Endophthalmitis increase warrants move to new antibiotics, speakers say

NEW ORLEANS — A documented increase during the past decade in the incidence of endophthalmitis after cataract surgery justifies the trend toward use of newly available fluoroquinolones, according to surgeons at a session on cataract controversies.

During a session on cataract controversies at the American Academy of Ophthalmology meeting, speakers said post-cataract endophthalmitis has increased during the same period of time that use of clear corneal sutureless incisions has increased. They discussed the possibility that these two trends are related and focused on possible prevention of endophthalmitis with the newest generation of fluoroquinolones.

Peter J. McDonnell, MD, presented a review of the ophthalmic literature showing an increase in the reported incidence of post-cataract endophthalmitis since 1992, reversing a declining trend over the previous 3 decades. Similarly, he said, a review of Medicare data showed that the incidence of post-cataract endophthalmitis was higher from 1998 to 2001 than in the previous 4 years.

Dr. McDonnell described cadaver eye studies done at the Wilmer Eye Institute showing that fluid on the surface of the cornea can travel through a clear corneal incision and reach the interior of the eye. Observations during cataract surgery also showed that blood from the surface of the cornea can enter the anterior chamber through the wound, he said.

These factors suggest that the unsutured corneal wound can be a route for ingress of bacteria during or after surgery, Dr. McDonnell said.

I. Howard Fine, MD, said there is no question there has been an increase in the incidence of endophthalmitis during the era of clear corneal surgery, but “not all clear corneal incisions are the same.”

Dr. Fine said meticulous attention to detail in surgery can help to prevent endophthalmitis.

“We have gone at least 8 years and 7,000 cataract surgeries without a case of endophthalmitis, and I do not believe that has been because of good luck,” Dr. Fine said.

He said several factors have contributed to the avoidance of endophthalmitis in his practice. These factors include careful draping, preparation of the surgical field with povidone iodine, attention to incision architecture and surgical technique, careful wound closure including stromal hydration in all the incisions, testing of the wound for leaks, and use of a newer generation fluoroquinolone preoperatively, intraoperatively and postoperatively.

Francis S. Mah, MD, said that, since their introduction in the 1990s, fluoroquinolones have become the standard topical antibiotic for ophthalmologists. Unfortunately, he said, resistance to the second- and third-generation topical fluoroquinolones has emerged, especially among staphylococcal strains.

Dr. Mah said the current generation of fluoroquinolones, which includes gatifloxacin and moxifloxacin, covers resistant isolates and shows improved activity against gram-positive organisms.

For surgical prophylaxis, Dr. Mah recommended the use of povidone iodine and a topical antibiotic.

He noted that ophthalmologists have rapidly moved to use of the latest generation of fluoroquinolones. Only months after the commercial introduction of the two drugs in 2003, the annual survey of practice trends among members of the American Society of Cataract and Refractive Surgery showed that 60% of respondents had already adopted the fourth-generation agents, he said.

Given the broad-spectrum efficacy and good safety profile of the new agents, Dr. Mah said, “there is no place for ciprofloxacin and ofloxacin in ophthalmology.”