Intracameral Use Research Articles

Surgical, antiseptic, and antibiotic practice in cataract surgery: Results from the European Observatory in 2013

To report the results from the first iteration of the European Observatory of Cataract Surgery, which was initiated to track changes in surgical, antiseptic, and antibiotic practices in cataract surgery over the coming years. Practicing European cataract surgeons (n = 479). Internet-based declarative questionnaire or telephone questionnaire. The questionnaire comprised 37 questions divided into 8 categories as follows: screening, surgeon profile, surgical procedure used, product use before arrival at the operating room, techniques for mydriasis and anesthesia, product use during the surgery, product use after the patient leaves the operating room, and surgeon's attitude to guidelines. Cataract surgeons (n = 2700) were initially contacted, of whom 479 (17.7%) were included in the survey. The current baseline survey revealed considerable variation between countries in their implementation of infectious postoperative endophthalmitis (IPOE) prophylaxis. In some countries, adoption of intracameral cefuroxime is almost universal, whereas in others, the use of such prophylaxis is below one half. When intracameral cefuroxime is used, it is generally cefuroxime powder designed for parenteral use. A preparation specifically registered for intracameral use is now available, and this formulation is more commonly used in countries in which intracameral cefuroxime was most widely adopted. The baseline results from this ongoing survey suggest a considerable level of heterogeneity between European countries in IPOE prophylaxis. Further iterations of this survey will monitor whether a consensus begins to emerge. This work was supported by Laboratoires Théa, under the supervision of the expert group. Members of the expert group were remunerated by Laboratoires Théa. J.F. Stolz, MD, PhD, provided editorial assistance in manuscript preparation, for which he was remunerated by Laboratoires Théa. Anders Behndig, Rita Mencucci, and Jacek P. Szaflik report no relevant conflicts of interest.

Prophylactic intracameral antibiotic use during cataract surgery: response

Prophylactic intracameral antibiotic use during cataract surgery: response

Toxic anterior segment syndrome after uncomplicated cataract surgery possibly associated with intracamaral use of cefuroxime.

PurposeTo report toxic anterior segment syndrome (TASS) after cataract surgery possibly associated with intracameral use of cefuroxime.MethodsWe conducted a retrospective chart review and analysis on the pre- and postoperative conditions of the subjects who had developed TASS.ResultsThe patient group consisted of 17 patients. Tyndallization and fibrin fibers were positive in all eyes. In four eyes, hypopyon formation developed. These reactions diminished on the third day and fully resolved 1 week after the operations with the use of intensive topical steroid and mydriatic therapy. To determine the etiology of TASS, infusion fluid, viscoelastics, and intracameral antibiotic agent were changed respectively. After changing intracameral antibiotic agent from cefuroxime axetile to moxifloxacin no new cases of TASS were diagnosed.ConclusionAll agents injected into the anterior chamber can cause TASS. Ophthalmologists and operating room staff need to pay careful attention to all drugs and irrigating solutions.

Pre-operative use of the topical steroidal and non-steroidal anti-inflammatory agents to maintain intra-operative mydriasis during cataract surgery

Dear Editor, I read with interest an article by Lira et al. on pre-operative use of prednisolone and non-steroidal anti-inflammatory agents to maintain mydriasis during phacoemulsification of the cataract.[1] I congratulate the authors for documenting the role of pre-operative use of 1% prednisolone eye drops to maintain the pupillary dilatation. In the era of phacoemulsification, the handling of the intraocular tissue is very minimal. Mydriasis during the surgery is maintained by the continuous irrigation of the balanced salt solution and the use of viscoelastic due to closed anterior chamber. Even if the pupil becomes small we can inject intracameral 1% lignocaine, which helps in the dilatation of the pupil. The safety of the intracameral use of 1% lignocaine during phacoemulsification has been proved in various studies.[2,3,4] Maresova et al. has shown phacoemulsification can be done without putting pre-operative mydriatic drops or any steroidal or non-steroidal anti-inflammatory agents.[5] Do we need pre-operative use of steroidal or non-steroidal anti-inflammatory agents to maintain the mydriasis during the phacoemulsification of uncomplicated cataract? Why authors preferred to instill drops 48 h before performing phacoemulsification of the cataract? I feel the authors should have studied the effect of prednisolone eye drops on the normal conjunctival flora.

