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One cataract surgeon’s regimen: Intracameral antibiotic in combination with topical antibiotic in every case
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Intracameral antibiotic use for prophylaxis against endophthalmitis following cataract surgery has been proven, in my opinion, beyond a reasonable doubt to be safe and effective. However, no method of intracameral antibiotic use is approved by the U.S. Food and Drug Administration, and all regimens are off label, but of course, the same is true for topical or subconjunctival antibiotic prophylaxis as well.
To be on label, we would, as American surgeons, need to use no antibiotics in combination with our cataract surgery, just a povidone iodine prep and careful draping to isolate the lids and lashes. The vast majority of ophthalmologists, close to 100%, use some form of off-label antibiotic prophylaxis against infection, usually topical drops.
In Europe, intracameral antibiotics, mostly cefuroxime, predominates. In the U.S., a topical fluoroquinolone antibiotic is chosen by the majority. In my opinion, the U.S. surgeon should consider the growing body of evidence supporting intracameral antibiotics as superior to topical antibiotics in reducing the incidence of endophthalmitis following cataract surgery. This evidence is another example of the benefit of “big data” and large national registries of postsurgical outcomes — another reason to sign up for the American Academy of Ophthalmology’s IRIS Registry.
The story begins with positive outcomes using cefuroxime in Sweden, confirmation of this finding by the European Society of Cataract and Refractive Surgeons study, and then several additional confirmatory studies of significant magnitude, including the Kaiser study in the U.S. I think it can be stated as a fact: Intracameral antibiotic use reduces the incidence of endophthalmitis following cataract surgery. I must disclose from the outset that I have been a user of intracameral antibiotics for more than 20 years. Influenced by Jim Gills, I started with vancomycin in the bottle decades ago, and about 3 years ago, influenced by Steve Arshinoff, Bob Osher, Steve Lane and Sam Masket, transitioned to a bolus of moxifloxacin at the end of the case. My incidence of endophthalmitis over these 25 years and 15,000-plus cases is zero. Toxic anterior segment syndrome has also been an extremely rare occurrence, and I have never associated it with intracameral antibiotic usage.
It is apparent from the multiple approaches used that there is no consensus on the ideal antibiotic or method of delivery. I personally start the patient on Tobradex ST (tobramycin 0.3%/dexamethasone ophthalmic suspension 0.05%, Alcon) twice daily, generic Tobradex four times a day or Zylet (loteprednol etabonate 0.5%, tobramycin 0.3% ophthalmic suspension, Bausch + Lomb) four times a day if concerned about a steroid pressure response (known steroid responder or axial myope), lid scrubs and artificial tears 1 week preoperative, primarily to tune up the ocular surface, as almost all seniors have meibomian gland dysfunction and most at least a mild dry eye.
An NSAID can also be used starting 3 days to 1 week preop depending on the risk of cystoid macular edema, which is also an off-label use. This is a two bottle regimen, and can be twice daily and every day with drops such as Tobradex ST and Ilevro (nepafenac ophthalmic suspension, Alcon) or Prolensa (bromfenac ophthalmic solution 0.07%, Bausch + Lomb) or four times a day and generic with Tobradex and ketorolac. Which is cheaper depends on the patient’s insurance, but both regimens are effective. I then use full-strength moxifloxacin out of the bottle as an intracameral injection. I have my scrub nurse draw up 0.2 mL in a TB syringe. A 27- or 30-gauge Rycroft cannula is placed on the syringe. I complete the case, hydrate the primary incision and paracentesis, loosen the speculum, pressurize the eye, and check for and remedy any wound leaks. In a case without intracameral antibiotics, I would be done except for application of topical drops.
Today, as a last step, I hydrate the paracentesis a second time with moxifloxacin. A small amount, 0.05 mL or less, can be seen to enter the anterior chamber, and the rest is left as a depot in the corneal stroma. I then continue Tobradex ST twice daily or generic Tobradex four times a day for 2 weeks and then taper to every day or twice daily, respectively, to 1 month. With Ilevro or Prolensa, I use one drop a day until gone, and with generic ketorolac, I prescribe four times a day for 2 weeks and then twice daily until gone. In patients at high risk for CME or persistent inflammation, I will extend the anti-inflammatory treatment for 2 months and utilize prednisolone acetate or difluprednate once the Tobradex is gone.
I do not have evidence that this is the “best” regimen, but it is what I do today.
The moxifloxacin and tobramycin are complementary antibiotics, and the tobramycin extends coverage against gram-negatives such as Pseudomonas. I used Tobradex after cataract surgery in thousands of cases before the fluoroquinolone antibiotics became available, and allergy or contact dermatitis is much rarer than with neomycin. This is a two bottle regimen, which simplifies treatment and reduces cost for the patient. It can be a twice daily and every day regimen with proprietary drops or a relatively inexpensive four times a day tapering to twice daily regimen with generics.
As an added thought, the surgeon or his assistant can look on the web at www.goodrx.com and find what every pharmacy in a given area charges for their preferred drops. The pharmacy selected can save the patient a lot of money.
As stated before, both intracameral and topical antibiotic uses are off label, but if I ever get another endophthalmitis case — and my goal is to retire from surgery in a decade or so with no additional cases — it is a regimen that I am comfortable defending, even in court if needed. This regimen also reduces the use of vancomycin, perhaps decreasing the chance for resistance development, and leaving it in reserve for the methicillin-resistant Staphylococcus epidermidis and methicillin-resistant Staphylococcus aureus that lurk more frequently every day. For my colleagues who prefer cefuroxime, I have no quarrel. It is a logical choice, and I have used a subconjunctival injection of cefuroxime in combination with a deposteroid in my keratoplasty cases for decades. Cefuroxime is effective against most gram-positive organisms, including Streptococcus and most staphylococcal species, and is also very synergistic with the tobramycin in Tobradex, the drop I start with in my cataract and keratoplasty patients. Recently, I have been injecting moxifloxacin in keratoplasty cases as well.
It would be great to have an FDA-approved intracameral antibiotic available in the U.S., but the study required would be expensive and time consuming, and no manufacturer to date has filed to pursue such an approval.
Twenty years ago, when I did my parents’ successful cataract surgery, I utilized intracameral vancomycin. In the next decade it is likely that both my wife and I will need cataract surgery. I will want an intracameral antibiotic used for both of our procedures. In good conscience, how could I do anything less for my current cataract surgery patients? I could not, so I use an intracameral antibiotic in combination with a topical antibiotic in every case.
Disclosure: Lindstrom is a consultant for and/or has equity interest in CXLO, Refractec, Alcon, AMO and Bausch + Lomb.