Healio
Healio
February 01, 2005
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At Issue: Cataract surgery prophylaxis regimen

Question At Issue posed the following question to a panel of experts:
“What is your preferred prophylactic regimen for cataract surgery?”

Answer Lid cleansing starts
4 days preop

Jorge L. Alio, MD, PhD: Four days prior to the surgery, the patient is prescribed a special eyelid soap gel that needs to be applied twice a day, immediately after waking up in the morning and before going to bed in the evening. The gel contains a neutral pH soap and antiseptic.

Three days before surgery, the patient uses ofloxacin 0.3% eye drops twice a day (early morning and before going to bed). The patient is instructed to clean his spectacles, if he uses them, with the soap and to report any discomfort, pain or redness of the eye the day of the surgery.

Just before entering the operating room, we wash the eye extensively with a solution of 50% povidone-iodine diluted in saline.

At the end of surgery, an intraocular injection of 250 µg (1% dilution on 0.1 cc) of cefuroxime is performed. This antibiotic is prepared daily at our pharmacy department in bottles for up to 20 surgeries. The eye is rinsed again with 50% povidone-iodine solution.

Postoperative prophylaxis includes the use of the same antibiotic and topical steroids.

High-risk patients such as diabetics, patients with simple occlusions of the lacrimal pathways or ocular surface disorders, or patients with poor hygiene habits or who do not have adequate hygiene at home are sometimes treated after surgery with oral ciprofloxacin, one capsule (500 mg) twice a day for 5 days. This is done in less than 0.5% of cases.

At this time, all the prophylaxis treatments are considered speculative. There are several studies that are contradictory concerning the use of topical antibiotics or even intraocular antibiotics or pipeline intraoperative antibiotics. For this reason, we have joined the European Society of Cataract and Refractive Surgeons study on the prevention of endophthalmitis that started in January 2004. The aim is to gather 35,000 cataracts in different European centers to examine whether topical levofloxacin, povidone-iodine prophylaxis or intraocular antibiotic (cefuroxime) is better than doing nothing else than topical prophylaxis with povidone-iodine.

Answer No antibiotics
prescribed

Rupert Menapace, MD: No preoperative measures are taken except in cases of blepharitis, which must be cleansed using a fusidic acid gel. In the operating room, the eye is repeatedly rinsed with pH-balanced (pH 6.8) povidone-iodine 2.5% while exposing the upper and lower cul-de-sac before and after insertion of the lid speculum. The eyelashes are meticulously draped. No antibiotic or epinephrine is added to the infusion fluid. Ringer’s solution and 2% methylcellulose are used for routine cases, which have been shown in a randomized comparative study to perform as favorably as their more expensive counterparts. Methylcellulose is also used to repeatedly coat the corneal surface and thus avoid postop tear-film problems. At the end of surgery, the eye is once again washed with povidone-iodine. Postoperatively, nonsteroid anti-inflammatory drug drops (ketorolac or diclofenac) are prescribed three times daily for 3 weeks. Cortisone drops are not used, as they compromise the immunological defense, while proof of an anti-inflammatory add-up effect to NSAIDs is lacking. No antibiotics are prescribed. Cases of endophthalmitis were rare and in the low range of the percentages reported in the literature. This I attribute mainly to the sclerocorneal tunnel incision used. For children, one-eyed patients and high-risk cases, an antibiotic (levofloxacin) was added for 1 week.

For theoretical reasons, I am considering the routine use of gentamicin drops three to five times daily for 1 week, which is effective against staphylococci, the most frequent cause of endophthalmitis. However, I definitely vote against the general use of highly potent antibiotics for mere prophylaxis, which unnecessarily blunts these valuable tools that are needed for cases of apparent infection.

The major causative factor of endophthalmitis is bacterial inoculation after eye rubbing. Meticulous tunnel preparation is essential, and sclerocorneal incisions should be used, as they provide for much greater stability against deformation as compared to clear corneal incisions.

