Intracameral Vancomycin Research Articles

Endophthalmitis after cataract surgery: an update on recent advances.

Prevention and management of postcataract endophthalmitis remain quite relevant for anterior segment and vitreoretinal surgeons. Although the Endophthalmitis Vitrectomy Study, published in 1996, remains the only level 1 evidence for the management of postcataract endophthalmitis, recent advances have resulted in an evolution of practice patterns. The aim of this review is to summarize the literature regarding postcataract endophthalmitis with a focus on the last 18 months. The IRIS registry indicates the rates of endophthalmitis are decreasing in the United States, and the outcomes appear to be improving. Intracameral moxifloxacin has become more widely accepted and intracameral vancomycin has been shown to be associated with retinal vasculitis. The role of systemic antibiotics and vitrectomy is unclear and practice patterns vary widely. Although practice patterns vary, prevention and treatment of endophthalmitis after cataract surgery continues to improve. More uniform guidelines regarding surgical and medical therapy are necessary but the standard of prompt referral to a vitreoretinal specialist for immediate intravitreal antibiotics remains the most important intervention in the management of postcataract endophthalmitis.

Incidence of cystoid macular oedema with intracameral cephalosporin or vancomycin in cataract surgery

Purpose: To compare the incidence of pseudophakic cystoid macular oedema (CME) in patients who receive intracameral cephalosporin versus intracameral vancomycin during cataract surgery.Methods: A retrospective chart review was conducted on subjects with the diagnosis of CME between January 1 2010 and July 31 2017. Inclusion criterion was the documentation of CME after cataract extraction. Exclusion criteria were intraoperative complication, prior history of macular oedema, epiretinal membrane, uveitis, other pre-existing retinal pathology, or other post-operative pathology including other ocular surgery in the post-operative period.Results: The final analysis included 89 eyes with optical coherence tomography (OCT) proven CME. The incidence of pseudophakic CME in our population of 10,165 cataract surgeries after applying the above-stated exclusion criteria was 0.88%. The incidence of pseudophakic CME in subjects who received intracameral cephalosporin was 0.87% (mean age in years 69 ± 11; 31 male [39%], 48 female [61%]). The incidence of pseudophakic CME in subjects who received intracameral vancomycin was 0.96% (mean age in years 66 ± 13; 4 male [40%], 6 female [60%]). Pearson’s chi-square test demonstrated no significant difference between these groups (p = 0.7705).Conclusions: There was no statistical difference in the incidence of pseudophakic CME in subjects who received intracameral cephalosporin versus intracameral vancomycin during cataract surgery.

Aqueous level abatement profiles of intracameral antibiotics: A comparative mathematical model of moxifloxacin, cefuroxime, and vancomycin with determination of relative efficacies

To create a model of the abatement profiles of the three most commonly employed endophthalmitis prophylaxis intracameral (IC) antibiotics-cefuroxime, vancomycin, and moxifloxacin-to enable comparison of their durations of efficacy against common endophthalmitis pathogens. Humber River Hospital and The Eye Foundation of Canada, Toronto, Ontario, the University of Toronto, Ontario, and McGill University, Montreal, Quebec, Canada. Literature review, as well as review of our clinical experience with 4797 consecutive cases with IC vancomycin, followed by 9185 consecutive cases with IC moxifloxacin. A detailed review of the prophylactic antibiotic literature was performed. Exponential decay models of the selected IC antibiotics were updated from previous work by the study authors with decay constants adjusted to agree with the available published objective data. The graphs generated by the study data demonstrate the relative duration of IC bactericidal activity of moxifloxacin, cefuroxime, and vancomycin. They suggest that at present, IC moxifloxacin, when administered in appropriate doses, is the most effective agent in preventing postoperative endophthalmitis. Unlike vancomycin and cefuroxime, bacterial resistance to moxifloxacin is dose-dependent, and it is overcome in the vast majority of cases with doses that can safely be achieved intracamerally. The graphs can serve as a useful tool to assess the expected efficacy of each antibiotic in reference to local pathogen resistances. The model shows IC moxifloxacin, cefuroxime, and vancomycin durations of bactericidal efficacy post-cataract surgery, which correlate well with the published objective data.

