Prophylactic Subconjunctival Antibiotics Following Cataract Extraction

Abstract

The development of endophthalmitis is as serious a postoperative complication as any that can occur following cataract surgery. In the majority of such cases, there is perma­ nent loss of useful vision; frequently the globe is lost. Although the incidence of postoperative infection has been quite low in all series re­ ported, various special procedures, in addi­ tion to aseptic techniques, have been advo­ cated and utilized in an attempt to eliminate post-operative infection. Among these meth­ ods a r e : (1) routine preoperative conjunctival cultures, (2) use of preoperative antibiotics,' (3) subconjunctival injection of penicillin and streptomycin. Several authors have studied the inci­ dence of postoperative endophthalmitis in large series of cataract extractions. Allen and Mangiaracine reviewed the major series from 1898 to 1960 and found an inci­ dence of 59 infections in 27,926 cases ( 0 . 2 1 % ) . Various series in which no preop­ erative antibiotic prophylaxis was used show an occurrence of infection of 0.49% in 2,508 extractions (Locatcher-Khorazo and Gutierrez) ; 0.57% in 6,137 cases (Callahan) ; 1.01% in 2,086 cases (Hughes and Owens 6 ) . Allen and Mangiaracine's series, in which routine topical antibiotics were employed in 19,340 cases, had a 0.06% incidence of en­ dophthalmitis, suggesting to these authors that prophylactic topical antibiotics should be routinely employed for protection against infection. However, Pearlman's postopera­ tive infection rate of 0 .51% in 1,773 cases with preoperative topical antibiotics and Lo­ catcher-Khorazo and Gutierrez's rate of 0 .81% in 7,602 cases with similar preopera­ tive topical antibiotics suggest that there is no significant improvement over series in which no antibiotic prophylaxis was used. In spite of preoperative cultures and/or preoperative topical antibiotics, there has been no large series of lens extractions without some incidence of postoperative en­ dophthalmitis. The first series of cataract extractions en­ tirely free of infection was reported by Pearlman who gave a subconjunctival in­ jection of penicillin-streptomycin at the con­ clusion of the operation in 3,226 cataract cases and no case of endophthalmitis oc­ curred. The purpose of the present paper is to present another series of cataract opera­ tions (1,212 cases) without any postopera­ tive infection (table 1) . Every patient in this series was given a subconjunctival in­ jection of 200,000 units of crystalline peni­ cillin mixed with either 20,000 units of strep­ tomycin or 20 mg of colymycin.* Subconjunctival antibiotics have been uti­ lized in every cataract operation I have per­ formed during the past 10 years. The anti­ biotic mixture is injected under the inferior bulbar conjunctiva at the conclusion of the operation. Penicillin was employed in every case, even in 52 patients (table 2) who re­ ported a penicillin sensitivity (although in these cases with apprehension). Fortunately, there were no instances of immediate reac­ tion to the injection. Only 11.5% of the pa­ tients reportedly allergic to penicillin experi­ enced an abnormal reaction, but no reaction was damaging to the eye or caused more than temporary discomfort to the patient. T w o of the patients presumed allergic to penicillin were given an intradermal skin test. There was no reaction in one patient and a three-plus reaction (test done on the second postoperative day) in the other pa­ tient who, however, showed no excessive eyelid or conjunctival reaction.