Answer Preventing
endophthalmitis

Okihiro Nishi, MD: Although postoperative endophthalmitis is rare, its prevention may be the most important issue for cataract surgery. Rationale for the administration of prophylactic topical antibiotics includes reduction or elimination of the periocular bacterial load. Preoperatively, we give the second-generation fluoroquinolone levofloxacin to the patient three times a day for 3 days, including the day of surgery. At the time of surgery, the lid and conjunctival sac are disinfected with povidone-iodine, and gentamicin is added as an intracameral antibiotic to the infusion bottle (4 mg/500 mL). At the end of surgery, gentamicin 4 mg is given subconjunctivally. Postoperatively, topical levofloxacin is administered for 2 weeks. This agent should have a broad spectrum against bacterial activity and be able to penetrate well into the aqueous.

For postoperative inflammation prophylaxis, I administer fluorometholone 0.1% three times daily for 12 weeks. I prefer this agent to prednisolone or dexamethasone because I have never experienced an IOP rise that appeared to be caused by the agent. The use of NSAIDs, in addition to steroids, is important for controlling inflammation because it can significantly reduce not only inflammation in general but also postoperative cystoid macular edema and lens epithelial cell-related fibrin reaction better than the use of steroids alone. Inhibiting effect on the synthesis of PGE2 may be greater since NSAIDs inhibit more specifically cyclooxygenase. I prescribe a single bottle of 0.1% diclofenac sodium for peri- and postoperative use. It is given 1 hour preoperatively to prevent intraoperative miosis. Postoperatively, it is administered once daily until the bottle is emptied, about 3 to 4 weeks. In case of fibrin reaction, which is rarely observed nowadays, it is increased to three times daily. One should be aware that NSAIDs can damage the corneal epithelium. If there is corneal erosion or wound dehiscence observed after surgery, diclofenac sodium is interrupted for several days.

Answer Adequate wound
closer essential

Noel Alpins, FRACO, FRCOphth, FACS: The underlying goal of prophylactic antibiotic treatment in cataract surgery is to reduce the bacterial load of organisms in the periocular environment.

This process begins at the initial consultation when any existing blepharitis is identified and treated, and continues until the patient is seen an hour prior to the small-incision cataract surgery. At this stage, the lids are cleaned of any debris and a drop of chloramphenicol 0.5% is instilled after the mydriatic.

Immediately before the surgery, the surrounding skin of the eye is further cleansed with povidine-iodine 10%, with a little of this allowed to trickle into the cul-de-sac. Eyelids and lashes are then draped with plastic, leaving only the ocular surface exposed. The irrigating solution used both intraocularly and to moisten the cornea throughout the surgery is primed with gentamicin (4 mg in 500 mL) to reduce the risk of endophthalmitis.

At the conclusion of surgery, a fluorescein Seidel test is performed to ensure the wound is adequately closed. If not, then stromal hydration or occasionally a suture may be required. Postoperatively, the patient is on a regimen of chloramphenicol 0.5% four times a day for the first week in addition to topical corticosteroids.

It has not been necessary to modify the regimen for antibiotic prophylaxis for cataract surgery in recent times. There is only a small incidence of infection associated with small-incision cataract surgery, and no cases of endophthalmitis have occurred in the past 3,000 cases. Assessing the risk factors preoperatively and the systematic approach of reducing the bacterial load at each step of the procedure allow the surgery to be performed under the optimal conditions and with minimal risk of infection.

For Your Information:
  • Jorge L. Alio, MD, PhD, can be reached at Avda, Denia 111, 03015 Alicante, Spain; +34-965-150-025; fax: +34-965-151-501; e-mail: jlalio@oftalio.com.
  • Rupert Menapace, MD, can be reached at Waehringer Guertel 18-20, A-1090 Vienna, Austria; fax: +43-1-40400-6630; e-mail: rupert.menapace@univie.ac.at. Dr. Menapace has no financial interest in any product mentioned in this article, nor is he a paid consultant to any company.
  • Okihiro Nishi, MD, can be reached at 4-14-26, Nakamichi, Hagashinari-ku, Osaka City, Osaka, 537-0025 Japan; +81-6-6981-1132; fax: +81-6-6981-5630; e-mail: okihiro@nishi-ganka.or.jp.
  • Noel Alpins, FRACO, FRCOphth, FACS, can be reached at 7 Chesterville Road, Cheltenham, VIC 3192 Australia; +61-3-9584-6122; fax: +61-3-9585-0995; e-mail: alpins@newvisionclinics.com.au.