Successful Clinical Outcome of Vancomycin-induced Hemorrhagic Occlusive Retinal Vasculitis

ABSTRACT We present a case of a patient that experienced severe hemorrhagic occlusive retinal vasculitis secondary to injection of 1.0 mg/0.1 ml of intracameral vancomycin for endophthalmitis prophylaxis after an uneventful cataract surgery. The case is especially unique in that our patient ended up maintaining 20/25 vision with an ocular disease that is typically visually threatening. This may be due to the aggressive administration of periocular and oral steroids combined with scheduled anti-VEGF injections that were later transitioned into a treat and extend regimen.

Intracameral antibiotics for prophylaxis of postoperative endophthalmitis in Australia: a review.

Postoperative endophthalmitis is a severe complication which may result in loss of vision. Intracameral antibiotics have been shown to reduce the risk of this complication and are extensively used worldwide, with vancomycin, cefuroxime and moxifloxacin most commonly used. Choices in Australia are currently limited to vancomycin and cefazolin, since cefuroxime and moxifloxacin are not available. Vancomycin has been safely and effectively used in our department for more than two decades. Recent publications have risen concerns regarding the association of haemorrhagic occlusive retinal vasculitis a potentially blinding complication with intracameral vancomycin. This concern has driven us to review the safety and efficacy of currently available antibiotics in the context of Australian practice.

The Routine Use of Intracameral Antibiotics to Prevent Endophthalmitis After Cataract Surgery: How Good is the Evidence?

Post-operative endophthalmitis (POE) following cataract surgery is an uncommon, vision-threatening complication that has been reported to occur at rates of between approximately 0.03% and 0.2%. Prompt diagnosis and treatment of endophthalmitis is critical for minimizing vision loss, but most recent efforts have focused on the prophylactic administration of antibiotics to prevent the development of endophthalmitis. Surgeons from around the world have different topical and intracameral antibiotic usage patterns to prevent endophthalmitis, and to date no general consensus regarding best practice has emerged. Several studies have reported on the routine use of intracameral cefuroxime, moxifloxacin, and vancomycin, including a single randomized clinical trial by the European Society of Cataract and Refractive Surgery (ESCRS) in 2007. These studies have notable shortcomings, but many authors suggest that intracameral cefuroxime together with topical antibiotics probably decreases the risk of endophthalmitis. However, the deleterious effects of routine prophylactic antibiotics, which include toxicity, cost, and increasing antimicrobial resistance, among others, are noteworthy. In contrast, aseptic technique with pre-operative instillation of povidone-iodine remains the only technique supported by level I evidence to reduce the incidence of endophthalmitis. Although the routine use of intracameral antibiotics continues to increase throughout the world, data from multicenter, randomized, prospective trials is needed to provide better guidance regarding the prophylactic use of antibiotics.

Comparative analysis of the safety and efficacy of intracameral cefuroxime, moxifloxacin and vancomycin at the end of cataract surgery: a meta-analysis

BackgroundCurrent practice methods are unclear as to the most safe and effective prophylactic pharmacotherapy and method of delivery to reduce postoperative endophthalmitis occurrence.MethodsA systematic review and meta-analysis using Meta-analysis of...

Early anti-VEGF treatment for hemorrhagic occlusive retinal vasculitis as a complication of cataract surgery

BackgroundWe report a case of hemorrhagic occlusive retinal vasculitis (HORV) after prophylactic intracameral vancomycin use during an uneventful cataract surgery treated with early anti-VEGF treatment.Case presentationA 51-year-old female underwent uneventful cataract surgery with prophylactic intracameral vancomycin during the procedure. On the seventh post-operative-day, she presented with sudden painful, visual loss. Fundus examination revealed peripheral hemorrhagic retinal vasculitis. She received anti-VEGF therapy to prevent further vision loss and retinal neovascularization due to extensive retinal ischemia. At the 6-month follow-up visit, visual acuity was 20/20 with no sign of neovascularization.ConclusionsPostoperative HORV is a devastating condition that can occur after otherwise uncomplicated cataract surgery. The nature of this rare condition remains unknown. Early anti-VEGF administration seems to demonstrate favorable results.

