Steinert advises on prevention of endophthalmitis in cataract surgery

KOLOA, Hawaii — A comprehensive drug regimen and meticulous surgical steps are key to endophthalmitis prevention in cataract surgery, according to a speaker here.

Roger F. Steinert, MD, discussed endophthalmitis prevention at the Hawaiian Eye 2007 meeting.

Image: Singer H, OSN

Roger F. Steinert, MD, presented his preoperative, intraoperative and postoperative steps for infection prevention here at the Hawaiian Eye 2007 meeting.

Preoperatively, Dr. Steinert said he first treats chronic meibomian gland disease in blepharitis. He also tells his patients to stop wearing any and all cosmetics.

"We used to use antibiotic skin cleanser," he said, but that has fallen out of practice. "Perhaps it is time to revisit that."

Dr. Steinert also prescribes currently available fluoroquinolones, either Zymar (gatifloxacin 0.3%, Allergan) or Vigamox (moxifloxacin 0.5%, Alcon) four times a day, 1 to 3 days preop.

On the day of surgery, Dr. Steinert gives his patients antibiotic drops immediately upon their arrival in the preoperative area.

"You need to give antibiotic drops at least 30 minutes prior to surgery," he said.

In the operating room prior to surgery, Dr. Steinert said he makes sure that his assistants use proper technique preparing the skin and eyelashes, which is to stroke from the center to the periphery without return.

"Five percent betadine is a good thing applied to the globe but do not use lidocaine jelly before the betadine," he said.

Next cover and isolate the lashes and meibomian glands with an incision drape.

Prior to the incision, copiously irrigate the surgical field.

Dr. Steinert said there is still debate over clear corneal incisions.

"The only thing we can say with certainty is that not all incisions are created equally," he said.

There are also a number of issues with intraoperative antibiotics, including the debate over the ESCRS cefuroxime study. He noted that there will be a special session about the study at this year's ASCRS meeting.

After the incision closure, Dr. Steinert recommends meticulous testing for a watertight seal using fluorescein and observation of both the main incision and the paracentesis.

"When in doubt, suture," he said.

Postoperatively, Dr. Steinert starts his patients on a fluoroquinolones as soon as possible on the day of surgery.

He said there is no evidence regarding dosing frequency and duration, but fluoroquinolones are commonly prescribed four times daily for 5 to 7 days.

"The only strong evidence is for topical betadine antisepsis at the time of surgery," Dr. Steinert added.

"Draping to isolate the lashes and meibomian glands follows sound surgical principles," he said.