Postsurgical therapeutic choices vary among practitioners

“At Issue” asked: Are there any differences between your post-cataract and post-refractive surgery anti-infective prophylaxis regimens?

Same regimen

Brett G. Bence

Brett G. Bence, OD, FAAO: For our clinics, the postoperative prophylactic drug regimen is the same for refractive and cataract surgery patients.

Since U.S. Food and Drug Administration approval in May 2010, we have used Zymaxid (gatifloxacin ophthalmic solution 0.5%, Allergan). Patients recovering from surgery in either of these procedure groups dose the same, at breakfast and bedtime. The duration of treatment varies based primarily on anticipated wound repair, typically 1 week.

We have been very satisfied with later-generation fluoroquinolones as providing excellent efficacy and minimal toxic ocular response and promoting patient compliance with twice-a-day dosing. While we have not experienced any presentations of mycobacterial keratitis in our LASIK patients, we feel that prescription of Zymaxid affords us a superior measure of protection against this and other more common pathogens in the conjunctival flora.

We make an infrequent exception for postoperative cataract surgery patients who are unable to afford the proprietary anti-infective medication. In these cases, we may prescribe generic ofloxacin 0.3% ophthalmic solution with four-times-daily dosing as long as surgery was uneventful and the patient is not considered at high risk for endophthalmitis.

• Brett G. Bence, OD, FAAO, is a partner and director of optometry at Northwest Eye Surgeons. He can be reached at 1306 Roosevelt Ave., Mount Vernon, WA 98273; (360) 428-2020; fax: (360) 428-6918; bbence@nweyes.com.
• Disclosure: Dr. Bence has no direct financial interest in the products he mentions, nor is he a paid consultant for any companies he mentions.

Selective regimens

Steven B. Siepser

Steven B. Siepser, MD, FACS: We are selective in our postoperative regimens. According to different series, the rate of endophthalmitis in cataracts decreased from one in every 2,500 in 1995 to 2001 to one in every 3,300 in 2002 to 2009. It is now accepted that the later-generation fluoroquinolones (Vigamox [moxifloxacin ophthalmic solution 0.5%, Alcon] in our practice) represent the antibiotic of choice. This, with the combination of topical 5% Betadine (5% sterile ophthalmic preparation solution, Alcon) application at the start and end of cataract surgery has brought endophthalmitis to its lowest reported incidence. In addition, we are now considering the introduction of cefuroxime intracamerally at the end of surgery. There is definitely a decrease in postoperative infection, but careful review of the pros and cons of this decision is necessary.

The intraocular use of a new drug and chance of misdosing are studied and reviewed by several levels within our organization. We add Nevanac (nepafenac ophthalmic suspension 0.1%, Alcon), one of the most effective nonsteroidals, combined with Durezol (difluprednate ophthalmic emulsion 0.05%, Alcon) to get the maximum anti-inflammatory control. If we get high IOP due to Durezol we can burp the wound, add Alphagan (brimonidine tartrate, Allergan) and follow the patient carefully. With so many of our patients electing to have the Crystalens (Bausch + Lomb) implanted, we cannot risk the postoperative complications of inflammatory responses, cystoid macular edema or infection.

In LASIK we are on another tack. Cataract patients are at a higher risk of infection than LASIK patients, and occasional high IOP can be tolerated with close supervision. In LASIK we are more concerned about atypical infection. The use of later-generation fluoroquinolones, such as Zymaxid [gatifloxacin 0.5%, Allergan], covers the threat of the most common Mycobacterium. We find that postoperative inflammation is less of a threat and do not want to risk high IOP in a closed eye. Therefore, we use Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch + Lomb), a milder steroid with a limited IOP elevation response. Acuvail (ketorolac tromethamine 0.45%, Allergan), in its nonpreserved vials, is added to top off the triad.

• Steven B. Siepser, MD, FACS, is chief medical officer and chairman/founder of Patient Confidence Corporation of America. He can be reached at 860 E. Swedesford Road, Wayne, PA 19087; (610) 265-1637; (800) 238-3937; fax: (610) 265-4054; ssiepser@visionlock.com.
• Disclosure: Dr. Siepser has no direct financial interest in the products he mentions, nor is he a paid consultant for any companies he mentions.

Same regimen

Edward W. Harmer

Edward W. Harmer, OD: My pre- and postoperative care of a cataract and a refractive surgery patient are basically identical, that is, a later-generation fluoroquinolone a day or two before, followed by four times daily for 1 week postoperatively. The only time I make a change is if the patient is a hospital worker or involved in the health care field; I will then add Polytrim (polymyxin B-trimethoprim, Allergan) pre- and postoperatively to guard against methicillin-resistant Staphylococcus aureus. I will also add Azasite (azithromycin ophthalmic solution 1%), at least 2 weeks preoperatively, if there is any indication of lid disease.

• Edward W. Harmer, OD, is clinical director of the Dry Eye Center of Excellence at Omni, Clarity Refractive Services. He can be reached at 475 Prospect Ave., West Orange, NJ 07052; edward-h@clarityrefractive.com.
• Disclosure: Dr. Harmer is on a speaker panel for Allergan and Inspire.