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Should ophthalmology adopt the practice of intracameral prophylaxis during cataract/refractive surgery?
One antibiotic bottle per patient
 Stephen S. Lane |
While there have certainly been a number of concerns raised with the methodology and results of the European Society of Cataract and Refractive Surgeons endophthalmitis study, it did clearly show that patients who received intracameral cefuroxime had a lower incidence of endophthalmitis than patients who did not receive intracameral cefuroxime or who received topical antibiotics. In terms of the spectrum of activity and resistance patterns, the fourth-generation fluoroquinolones are better drugs, and so using a better antibiotic intracamerally should give you as good, if not better results – and that is the rationale that I have used over the past 2 years to justify my use of intracameral Vigamox (moxifloxacin, Alcon). I have yet to see a single complication from its use, nor have I had a single case of endophthalmitis.
Studies performed by Arshinoff, Espiritu and, more recently, myself, Osher and Masket show Vigamox 0.05 cc right out of the bottle to be safe when used intracamerally at the conclusion of surgery. Vigamox does not contain any preservatives that might otherwise cause toxicity if used intracamerally and requires no mixing, thereby avoiding any possible dilutional errors.
There are several ways to “prepare” intracameral Vigamox. At our center, we use a brand-new bottle for each patient. The patient comes into the preop area of our surgery center with a brand-new, unopened bottle, with the seal still intact. This bottle is brought to the operating room, again with the seal intact, and then after opening it is either drawn directly out of the bottle by the scrub nurse with a needle attached to a syringe or drawn up from drops that have been dropped into a sterile Petri dish on the Mayo stand. Regardless, each patient receives sterile Vigamox from their own bottle, which was not opened until they got into the operating room. What is left in the bottle goes home with them and used topically for the rest of their postoperative course.
We also treat all of our patients before surgery with topical Vigamox in the preoperative area along with their preoperative dilating drops and topical anesthesia. I firmly believe that the use of intracameral antibiotics will become a standard procedure for prophylaxis at the conclusion of cataract surgery in the future.
Stephen S. Lane, MD, is a clinical professor of ophthalmology at the University of Minnesota, St. Paul.
Intracameral antibiotics for lens-based surgery
The 2006 ESCRS endophthalmitis study, utilizing solely intracameral cefuroxime 1 mg/mL, was most compelling in reducing the incidence of infection to about one per 1,400 cases and even suggests that pre- and postoperative topical antibiotics may be superfluous. In the U.S., use of vancomycin either in the irrigating fluid or as an intracameral injection at the close of cataract surgery is similarly compelling. Thus, I would have to favor such practices for any and all intraocular surgical procedures. Indeed, the only downside risk would be the low probability of ocular toxicity from an inadvertent dilution error, and such cases of severe retinal damage have been rarely reported, especially in response to intraocular aminoglycoside antibiotics.
 Kenneth R. Kenyon |
As to the use of intracameral antibiotics for refractive surgery, I would only favor their use for lens-based refractive surgeries (refractive lens exchange, ICL, etc.) but certainly not recommend such use for routine laser vision corrective procedures (LASIK, PRK), as the infection risk is extremely rare and limited to the cornea and/or ocular surface. Although MRSA is becoming somewhat more prevalent in refractive surgical settings, at this time only topical fluoroquinolone prophylaxis remains indicated.
In summary, the “con” to consider for intracameral antibiotic prophylaxis is the unlikelihood of antibiotic dilutional errors causing intraocular toxicity, and I presume the ocular pharmaceutical industry will obviate this with unit dose preparations of appropriate agents at efficacious but non-toxic concentrations.
Kenneth R. Kenyon, MD, is OSN Cornea/External Disease Section Editor Emeritus.