Arshinoff and Modabber5 call into question two assumptions of our mathematical model describing the residence times of moxifloxacin in the anterior segment with two different intracameral injection strategies.1 The authors of the letter agree with us on the underlying principle of our publication but disagree on the volume of the anterior chamber (AC) and the half-life of antibiotics. We selected two representative mean pseudophakic AC volumes (0.19 mL and 0.33 mL), substantiated by the literature,2,3 to demonstrate the principle that injecting the same dose of antibiotics (eg, 500 μg) into ACs with varying volumes produces varying concentrations of antibiotics within the total aqueous humor volume. The larger volume of 0.33 mL of Matsuura was derived from aqueous humor sampling immediately after intracameral injection in humans, before any possible fibrosis of the capsule. Libre and Mathews4 also agree with this volume. Arshinoff and Modabber's5 estimation of 0.5 mL is based on a mean phakic AC volume in the human eye of 0.25 mL; however, measurements of the AC volume in the elderly phakic eye average only 0.15 mL.6,7 With this experimentally derived volume, Arshinoff's estimation of the mean pseudophakic aqueous volume would be 0.4 mL, close to Matsuura and Libre's reported value of 0.33 mL. The AC size is known to vary from patient to patient, which cataract surgeons recognize when operating on smaller eyes and myopic eyes with longer axial lengths and larger chambers. Therefore, attempting to replace the aqueous contents with an antibiotic solution of known concentration will achieve the more consistent final concentration of drug, irrespective of the patient's pseudophakic AC volume. This same principle would have been demonstrated had we chosen two different AC volumes. There is a wide variation in the reported half-life elimination of antibiotics in the AC. Generally speaking, interdrug variation in elimination times, especially in the eye, may be due to factors such as differences in the drug molecular size, tissue binding, active pump mechanisms, and obstructions or reductions to outflow and drug elimination. Asena obtained antibiotic half-lives between 1.2 hours and 13 hours in rabbits, depending on which time points were used8; Lipnitzki et al.9 found between 0.64 hours and 1.8 hours in rabbits. Matsuura et al.3,10 demonstrated a half-life in rabbits and humans that averaged 1.2 hours over most time points. We chose 1.2 hours as it agrees with the 1% per minute aqueous turnover rate noted by Goel et al.11 The varied measures of the intradrug half-life elimination time of moxifloxacin and other antibiotics in the AC may be due to imprecision in injection and sampling techniques, pharmacokinetics that are not single compartment, and variations in individual subject anatomy and physiology. We would caution against the speculation of postantibiotic effects in regard to half-life because efficacy should be related to the target microorganism.12 Furthermore, principles that apply to the multidose administration of antibiotics in the treatment of systemic infections should not be presumptively applied to the scenario of single-dose intraocular injection without empirical evidence. Our study used two different and substantiated aqueous volumes and demonstrated that injecting small volumes of an agent can result in unequal final drug concentrations in the AC. Given the patient-to-patient variations, the “flushing” or large-volume injection technique should offer some degree of standardization and assurance of a more uniform final drug concentration in the pseudophakic AC as compared with smaller-volume–injected aliquots, thereby minimizing the interpatient variable of AC volume differences during cataract surgery.
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