Endophthalmitis prophylaxis by intracameral antibiotics: In vitro model comparing vancomycin, cefuroxime, and moxifloxacin

To compare the efficacy of intracameral vancomycin, cefuroxime, and moxifloxacin on postoperative bacterial endophthalmitis rates. Norwalk Hospital, Norwalk, Connecticut, USA. Experimental study. Bacteria and intraocular lenses (IOLs) were incubated with vancomycin, cefuroxime, moxifloxacin, or combinations. Antibiotic concentrations were high, corresponding to clinical maximum intracameral doses (1.0mg vancomycin or cefuroxime, 0.5mg moxifloxacin), or low (one third of clinicalmaximum dose). The following bacteria were isolated from patients with endophthalmitis: 18 strains including 6 staphylococci, 6 streptococci, 3 pseudomonad, and 3propionibacteria. Samples were diluted by half every 2hours to model the half-life of intracameral antibiotics. At 24hours, samples were vortexed to shake bacterial biofilms loose from the IOLs. The bacterial broth was plated and colonies were counted 24hours later. Efficacy against staphylococci was concentration dependent; all antibiotics were effective at high concentrations, while low concentrations were in general ineffective. Streptococci and propionibacteria were nearly eliminated by all antibioticsat low concentrations. Pseudomonads were most effectively treated by high-dose moxifloxacin and its combinations. Broadest coverage against common pathogens should be obtained by high-dose moxifloxacin (0.5mg intracameral). Submaximum dosing, which could occur if aqueous is released to lower intraocular pressure after injection, compromises the efficacy against staphylococci and pseudomonads. All antibiotics, even at low doses, were effective against streptococci and propionibacteria, suggesting that many of the worst endophthalmitis outcomes could be prevented by intracameral use of any of the 3 antibiotics used in this study.

Prophylactic intracameral vancomycin: efficacy in preventing endophthalmitis after cataract surgery

Background and objective: Post Operative endophthalmitis is rare but devastating complication in ocular surgery. The present study determined the efficacy of intracameral vancomycin after phaco-emusification cataract surgery to prevent endophthalmitis.Method: A total of 768 cases who had undergone phaco-emusification cataract surgery were included in the study. Every alternate patient received 0.5 ml injection of vancomycin (1mg in 0.1 ml) in the anterior chamber after completion of phaco-emulcification and formation of anterior chamber. All the patients were examined for symptoms and signs of bacterial endophthalmitis at 24 hrs, 7 days, 15 days and subsequently at 1, 3 and 6 months following surgery.Results: No endophthalmitis case was recorded at any time period during 6 month follow up in either group. However, significantly higher number of cases in vancomycin group had cells in anterior chamber and disturbances in visual acuity at day 15 following surgery.Conclusion: Vancomycin did not have any prophylactic role in preventing endophthalmitis. Proper aseptic measures are important to prevent any infection in ocular surgery.IMC J Med Sci 2016; 10(1): 24-28

Efficacy and cost-effectiveness of intracameral vancomycin in reducing postoperative endophthalmitis incidence in Australia.

