This article is more than 5 years old. Information may no longer be current.
Antibiotic prophylaxis: Is it necessary?
Click Here to Manage Email Alerts
[MAIN ARTICLE: Define a treatment plan for common LASIK complications]
In addition to the management strategies applied to common complications that may accompany laser in situ keratomileusis (LASIK), another concern for many practitioners is the risk of the patient developing an ocular infection postoperatively. To reduce this risk, some doctors feel that prescribing antibiotics for the postrefractive surgery patient serves as peace of mind for the surgeon as well as the patient, even if it is not a necessity.
A crucial part of postsurgical treatment
There is no question that antibiotics are a necessity, said Vance Thompson, MD, of Ophthalmology Limited in Sioux Falls, S.D. “It’s a surgical procedure, and we’re invading the body’s first line of defense to corneal infection, the epithelium,” he noted. “Because the lids and lashes are not sterile, but have a flora around them, it is important to cover for infection for at least the first week. For some patients, it is important for the first few weeks.”
While the bacterial load has been reduced with antibiotics, he stressed, after the procedure, the tear film is still not guaranteed to be completely sterile. Dr. Thompson said that, typically, he will prescribe TobraDex (tobramycin dexamethasone, Alcon) for its broad-spectrum coverage. “After LASIK, because of the potential for inflammation, we like to have a little bit of steroid on board also,” he said. “We have found the convenience of TobraDex — with pretty good antibiotic coverage in combination with the steroid — to be helpful.”
As a prophylaxis
Decreasing the ocular surface bacterial concentration prior to LASIK surgery with topical antibiotics is very important. While there is no definitive proof that they are necessary, antibiotics are a good idea in the days following surgery, said Clifford Salinger, MD, a cornea and external disease and refractive surgery specialist at the Visual Health and Surgical Center in Lake Worth, Fla. Dr. Salinger said that while he, too, uses TobraDex, he has contemplated switching to a fluoroquinolone such as Ciloxan (ciprofloxacin, Alcon) or Ocuflox (ofloxacin, Allergan) in combination with a steroid drop. “For the best coverage and most effective reduction of bacterial concentration, fluoroquinolones are better; for ease of administration, compliance and cost, the combination TobraDex drops are better,” he said. “I’ve often considered switching to the two separate drops. Maybe if I started to see a series of infectious problems following refractive surgery I would, but so far I have not had any.”
Using antibiotics postoperatively may just serve as peace of mind for the doctor as well as the patient, said Jeffrey J. Machat, MD, the national medical director or TLC Laser Eye Centers in Toronto, Canada. “I really do believe that postoperative antibiotics are more for the surgeon than for the patient,” Dr. Machat said. “However, I will continue to use them because it allows me to sleep better at night. Certainly from the perspective of the patient, I don’t think it makes any difference, but in an elective procedure we want to limit our risks as much as possible.”
Aminoglycosides vs. fluoroquinolones
Dr. Machat said he has alternated between TobraDex and fluoroquinolones for the past few years. While he has been using Ocuflox recently to help better guard against bacteria, he concedes that the advantage of using fluoroquinolones over TobraDex is still indistinguishable. “Clinically, we have not found any difference between the two,” he said. “We have not seen a change in the incidence of infection, but there was concern from a few of our surgeons that perhaps we were better served using a fluoroquinolone than an aminoglycoside in terms of the broad-spectrum coverage and penetration. We did use TobraDex with Ciloxan in the past, but patients complained about the irritation from Ciloxan upon instillation. After LASIK, you really don’t want people squeezing their eyes.”
Dr. Machat said that a regimen of four times a day for 4 days is sufficient. “My personal feeling is that 2 days are enough, because the epithelium is healed by that point and, typically, if you’re going to have an infection or an infiltrative process underneath the flap, you’ll note that in the first 48 hours,” he said. “If you don’t see it by then, you’re not going to see it at all.”
Special circumstances
Another benefit of using a fluoroquinolone, said Dr. Machat, is that treatment can be tailored to the needs of each particular individual as to whether the patient requires more antibiotics or more steroids. “Because it’s not a combination drop, I don’t have to worry that they’re going to get toxicity from the tobramycin in the TobraDex,” he said. “Therefore, I can give extra steroids to someone who has striae that I’m fixing. I know they’re going to swell more, but their chance of infection won’t be any higher. Or, if worried about Sands of the Sahara, I can give them more steroids but I don’t have to extra-dose them with antibiotics.”
Be careful when treating diffuse lamellar keratitis, however, cautioned Dr. Salinger. “It is felt to be an inflammatory process, not a truly infectious process, with the treatment being frequent topical steroid drops while continuing the antibiotic coverage four times a day,” he said. “If a focal area of infiltrate develops within 24 to 48 hours, then it needs to be considered as infectious and treated with frequent antibiotics. Sometimes it’s inflammatory, but it could be infectious, and you’re just seeing it before it becomes an obvious infection.”
For Your Information:
- Vance Thompson, MD, can be reached at Ophthalmology Limited, 1200 S. Euclid Ave., Ste. 104, Sioux Falls, SD 57105; (605) 336-6294; fax: (605) 336-6970. Dr. Thompson did not disclose if he has a direct financial interest in the products mentioned in this article, or if he is a paid consultant for any companies mentioned.
- Clifford Salinger, MD, is a cornea and external disease and refractive surgery specialist. He may be contacted at the Visual Health and Surgical Center, 2889 10th Ave. North, Lake Worth, FL 33461; (561) 964-0707; fax: (561) 227-3192. Dr. Salinger has no direct financial interest in any of the products mentioned in the article, nor is he a paid consultant for any companies mentioned.
- Jeffrey J. Machat, MD, is the national medical director of TLC Laser Eye Centers. He may be reached at 4101 Young St., Ste. 100, North York, Ontario, M2P1N6, Canada; (416) 733-2020; fax: (416) 733-0316. Dr. Machat has no direct financial interest in any of the products mentioned in the article, nor is he a paid consultant for any companies mentioned.