Infektionen nach Linsenchirurgie: Implikationen für die refraktive Chirurgie

Apart from the classical indication of removing an opaque lens that is compromising vision, extraction of the crystalline lens is gaining increasing importance as a refractive procedure. This literature review which considers the present guidelines of various ophthalmological societies and recently published studies is intended to give an estimate of the incidence of postoperative endophthalmitis and evidence-based recommendations for its prophylaxis, diagnosis, and therapy. The incidence of endophthalmitis after cataract extraction is reported to be 0.04% to 0.3% in most sizeable studies. Immediate sequential bilateral cataract surgery is internationally gaining popularity. It remains difficult to estimate whether or not the risk of endophthalmitis is affected with this approach. A toxic anterior segment syndrome (TASS) needs to be differentiated from postoperative endophthalmitis. TASS is an acute sterile inflammation after cataract surgery. Remnants of detergents and antiseptics on the surgical instruments are supposed to be main triggers. Additionally, the inappropriate preparation of solutions and antibiotics for intracameral use is considered to be a major cause. A case of TASS was also reported after implantation of an iris-fixated anterior chamber lens in a phakic eye. The cefuroxime solution that was prophylactically used in the ESCRS study and that is recommended for routine cataract surgery is not commercially available in Germany as a ready preparation for intraoperative application. Different measures are undertaken in different countries to prevent postoperative endophthalmitis, whose values are not exactly quantifiable. Antisepsis with povidone-iodine is still considered to be the component with the best evidence. For management of acute postoperative endophthalmitis, the systemic application of antibiotics is recommended in addition to their intravitreal injection. Few case reports have been published describing an infection after the implantation of refractive intraocular lenses (IOLs) in a phakic eye. However, we could not find meaningful information regarding the incidence of endophthalmitis after implantation of refractive IOLs. Based on the fact that these IOLs are not implanted into the capsular bag but in front of the crystalline lens or into the anterior chamber, and the presumably better anti-microbial immunity of this younger population compared to cataract patients, one may assume that the infection rate is lower than after cataract surgery. Nevertheless, a prospective register to document all endophthalmitis cases is desirable.

Effects of intracameral use of adrenalin solution with preservative on corneal endothelium

Objective: To evaluate the effects of injection of 1:100,000 dilution adrenalin with sodium bisulfite preservative on the corneal endothelium in phacoemulsification cataract surgery.Methods: This retrospective study comprised 70 patients with age-related cataracts who had undergone phacoemulsification cataract surgery with intraocular lens (IOL) implantation without any surgical complications. In the adrenalin group, patients with intraoperative intracameral adrenalin use were included. The intracameral adrenalin was composed of 1 mL of 1:100,000 dilution adrenalin with sodium bisulfite preservative. The control group included patients who underwent surgery without any intracameral adrenaline use. There were 36 patients in the adrenalin group and 34 patients in the control group. Corneal endothelial density, endothelial cell morphology, and endothelial cell area were measured via specular microscopy both preoperatively and 3 months after surgery. The 2 groups were compared with regard to changes in specular microscopy measurements.Results: The mean (± standard deviation) age was 66.51 ± 8.32 years in the adrenalin group and 67.58 ± 7.83 years in the control group. The difference in age between the 2 groups was not significant (p = .611). The preoperative mean corneal endothelial cell density was 2,270 ± 286 cells/mm2 in the adrenalin group and 2,226 ± 260 cells/mm2 in the control group, and the difference between the 2 groups was not statistically significant (p = .550). In the adrenalin group, the postoperative mean corneal endothelial cell density was 2,191 ± 268 cells/mm2. Although the postoperative mean cell density was lower than the preoperative mean cell density, the difference between the 2 measurements was not statistically significant (p = .117). In the control group, the postoperative mean corneal endothelial cell density was 2,169 ± 272 cells/mm2, and the difference between the preoperative and postoperative measurements was not statistically significant (p = .161). Comparisons of postoperative specular microscopy measurements between the adrenalin and control groups with regard to cell density, cell sizes, and cell shapes showed that there were no statistically significant differences in comparison of all parameters between the 2 groups.Conclusions: Intracameral injection of 1:100,000 dilution adrenalin with sodium bisulfite preservative is not toxic to corneal endothelium.