Endophthalmitis is a rare but devastating postoperative complication of cataract surgery. We aimed to describe the incidence of acute postoperative endophthalmitis in an Australian population over a 14-year period. This was a retrospective longitudinal cohort study performed at Westmead Hospital, a major tertiary hospital in Sydney, Australia. Patients who had acute postoperative endophthalmitis within 6 weeks of their cataract surgery at Westmead Hospital were included. Endophthalmitis cases from 2000 to 2014 were identified from computerized diagnostic coding. These were cross-referenced with the cataract surgery list over this time period. The routine use of intracameral vancomycin at the end of cataract surgery was introduced in Westmead Hospital in 2004. We quantified the incidence of acute postoperative endophthalmitis pre and post the routine use of intracameral vancomycin. A total of 14 805 cataract cases were performed at Westmead Hospital from 2000 to 2014. Seventeen cases of endophthalmitis were within 6 weeks post cataract surgery performed at Westmead Hospital. In the period 2000 to 2003, the incidence of postoperative endophthalmitis was 0.43% (11/2539). From 2004 to 2014, there was a dramatic decrease in the incidence of postoperative endophthalmitis to 0.049% (6/12 266, P < 0.0001). There has been a nine-fold reduction in the rate of acute postoperative endophthalmitis with the use of intracameral vancomycin in cataract surgery. Post-cataract surgery endophthalmitis is now a relatively rare cause of endophthalmitis in this Australian population. Our study supports the routine use of intracameral vancomycin as postoperative endophthalmitis prophylaxis.

The Safety and Efficacy of Intracameral Vancomycin During Cataract Surgery

The Safety and Efficacy of Intracameral Vancomycin During Cataract Surgery

Postoperative Hemorrhagic Occlusive Retinal Vasculitis: Expanding the Clinical Spectrum and Possible Association with Vancomycin

To describe a syndrome of hemorrhagic occlusive retinal vasculitis (HORV) that developed after seemingly uncomplicated cataract surgery. Retrospective case series. Eleven eyes of 6 patients from 6 different institutions. Cases were identified after discussion among retina specialists. The findings on presentation, clinical course, and outcome of a series of 7 eyes of 4 patients were compared with a previous report of 4 eyes of 2 patients, and data from both series were combined for a comprehensive analysis. Historical data, examination findings, imaging results, systemic evaluation findings, treatment regimens, and visual outcomes. Eleven eyes of 6 patients underwent otherwise uncomplicated cataract surgery, receiving viscoelastic and prophylactic intracameral vancomycin during the procedure. Despite good initial vision on postoperative day 1, between 1 to 14 days after surgery, all eyes demonstrated painless vision loss resulting from HORV. Extensive ocular and systemic evaluations were unrevealing in all patients. All patients were treated with aggressive systemic and topical corticosteroids. Additional treatments included systemic antiviral medication in 4 patients, intravitreal antibiotics in 4 eyes, and pars plana vitrectomy in 4 eyes. Skin testing for vancomycin sensitivity showed negative results in 3 patients and was not performed in the others. Neovascular glaucoma developed in 7 eyes, and all eyes received intravitreal anti-vascular endothelial growth factor (VEGF) injection, panretinal photocoagulation, or both for retinal ischemia. Final visual acuity was less than 20/100 in 8 of 11 eyes. Postoperative HORV is an exceedingly rare and potentially devastating condition that can occur after otherwise uncomplicated cataract surgery. Although the precise cause remains unknown, this disease may represent a delayed immune reaction similar to vancomycin-induced leukocytoclastic vasculitis. Despite treatment with high-dose corticosteroids, antiviral medication, and early vitrectomy in many patients, visual outcomes typically were poor in this series. Early intervention with intravitreal anti-VEGF medication and panretinal photocoagulation may help to prevent additional vision loss resulting from neovascular glaucoma.

Antibiotic prevention of postcataract endophthalmitis: a systematic review and meta-analysis.

