cent of respondents said that they use intracameral antibiotics in all cases, and of those, 67 per cent use Aprokam® (Théa), a single dose preparation of cefuroxime for intracameral use, and 26 per cent used generic cefuroxime.

Which antibiotic is best?

Among proponents of intracameral antibiotics, there is still considerable debate about which agent is most ideal for endophthalmitis prophylaxis. The contentious issues include whether a newer broader spectrum antibiotic like moxifloxacin might provide a significant improvement in safety, and whether cefuroxime’s efficacy may vary by geographical location, since the causative organisms vary throughout the world.

Regarding moxifloxacin, he noted that in a survey by the International Society of Bilateral Cataract Surgeons in 2011, the rate of endophthalmitis was only 0.003 per cent among patients receiving intracameral moxifloxacin by injection compared to 0.01 per cent among patients receiving intracameral cefuroxime. A study by Dr Montan using data from the Swedish database showed that the rates of endophthalmitis with the use of cefuroxime and moxifloxacin are more similar, 0.025 per cent and 0.030 per cent respectively, Dr Cordoves said.

Coming around to idea

Tat Keong Chan MD noted that there has also been a slow but sure narrowing of the transatlantic divide regarding the antibiotic prophylaxis of endophthalmitis following cataract surgery since the publication of the ESCRS Endophthalmitis Study.

“ASCRS practice surveys show that more US surgeons are routinely administering an intracameral antibiotic now than were in 2007, and the majority are now giving it by a direct bolus injection,” said Dr Chan, Singapore National Eye Centre, Singapore.

He noted that, in a survey of ASCRS members carried out in 2007, only 30 per cent of respondents said that they used intracameral antibiotics for endophthalmitis prophylaxis in their cataract surgeries, and of those, only half used a bolus injection at the end of surgery. The remaining respondents used antibiotics in their infusion bottle. Nonetheless, 82 per cent said that they would use intracameral injections if there was a commercially available product at a reasonable cost.

Despite some initial resistance, by 2011 the AAO had acknowledged the efficacy of the approach, stating that “there is mounting evidence that injecting intracameral antibiotics as a bolus at the conclusion of surgery is an efficacious method of endophthalmitis prophylaxis”, and in the same year the ASCRS Cataract Clinical Committee published a white paper stating that “of the various methods of antibiotic prophylaxis, the strongest evidence supports a direct intracameral bolus at the conclusion of surgery”, Dr Chan noted.

And if more evidence was needed, it was provided by a study by Neil Shorestein MD and his associates in California, and published in the January 2013 issue of the Journal of Cataract and Refractive Surgery, in which there was a 22-fold reduction in the endophthalmitis rate with no adverse reactions to the injections, Dr Chan noted.

Because of these and other factors, when ASCRS members were again surveyed in 2014, the proportion of those using intracameral antibiotics had risen from 30 per cent to 50 per cent, and of those, 84 per cent administered the agent through direct injection. The antibiotics used were moxifloxacin, by 33 per cent, vancomycin by 37 per cent, and cefuroxime by 26 per cent.

As for Aprokam, 21 per cent of respondents without access to the product said they would use it if it were available and another 48 per cent said they would use it if the cost were right.

“Most US surgeons are now in favour of the intracameral strategy in cataract surgery and there are key opinion leaders in the US who are calling for the FDA to quickly approve a commercially available antibiotic for intracameral injections. However, because of regulatory and legal issues, your guess is as good as mine when one will be approved,” Dr Chan added.

Luis Cordoves: luis.cordoves@hotmail.es

Tat Keong Chan: tatkeongchan@gmail.com