Reply

Abstract

We thank Dr. Carifi et al. for their interest in our paper concerning corneal endothelial changes after intracameral vancomycin in cataract surgery, and we will attempt to answer to their constructive comments. With regard to the first comment, we are aware of the commercially available formulation of cefuroxime for intracameral use (Aprokam) and strongly recommend its use in the prophylaxis of postoperative endophthalmitis. Unfortunately, Aprokam was not available in a large number of public and university hospitals in Spain at the time of the study (2012 to 2013). Although we understand and share the authors’ concern for patient safety, we would like to state that all patients were fully informed of the procedure and its benefits and risks and that no single-dose alternative was approved by the drugs and therapeutic committee of our hospital during the entire study period. Second, before the publication of the European Society of Cataract and Refractive Surgeons (ESCRS) 2013 guidelines,1 most commonly used protocols for the prophylaxis of postoperative endophthalmitis in Spain described the use of vancomycin (0.1 mg/0.1 mL) in cases of beta-lactam antibiotic allergy.2 This was taken into consideration when designing our study. In fact, the paper of Behndig et al.2 describes the routine use of intracameral vancomycin in several European countries in 2013, even in nonallergic patients. For example, vancomycin was the first choice in 41% of procedures by Italian surgeons who were injecting intracameral antibiotics after cataract surgery. Moreover, results in the American Society of Cataract and Refractive Surgery 2014 surveyA show that intracameral vancomycin is still considered the first choice of 37% of surgeons using intracameral antibiotics. Surprisingly, only 5% of them were using Aprokam at the time of the survey. Nevertheless, since the publication of the ESCRS guidelines in 2013 and some reviews regarding the issue of cross-reactivity between penicillin and cefuroxime,3 we encourage the use of intracameral cefuroxime in patients with documented allergy to penicillin and no history of cephalosporin allergy. Vancomycin is considered an extremely effective drug in the treatment of resistant gram-positive infections and thus should be reserved for endophthalmitis treatment or for cases of confirmed cephalosporin allergy. We again thank the authors for their interest in our study and the editor for the opportunity to address the comments and concerns raised by Dr. Carifi et al.