Endophthalmitis is one of the most feared complications after cataract surgery. The aim of this systematic review was to evaluate the effect of intracameral and topical antibiotics on the prevention of endophthalmitis after cataract surgery. A systematic literature review in the MEDLINE, CINAHL, Cochrane Library and EMBASE databases revealed one randomized trial and 17 observational studies concerning the prophylactic effect of intracameral antibiotic administration on the rate of endophthalmitis after cataract surgery. The effect of topical antibiotics on endophthalmitis rate was reported by one randomized trial and one observational study. The quality and design of the included studies were analysed using the Cochrane risk of bias tool. The quality of the evidence was evaluated using the GRADE approach. We found high‐to‐moderate quality evidence for a marked reduction in the risk of endophthalmitis with the use of intracameral antibiotic administration of cefazolin, cefuroxime and moxifloxacin, whereas no effect was found with the use of topical antibiotics or intracameral vancomycin. Endophthalmitis occurred on average in one of 2855 surgeries when intracameral antibiotics were used compared to one of 485 surgeries when intracameral antibiotics were not used. The relative risk (95% CI) of endophthalmitis was reduced to 0.12 (0.08; 0.18) when intracameral antibiotics were used. The difference was highly significant (p < 0.00001). Intracameral antibiotic therapy is the best choice for preventing endophthalmitis after cataract surgery. We did not find evidence to conclude that topical antibiotic therapy prevents endophthalmitis.

The Safety and Efficacy of Routine Administration of Intracameral Vancomycin during Cataract Surgery.

Purpose. To evaluate the safety and efficacy of intracameral vancomycin during cataract surgery using a standardized dosage and delivery technique. Methods. The charts of 20,719 consecutive eyes that underwent phacoemulsification with intraocular lens implantation in a single ambulatory surgery center were retrospectively reviewed over a 5-year period. Results. The first 11,333 consecutive cases did not receive intracameral vancomycin, whereas the next 9,386 consecutive cases all received intracameral vancomycin. There were no significant differences in the baseline characteristics between the cohort of subjects who received intracameral vancomycin and the cohort of subjects that did not. There were a total of 11 subjects (0.97 cases per 1,000) that developed postoperative endophthalmitis in the group that did not receive intracameral vancomycin, whereas there were no cases of postoperative endophthalmitis in the group that received intracameral vancomycin (p = 0.0015). The overall rate of intraoperative and postoperative complications and the final postoperative visual acuities were similar among cohorts. There were no cases of toxic anterior segment syndrome occurring in either group during the study period. Conclusions. Routine administration of intracameral vancomycin during cataract surgery significantly decreased the incidence of postoperative endophthalmitis and was not associated with an increased incidence of postoperative adverse events.

Ischemic Retinal Vasculitis Associated with Cataract Surgery and Intracameral Vancomycin.

Recently, there have been reports suggesting that intracameral vancomycin has been associated with retinal vasculitis; some have described this phenomenon as postoperative hemorrhagic occlusive retinal vasculitis. We present a case of a 65-year-old woman who underwent uncomplicated phacoemulsification and posterior chamber intraocular lens implantation followed by intracameral antibiotic prophylaxis. Unlike prior reports, this report demonstrates a case of mild visual reduction and minimal inflammation with subtle but complete unilateral peripheral retinal ischemia associated with cataract surgery and intracameral vancomycin, suggesting a spectrum of toxicity that may be underrecognized.

Corneal endothelial changes after intracameral vancomycin injection in cataract surgery

To evaluate corneal endothelial changes after intracameral injection of vancomycin at the end of routine cataract surgery. Department of Ophthalmology, Hospital Virgen de los Lirios, Alcoy, Alicante, Spain. Prospective comparative case series. Eyes received an intracameral injection of vancomycin (1 mg/0.1 mL) or cefuroxime (1 mg/0.1 mL) at the end of surgery. The visual acuity, corneal clarity, pachymetry, anterior chamber reaction, endothelial cell density (ECD), coefficient of variation (CoV), and hexagonality were evaluated at baseline and 1 week, 1 month, and 3 months after surgery. Sixty eyes (42 patients), 30 in each group, were enrolled. In the vancomycin group, there was a significant decrease in ECD 1 week after surgery (P = .000), after which the ECD stabilized. There were no statistically significant changes in postoperative CoV values between preoperatively and postoperatively, although there was a transient decrease in hexagonality 1 week after surgery (P = .006). In the cefuroxime group, the ECD significantly decreased 1 week after surgery (P = .000) and then stabilized. There was a statistically significantly decrease in the CoV between preoperatively and 3 months postoperatively (P = .014). No changes were noted in hexagonality. The postoperative ECD, CoV, and hexagonality values were not significantly different between the vancomycin group and the cefuroxime group. Endothelial cell changes observed after intracameral vancomycin were similar to those observed after intracameral cefuroxime in cataract surgery. The results indicate that intracameral vancomycin is safe for use in cataract surgery. No author has a financial or proprietary interest in any material or method mentioned.

