Experts debate pros and cons of intracameral cefuroxime

STOCKHOLM, Sweden — Concerns about the unavailability of cefuroxime in single sterile doses for intracameral injection are the main reasons why American cataract surgeons do not use this antibiotic for prevention of postoperative endophthalmitis, according to a surgeon speaking at a pros and cons debate at the European Society of Cataract and Refractive Surgeons meeting.

In the ESCRS endophthalmitis study, intracameral injection of cefuroxime at the end of cataract surgery was shown to be a powerful agent in preventing this severe complication, reducing by a factor of five the risk of contracting endophthalmitis after phacoemulsification. Intracameral cefuroxime was therefore included in the recent ESCRS endophthalmitis prophylaxis guidelines.

Peter Barry

"This technique was first developed in Sweden, and its efficacy was demonstrated retrospectively and prospectively in over 400,000 Swedish patients," said Peter Barry, MD, ESCRS study coordinator.

Despite this evidence, intracameral cefuroxime is not approved by the U.S. Food and Drug Administration and is therefore not used in the United States.

"There are several concerns about the use of cefuroxime. First is its inability to provide coverage for pseudomonas," Randall J. Olson, MD, said. Allergic reactions were also reported in some patients treated with this antibiotic.

"However, the main problem is the fact of not having single-unit sterile doses of the drug for intracameral use. Preparing our own dilution exposes us to the risks of kitchen pharmacy, with potential medical-legal consequences, which are probably even more an issue in the U.S. than they are in Europe," he said.

Dr. Barry, on the other hand, expressed concern about the wide preoperative use of intracameral vancomycin and topical latest-generation fluoroquinolones. As stated in the ESCRS guidelines, these antibiotics should be strictly reserved to treatment.

Resistance to antibiotics, including the latest-generation fluoroquinolones, is becoming a major concern, Dr. Barry noted, and increasingly so because these agents are widely used in the animal husbandry business in the United States.

"In 2 years time, the fourth-generation fluoroquinolones will become useless if you have this antibiotic drug policy," he said.

"I don't think that vancomycin should be used for prophylaxis, and personally, I am not convinced it works because it is very slow in its action. The fluoroquinolones are rapid, but the sad news is that the cat is out of the bag already. The government should have blocked their use in animal husbandry 3 or 4 years ago," Dr. Olson said.

He said he believes that if unit doses were manufactured and approved, intracameral cefuroxime would become the international standard.

In an interview with Ocular Surgery News, Dr. Barry explained that there is a manufacturing problem in preparing cefuroxime in small doses.

"Biological stability is a problem, but some small companies are trying to solve it, and I truly hope that over the next several months the preparation we need will be available," he said.