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Surgeon questions rationale of intracameral prophylactic antibiotics
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CHICAGO — Intracameral antibiotics, although used by many European-based ocular surgeons, remains in infrequent use in the United States because of a lack of evidence showing any benefit.
 Sue E. Ormonde |
The idea for intracameral prophylactic antibiotics arose from case studies suggesting benefit. Additionally, the well-known ESCRS-backed study suggested use of cefuroxime perioperatively has benefit in reducing endophthalmitis.
However, the rationale for its practice is somewhat suspect, Sue E. Ormonde, MBChB, said here at Cornea Subspecialty Day preceding the joint meeting of the American Academy of Ophthalmology and the Middle East Africa Council of Ophthalmology, the rationale for its practice is somewhat suspect.
For one, surgical complications are the primary risk factor for postoperative endophthalmitis. Preoperative use of povidone-iodine, she said, substantially reduces bacterial count on the ocular surface, and studies have shown that its use immediately at the end of a case also reduces bacterial accumulation. In that regard, bacterial infiltrates introduced during the course of surgery may be eliminated without antibiotic use.
Secondly, intracameral antibiotics are only sufficient for eliminating bacteria introduced during the surgery, and thus have no impact on microbes introduced during the healing period after surgery - that is, bacteria that may come in contact with the healing incision in the days and weeks following operation.
"There is no clear evidence to support [intracameral antibiotic use], except for the ESCRS study, which a lot of people dispute," Dr. Ormonde said.
Sue E. Ormonde, MBChB, should be commended for a thoughtful and insightful review on the growing controversial topic of surgical prophylaxis with an intracameral antibiotic. Her discussion includes the conclusion that the current evidence-based data is incomplete to support a recommendation of a paradigm shift toward intracameral antibiotics. However, as she correctly notes, the experience and information are growing, including the ESCRS study, which is the first prospective clinical trial to evaluate the role of perioperative antibiotics — critically acclaimed or not. Even the data surrounding povidone-iodine, now rightly considered part of the standard of care, still has only surrogate evidence of diminishing local flora and a retrospective, nonrandomized clinical trial as its basis for use in ocular surgery. Although the current evidence does not seem to support a wholesale recommendation for intracameral antibiotic prophylaxis, the data is admittedly growing, and it definitely warrants close following.
– Francis S. Mah, MD
Pittsburgh