Evaluation of macular thickness changes after intracameral vancomycin in cataract surgery.

The purpose of this study was to determine the effect of intracameral injection of vancomycin at the end of routine cataract surgery on macular thickness using spectral domain optical coherence tomography. This prospective comparative case series included sixty eyes of 42 patients undergoing cataract surgery. Eyes were divided into two groups: 30 eyes (Group 1) received an intracameral injection of vancomycin (1 mg/0.1 ml) at the end of surgery, and 30 eyes (Group 2) received an intracameral injection of cefuroxime (1 mg/0.1 ml). Visual acuity, average macular thickness, and retinal thickness in 9 Early Treatment Diabetic Retinopathy Study (ETDRS) sectors were measured at baseline, and 1 week, 1 month, and 3 months after surgery. There were no differences in age, gender, visual acuity, and preoperative macular thickness between groups. In Group 1, average macular thickness significantly increased 1 month after surgery compared with baseline (P = 0.000) and then stabilized. Retinal thickness significantly increased in most of the ETDRS map sectors at 1-month follow-up. In Group 2, there was a significant increase in average macular thickness 1 month after surgery compared with baseline (P = 0.037). Likewise, retinal thickness increased in most of the ETDRS subfields at 1 month. Postoperative retinal thickness values and best-corrected visual acuity were similar in both groups 1 week, 1 month, and 3 months after surgery. Intracameral injection of vancomycin at the end of cataract surgery showed comparable effects to cefuroxime in terms of macular thickness changes and visual acuity.

The incidence of postoperative endophthalmitis after cataract surgery in China: a multicenter investigation of 2006–2011

AimsTo estimate the cumulative incidence of postoperative endophthalmitis, identify risk factors and determine clinical outcomes in China.MethodsMedical records were reviewed for all patients with acute-onset endophthalmitis after cataract surgery from...

Nosocomial acute-onset postoperative endophthalmitis at a university teaching hospital in China

A retrospective study of all intra-ocular operations performed at Zhongshan Ophthalmic Centre, China between 1 January 2000 and 30 December 2009 was conducted to gain further knowledge about nosocomial acute-onset postoperative endophthalmitis. In total, 147,244 intra-ocular operations were performed during this period. Acute-onset postoperative endophthalmitis was diagnosed in 29 cases, giving a frequency of 0.020%. The frequency remained low and did not increase over the 10-year period. The highest rate of endophthalmitis was found following secondary intra-ocular lens implantation (0.129%). Cataract surgery had a rate of 0.01%, which is on the lower end of estimates from other large-scale studies. Gram-positive bacteria were the most commonly isolated organisms (71%), with the majority being Staphylococcus epidermidis (64%). However, no S. epidermidis was identified in the cases following cataract extraction; these patients received intracameral vancomycin at the end of the procedure. Visual outcomes of patients with postoperative endophthalmitis were generally poor. Three (10%) patients had visual acuity (VA) ≥20/40 at the final follow-up visit (all had undergone cataract surgery) and 15 (52%) patients had VA ≤20/400 at the final follow-up visit (10 had undergone pars plana vitrectomy). Factors associated with poor visual outcomes included initial VA of hand motions or worse, and positive culture results. Theresults of this 10-year study may serve as a source of comparison for other centres and future studies.