Assessing the accuracy of intracameral antibiotic preparation for use in cataract surgery

To evaluate 2 local dilution protocols to assess the accuracy and variability of intracameral antibiotic dosage in cataract surgery. Tennent Institute of Ophthalmology, Glasgow, United Kingdom. Ten ophthalmic operating room nurses from 2 local hospitals participated. Oven-dried analytical grade potassium chloride (KCl) was used as a surrogate for cefuroxime. Solutions intended for intracameral use (1.0 mg in 0.1 mL) were prepared according to the 2 protocols. Twenty samples were obtained for each protocol. Ten analytical chemists also performed both dilutions. Concentrations of KCl in each 0.1 mL sample were analyzed by flame photometry. Thirty samples were obtained for each protocol. The median dose after dilution was 1.17 mg (range 0.62 to 1.77 mg) for protocol 1 and 2.05 mg (range 0.52 to 7.25 mg) for protocol 2. The median was significantly higher for protocol 2 (P < .001). There was also greater variability with protocol 2. This study shows that the mathematical accuracy of a dilution protocol does not ensure dosage accuracy in the clinical scenario. Inadequate mixing in a 1.0 mL syringe was probably responsible for the inaccuracy of protocol 2, indicating that small-volume syringes should not be used for mixing. However, protocol 1 had an acceptable range of variability. Replication of this study could evaluate other protocols and address concerns regarding the accuracy of intracameral antibiotic preparations.

Intracameral use of 2% lignocaine with preservative: Is it really safe?

Intracameral use of 2% lignocaine with preservative: Is it really safe?

Intracameral Moxifloxacin: In Vitro Safety on Human Ocular Cells

The fourth-generation fluoroquinolone, moxifloxacin, covers most gram-positive and gram-negative isolates causing endophthalmitis. It is safe and effective for systemic and topical use, but only limited data are available on prophylactic intracameral administration to prevent endophthalmitis. This study uses a cell culture model to investigate the safety of moxifloxacin for intracameral application. Endothelial toxicity of moxifloxacin was evaluated in cultured human corneas. Possible toxic effects of moxifloxacin (10-750 microg/mL) in corneal endothelial cells (CEC), primary human trabecular meshwork cells (TMC), and primary human retinal pigment epithelial (RPE) cells were evaluated after 24 hours and under conditions of oxidative and inflammatory stress by treatment with tumor necrosis factor alpha, lipopolysaccharides, or interleukin-6. Toxicity was evaluated by tetrazolium dye reduction assay, and cell viability was quantified by a microscopic live-dead assay. No corneal endothelial toxicity could be detected after 30 days of treatment with 500 microg/mL moxifloxacin. Concentrations up to 150 microg/mL had no influence on CEC, TMC, or RPE cell proliferation or on cell viability when administered for 24 hours. After preincubation with tumor necrosis factor alpha, lipopolysaccharides, or interleukin-6 for 24 hours and subsequent treatment with moxifloxacin at concentrations from 10 to 150 microg/mL for 24 hours, no significant decrease in proliferation or viability was observed. Hydrogen peroxide exposure did not increase cellular toxicity. This study showed no significant toxicity for moxifloxacin on CEC, TMC, RPE cells, or human corneal endothelium for concentrations up to 150 microg/mL. The minimum inhibitory concentration of moxifloxacin to inhibit 90% of pathogens commonly encountered in endophthalmitis is known to be in the range of 0.25-2.5 microg/mL. Therefore, prophylactic intracameral use of moxifloxacin at concentrations up to 150 microg/mL may be safely used to prevent endophthalmitis after intraocular surgery.

