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Publication Exclusive: Surgeons debate choices for preventing infection after cataract surgery
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Prophylactic regimens for preventing infection after cataract surgery are effective, but choosing among the increasing number and combinations of washes, drops and injections is becoming more and more a matter of physician preference and physician debate.
Variations in surgical technique, variations in bacteria type and prevalence, variations in patient health and risk factors, and variations in medical management all play a role when choosing prophylactic measures. Establishing a control group to compare protocol effectiveness is difficult because of these variations.
As well, establishing an overarching rate of endophthalmitis following cataract surgery in the U.S. is elusive. It is known, however, that endophthalmitis is rare. In one study that looked at Medicare data for more than 220,000 cataract patients, Joshua D. Stein, MD, and colleagues found that 1,086 patients had a severe complication within 1 year after surgery; of these, 357 cases were endophthalmitis. In another analysis by Stein of eight large studies, not all based in the U.S., estimated incidence of endophthalmitis ranged from 0.05% to 0.3%.
The consequences of endophthalmitis are sight threatening, so prevention is key. In the U.S., a combination of a topical antiseptic with preoperative and postoperative topical antibacterial agents is broadly used by cataract surgeons, according to OSN Cornea/External Disease Board Member Terrence P. O’Brien, MD.
“The most widely used antiseptic is povidone-iodine, normally diluted to 5% and applied directly to the ocular surface prior to surgery,” O’Brien said. Among povidone-iodine’s assets are its broad-spectrum of activity and absence of microbial resistance. Postoperatively, most surgeons prescribe a topically administered antibiotic for 7 to 10 days.
And now things get more complicated.
“Because of the lack of and impracticality of sufficiently large prospective clinical trials, there is insufficient evidence to recommend a specific antibiotic drug or method of delivery for endophthalmitis prophylaxis,” according to the American Academy of Ophthalmology’s Preferred Practice Pattern (PPP) for Cataract in the Adult Eye.
The PPP later states: “[T]he surgeon must ensure that antisepsis of the periocular surface, typically with povidone iodine, is achieved and that all incisions are closed in a watertight fashion at the end of the procedure. It would appear that antibiotic use on the day of surgery is important rather than waiting until the next day. Any additional prophylactic antibiotic strategy in the perioperative period is up to the ophthalmologist to determine.”
In a survey of members of the American Society of Cataract and Refractive Surgery, topical gatifloxacin and moxifloxacin were the most frequent topical prophylactic antibiotics used by respondents.
“Some surgeons are now using a less expensive generic antibiotic before and after surgery,” O’Brien said. This includes aminoglycosides, as well as the combination product Polytrim (polymyxin B sulfate and trimethoprim, Allergan).
In O’Brien’s personally preferred protocol, he embraces the antiseptic as a universal standard practice of care. He also uses topical anti-infective agents, usually given 1 or 2 days before surgery and then continuing 7 to 10 days postoperatively, unless there is a higher risk or the appearance of a wound leak, for instance.
For routine cataract cases, O’Brien prefers a fluoroquinolone agent, based on recently published 5-year results of the Antibiotic Resistance Monitoring in Ocular Microorganisms (ARMOR) study, “which shows that fluoroquinolones still provide good efficacy against the gram-positive organisms, which are the most common causes of endophthalmitis.” The study demonstrated that besifloxacin, a fourth-generation fluoroquinolone antibiotic, had in vitro susceptibility that was comparable to vancomycin against gram-positive pathogens.
Click here to read the full cover story published in Ocular Surgery News U.S. Edition, July 10, 2016.