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High-volume cataract surgeons suggest antibiotic prophylaxis to reduce endophthalmitis risk
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SAN DIEGO — Two high-volume surgeons in the Czech Republic performed nearly 9,000 cataract cases in more than a 4-year-period without one case of endophthalmitis, which they attributed to use of intracameral cefuroxime natricum.
Petr Mašek, MD, PhD, and Dalibor Cholevík, MD, based in Ostrava, Czech Republic, presented their results of 8,928 cataract surgeries between May 2006 and September 2010 at the American Society of Cataract and Refractive Surgery meeting here in a poster.
In all cases, they performed clear corneal incisions of 2.6-mm to 2.75-mm with use of a topical anesthetic. They implanted a foldable IOL. They used 1 mg intracameral cefuroxime natricum. Postoperative care for 1 week included dexamethasone 0.1%. Patient follow-up was up to 30 days.
No postoperative inflammation complications were reported after surgery, with no cases of postoperative endophthalmitis.
"We recommend intracameral [cefuroxime] natricum as a standard procedure of modern phacoemulsification cataract surgery," Dr. Mašek and Dr. Cholevík said.
Disclosure: Dr. Mašek and Dr. Cholevík have no direct financial interest in the products discussed in this article, nor are they paid consultants for any companies mentioned.
Since the ESCRS study, intracameral antibiotics have become standard in Europe, not in North America, but their use is increasing. Americans cite excessively high reported European infection rates in cases without intracameral antibiotic use and some other irregularities in the ESCRS study, as well as the lack of an available approved single-use antibiotic preparation for intracameral use in the U.S., risk of dilution errors, risk of allergy (anaphylaxis has been reported with intracameral cefuroxime use), and uncertainty about whether cefuroxime would be the drug of choice for intracameral use if multiple antibiotics were studied. The ESCRS study only studied cefuroxime.
Despite American concerns, the collected European data on intracameral cephalosporin use is becoming compelling. Accumulated European reports now include data on 536,000 cases, with infection rates of about 1/2,000 using intracameral cefuroxime, whereas with no intracameral drugs the infection rate is 1/330.
Other studies suggest that intracameral moxifloxacin — which is much simpler to prepare and has a broader spectrum of activity, low risk of allergy, less resistance, and is dose-dependent rather than time-dependent activity — may be a better drug. Reported infection rates with intracameral moxifloxacin are not statistically significantly different from those with cefuroxime. (For more detail, see “The Dose & Administration of Intracameral Moxifloxacin,” poster presented at 2011 ASCRS available on the ASCRS website.)
Intracameral antibiotics, in an increasing number of presentations and publications, clearly have been demonstrated to reduce infection rates, irrespective of baseline rates without them. The best intracameral drug is still an active issue of discussion, and we should always be prepared to change as newer antibiotics emerge. It is time for North American surgeons to take a more serious look at this issue.
– Steve Arshinoff, MD, FRCSC
University
of Toronto and McMaster University, Canada
Disclosure: Dr. Arshinoff is a
consultant for Alcon Laboratories.