Comparison of in vitro safety profiles of vancomycin and cefuroxime on human corneal endothelial cells for intracameral use

To evaluate and compare the cytotoxic and apoptotic properties of cefuroxime and vancomycin on cultured human corneal endothelial cells (HCECs) to determine their safety for intracameral use. Human corneal endothelial cells were harvested from human donor eyes and exposed to various concentrations of cefuroxime and vancomycin (0.15 to 15 mg/mL). For cytotoxicity testing, the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) test was performed. Annexin V binding combined with propidium iodide (PI) co-staining was used for the distinction of viable, early, and late apoptotic cells. Odds ratios (ORs) and confidence intervals were calculated for the control group (without drug exposure) for 2.75 mg/mL and 15 mg/mL. Cell morphology and immunolocalization of zonula occludens 1 (ZO1) were assessed after 24 hours of drug exposure. Reduction in cell viability was observed in a dose-dependent manner after exposure to both drugs. Cefuroxime concentrations higher than 2.75 mg/mL and vancomycin concentrations higher than 5.0 mg/mL led to significant reduction in cell viability. The mean number of annexin V-positive and PI-positive cells was not significantly increased at 2.75 mg/mL for either antibiotic agent. After exposure to 15.0 mg/mL, however, the late apoptotic/necrotic cells predominated, with higher ORs indicating accelerated cell death. Increasing concentrations of both antibiotic agents resulted in fading immunopositivity for ZO1. These data suggest a dose-dependent toxicity of cefuroxime and vancomycin on HCECs in vitro with a narrow range of safety. Although the clinically used concentrations seem to be safe, slightly higher concentrations might induce irreversible cell death and thus should be avoided.

Intracameral moxifloxacin (Vigamox): in vitro safety on human ocular cells

Abstract Purpose The 4. generation fluorochinolon moxifloxacin covers most isolates causing endophthalmitis. It is safe and effective for systemic and topical use, however only very limited data is available on prophylactic intracameral administration to prevent endophthalmitis. This study investigates the safety of Viagamox (moxifloxacin) for intracameral application in a cell culture model Methods Endothelial toxicity of Vigamox (moxifloxacin) was evaluated in cultured human corneas. Toxic effects regarding primary human RPE, trabecular meshwork cells (TMC) and corneal endothelial cells (CEC) were evaluated after 24h and under conditions of oxidative stress. By treating cells with TNF‐a, LPS and IL‐6 the effects of moxifloxacin on viability under conditions of inflammation were investigated. Toxicity was evaluated by measuring the inhibition of cell proliferation (MTT). Cell viability was quantified by a microscopic live dead assay Results No corneal endothelial toxicity could be detected after 30 days treatment with 500µg/mL moxifloxacin. RPE,TMC,and CEC showed adverse effects on proliferation and viability at concentrations higher than 150µg/mL moxifloxacin only. Preincubation with TNF‐a, LPS, IL‐6 or H2O2 and subsequent treat with moxifloxacin concentrations up to 150µg/ml for 24h had no significant effect on proliferation and viability Conclusion Moxifloxacin concentrations up to 150µg/mL had no significant toxicity on RPE, TMC, CEC and human corneas. The MIC90 of moxifloxacin for common pathogens of endophthalmitis is known to be in the range of 0.25 ‐ 2.5µg/mL. Therefore, intracameral use of moxifloxacin at concentrations up to 150µg/mL may be safe and effective to prevent endophthalmitis after intraocular surgery

Intravitreal and intracameral bevacizumab to treat neovascular complications of retinopathy of prematurity

Editor, A 26-year-old White woman was referred for management of neovascular glaucoma complicating retinopathy-of-prematurity-related retinal detachment. She had previously undergone cryotherapy and scleral buckling for mixed tractional and exudative retinal detachment in the right eye (RE) and had lost her left eye because of phtisis bulbi. Visual acuity (VA) was hand movements (HM); intraocular pressure (IOP) was 31 mmHg. There was iris neovascularization in all quadrants, the drainage angle was open with isolated areas of peripheral anterior synechiae (PAS) and there was a long-standing partial retinal detachment. Treatment was started with topical hypotensive therapy but within 2 months the pain became worse with corneal oedema, florid iris neovascularization, ectropion uveae (Fig. 1A), angle neovascularization and 330° PAS. VA remained HM but IOP was 68 mmHg and unresponsive to oral acetazolamide. Photocoagulation was not feasible because of the retinal detachment. We treated the RE with an intravitreal injection of bevacizumab (1.25 mg in 0.05 ml) (Avastin®; Genentech Inc., San Francisco, California, USA). Two weeks after the injection, iris neovascularization had substantially regressed and we implanted a vicryl-ligated Baerveldt 350 mm2 aqueous shunt (AMO Groningen B.V. Groingen, the Netherlands) (Fig. 1B). One month later, IOP was 9 mmHg without ocular hypotensive medication, although iris new vessels had become more prominent in appearance (Fig. 1C). (A) Florid iris neovascularization and ectropion uveae at presentation. (B) Partial regression of iris new vessels following intravitreal bevacizumab injection and Baerveldt tube implant (10 days postoperatively). (C) More prominent iris new vessels at 6 weeks postoperatively. (D) Obstruction of the Baerveldt tube intracameral lumen by proliferating neovascular tissue (3 months postoperatively). (E) Partial resolution of the obstruction and regression of the iris new vessels 3 days after application of Nd-YAG laser and intracameral injection of bevacizumab. (F) Appearance of the anterior segment at the last follow-up, 5 weeks after intracameral injection of bevacizumab: note the large surgical iridectomy to prevent recurrent tube occlusion and the substantial regression of iris new vessels. Three months after the operation, the eye became painful again. IOP was 48 mmHg and the intracameral lumen of the Baerveldt tube was obstructed by proliferating neovascular tissue (Fig. 1D). We applied Nd-YAG-laser to tube opening, re-establishing aqueous outflow: IOP fell to 18 mmHg. An hour later, we gave an intracameral injection of bevacizumab (0.625 mg in 0.025 ml). Three days later, iris neovascularization had regressed (Fig. 1E) and at surgery we created a large surgical iridectomy adjacent to the tube lumen to remove the scaffold for recurrent fibrovascular proliferation (Fig. 1F). Five weeks later, VA was still HM and the eye was comfortable with an IOP of 18 mmHg. Bevacizumab is a recombinant, full length, anti-vascular endothelial growth factor (VEGF) monoclonal antibody able to bind all isoforms of VEGF-A. Previous case reports (Davidorf et al. 2006; Iliev et al. 2006; Silva Paula et al. 2006) have shown that bevacizumab can induce regression of anterior-segment neovascularization. We used anti-VEGF as a preoperative intravitreal injection before surgical treatment for neovascular glaucoma to reduce the risk of perioperative bleeding and gave a second injection 3 months later intracamerally to induce regression of a recurrent neovascular membrane occluding a glaucoma drainage device. A recent report (Beer et al. 2007) has shown that in humans, a single dose of intravitreal bevacizumab is likely to provide complete intravitreal VEGF blockade for a minimum of 4 weeks. Our patient developed recurrent neovascularization 6 weeks after injection. When this occluded the drainage tube, we chose to give bevacizumab via intracameral rather than intravitreal injection because the need was to treat an anterior chamber neovascular membrane; furthermore, intracameral injection is simpler and more comfortable for the patient. There is one previous report to our knowledge (Grisanti et al. 2006) of intracameral use of bevacizumab for treatment of neovascular glaucoma. Three patients were given 0.04 ml intracameral bevacizumab with a dramatic reduction of leakage demonstrated by iris fluoroscein angiography, which was still evident 30 days after injection. In our case, a significantly lower intracameral dose of bevacizumab resulted in rapid iris neovascularization regression. Intraocular bevacizumab, by either intravitreal or intracameral injection, can prove useful as an adjunct to glaucoma drainage surgery. The authors would like to thank the technicians Kanom Bibi, the photographer Matthew Richardson and the research officer Laura Gangadeen. This article has been supported by the National Health Service, Research and Development, UK.

Intracameral 2.3% Sodium Hyaluronate to Treat Postoperative Hypotony in Patients With Glaucoma

To evaluate the intracameral use of Healon5 (2.3% sodium hyaluronate) (Advanced Medical Optics, Santa Ana, CA) in patients with hypotony. Fifteen consecutive patients with glaucoma who had hypotony for at least 7 days were prospectively recruited. Indications for the intracameral injection of Healon5 were an intraocular pressure (IOP) of less than 6 mm Hg with negative results on Seidel test. The mean IOP readings at baseline, 1 to 2 weeks post-injection, and 4 to 6 weeks post-injection were 3.8 +/- 1.58, 6.58 +/- 2.62, and 6.50 +/- 2.24 mm Hg, respectively. The increase in IOP at both follow-up points was significant (P < .01). The visual acuity improvement was small but significant at the 4 to 6 week point (P = .05). In the early-onset cases, IOP increased significantly from baseline at both follow-up points (P< .05), but visual acuity did not. No significant change from baseline IOP or visual acuity occurred among the late-onset cases. The existing hypotony-related conditions consistently improved by the 4 to 6 week point. Intracameral injection of Healon5 raised IOP more in early-onset hypotony cases than in late-onset cases. Although the improvements in IOP and visual acuity were statistically significant, the overall clinical picture did not change because the endpoint IOP was still hypotonus. Twenty percent of the patients had IOP spikes that required medical treatment.

Antipsychotic agent as an etiologic agent of IFIS

Chang and Campbell's case series1 describes a triad of characteristic intraoperative features to define the intraoperative floppy iris syndrome (IFIS). We faced a similar problem in June 2005, when a well-controlled schizophrenic man using Zuclopenthixol attended for cataract surgery. The triad of poor pupil dilation, billowing iris with intraocular fluid currents, and a propensity to iris prolapse was observed at an early stage. One of us (R.P.) had begun using intracameral phenylephrine to increase iris rigidity and dilation as soon as features of IFIS are identified. This simple maneuver dramatically changed iris behavior and enabled safe, controlled lens removal by coaxial phacoemulsification followed by IOL implantation in the capsular bag. In Chang and Campbell's prospective series, IFIS occurred in 2.2% of cases; in 94.0% of these cases (15 of 16), patients were using or had been using the systemic α-adrenergic blocker tamsulosin. They noted that sphincterotomies and mechanical pupil stretch were often ineffective in maintaining adequate pupil dilation. Zuclopenthixol is a thioxanthene antipsychotic. It is thought to act by blocking dopamine D2 receptors in the brain, and its α-adrenergic blocking actions are well recognized.2 Phenylephrine is an α-adrenergic agonist known to act on the iris dilator. For intracameral use, it is prepared by diluting 7 drops of phenylephrine 2.5% preservative-free minims in 1 mL of balanced salt solution. Up to 1 mL is injected into the anterior chamber to prevent IFIS. It is an attractive proposition to suggest IFIS is caused by blockade of iris α-adrenoceptors and may be reversed perioperatively by an intracameral α-agonist. Edward Pringle MRCP, MRCOphth Richard Packard MD, FRCOphth Windsor, United Kingdom

The use of dye in ophthalmology.

Dyes are used in current ophthalmological practice, both as diagnostic and therapeutic aids. Commonly used dyes include sodium fluorescein, indocyanine green, rose bengal and methylene blue. The properties of these agents are outlined, along with indications for their use. The article concentrates mainly on intravenous sodium fluorescein and fundus fluorescein angiography, although topical and intracameral use of other dyes is highlighted. Ocular tissue responses are discussed, in particular those of the retinal vasculature and choroidal circulation. The normal blood-retinal barriers and pathology of abnormal angiography findings is presented. Pharmacokinetics and pharmacodynamics of intravenous dye are discussed, along with potential systemic complications.

Effects of intraocular dapiprazole in the rabbit eye

Dapiprazole produces miosis by blocking the alpha 1 receptors in the radial muscle of the iris; its intraocular effect has not yet been investigated. In this preliminary experimental animal study, we investigated the intracameral use of 0.2 ml of 0.005%, 0.0075%, 0.01%, and 0.05% dapiprazole to reverse mydriasis by 10% phenylephrine plus 0.5% tropicamide. With the 0.05% dapiprazole concentration, the values (mean ± S.E.) of pupillary diameter were as follows: prior to the experiment, 5.3 ± 0.31 mm; after mydriatics, 8.7 ± 0.22 mm; after intraocular dapiprazole, 5.6 mm ± 0.29. The results showed a dose-related miotic effect of dapiprazole. No difference in the toxicity parameters (inflammatory score, corneal thickness, endothelial cell counting, aqueous humor protein concentration, and intraocular pressure) was found between dapiprazoletreated eyes and saline-solution-treated eyes. Intraocular 0.01% and 0.05% dapiprazole is an effective miotic agent that may be helpful during surgery when the reversal of sympathomimetic mydriasis is needed.