Use Of Intracameral Antibiotics Research Articles

New Approaches to Overcoming Antimicrobial Resistance in Endophthalmitis.

Endophthalmitis is a rare but vision-threatening infection characterized by marked inflammation of intraocular fluids and tissues, uncommonly seen following surgery and intravitreal injection. Antimicrobials are used worldwide in the prophylaxis and treatment of bacterial and fungal infections of the eye and are standard treatment in the preoperative and postoperative care of surgical patients. However, antimicrobials are reported to be overprescribed in many parts of the world, which contributes to antimicrobial resistance (AMR). AMR complicates the prophylaxis and treatment of endophthalmitis. This article examines the prevalence and mechanisms of AMR in ocular microorganisms, emphasizing the importance of understanding AMR patterns for tailored treatments. It also explores prophylaxis and management strategies for endophthalmitis, with a discussion on the use of intracameral antibiotic administration. The use of prophylactic intracameral antibiotics during cataract surgery is common in many parts of the world but is still controversial in some locations, especially in the US. Finally, it highlights the role of stewardship in ophthalmology and its benefits in the treatment of endophthalmitis.

Complications during elective cataract surgery: did the COVID-19 lockdown affect outcomes of ophthalmic surgery?

PurposeOne of the many consequences of the COVID-19 pandemic was a worldwide lockdown of ophthalmic surgery procedures for several months in 2020. The present study aims to answer the following question: does an intermission of cataract surgery for two months cause an increase in complication rates?MethodsIn this retrospective clinical chart review, data was taken from Dutch cataract complication registration database that contains pre-, intra- and postoperative information of patients that underwent cataract surgery in the Netherlands. The amount as well as type of complications were extracted before and after the eight weeks surgical intermission period (SIP): six weeks before (SIP-6) and six weeks after this period (SIP+6) for the years 2016–2020.ResultsA significant decrease in complication rates was found between SIP-6 and SIP+6 in 2020. When SIP+6 2020 is compared to SIP+6 2019, a significant reduction is found. Overall, a downward trend in complication rates was observed in the period 2016–2020.ConclusionA two-months intermission of performing elective cataract surgery does not cause an increase in complications. In contrast, we observe a reduction of postoperative complications. This implicates that refraining from cataract surgery for two months might not compromise operative skills. The possible downward trend over the years can be partially explained by improved training, education and equipment, as well as an increased use of intracameral antibiotics during operation. Possible explanations for the reduction of complications after lockdown could be decreased time pressure as a consequence of a reduced number of operations at the restart of surgeries, and heightened awareness and cautiousness when resuming the operations.

Immediate versus delayed sequential bilateral cataract surgery

Thanks to progress in surgical techniques and intracameral antibiotic use, the safety of cataract removal procedures has improved substantially. 1 Friling E Johansson B Lundström M Montan P Postoperative endophthalmitis in immediate sequential bilateral cataract surgery: a nationwide registry study. Ophthalmology. 2022; 129: 26-34 Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Immediate sequential bilateral cataract surgery (ISBCS) is a procedure during which a cataract is removed from both eyes of a single patient during the same surgery, compared with delayed sequential bilateral cataract surgery (DSBCS) in which a cataract is removed sequentially within a certain timespan. 2 Malvankar-Mehta MS Chen YN Patel S Leung AP Merchea MM Hodge WG Immediate versus delayed sequential bilateral cataract surgery: a systematic review and meta-analysis. PLoS One. 2015; 10e0131857 Crossref Scopus (31) Google Scholar ISBCS offers multiple benefits from societal, health-care, psychological, and economic perspectives. Among these benefits, the reduction in the number of visits to the clinic appears to be of utmost importance, especially during the COVID-19 pandemic. 3 Dmuchowska DA Pieklarz B Konopinska J Mariak Z Obuchowska I Impact of three waves of the COVID-19 pandemic on the rate of elective cataract surgeries at a tertiary referral center: a Polish perspective. Int J Environ Res Public Health. 2021; 188608 Crossref Scopus (8) Google Scholar Safety, effectiveness, and cost-effectiveness of immediate versus delayed sequential bilateral cataract surgery in the Netherlands (BICAT-NL study): a multicentre, non-inferiority, randomised controlled trialOur results showed non-inferiority of ISBCS versus DSBCS regarding effectiveness outcomes, comparable safety, and superior cost-effectiveness of ISBCS. National cost savings could amount to €27·4 million (US$34·5 million) annually, advocating for ISBCS if strict inclusion criteria are applied. Full-Text PDF

Microbiological Profile of Post-cataract Surgery Endophthalmitis with Usage of Prophylactic Intracameral Moxifloxacin

ABSTRACT Purpose To study the effect of prophylactic intracameral moxifloxacin (ICM) on microbiological profile and antimicrobial sensitivity of culture-proven postoperative endophthalmitis (POE). Methods This study evaluated culture-proven POE diagnosed within 6 weeks of cataract surgery over two periods, period-1 (January 2010-March 2015) and period-2 (April 2015-December 2019), before and after introduction of prophylactic ICM, respectively. Results In period-1, 100 cases of culture-positive POE were reported (1 in 4879, 0.02%), while 20 cases (1 in 24635, 0.004%) were reported in period-2 (5-fold reduction, p < .001). The cumulative culture positivity rate decreased from 27.6% to 17.1% (1.6-fold) . Coagulase-negative Staphylococci (CoNS) were significantly reduced (p = .005). Conclusions ICM reduced the incidence of culture-proven POE, CoNS in particular. In future, POE caused by rarer pathogens may become more prevalent due to reduction in the rate of commoner and more virulent pathogens with use of intracameral antibiotics. The moxifloxacin sensitivity of CONS did not show change with the use of ICM. Studies with larger population of POE will be more helpful to understand the trend better.

Endophthalmitis prophylaxis in cataract surgery and intravitreal injection in the US

AbstractEndophthalmitis is not a “never event” following cataract surgery or intravitreal injection, therefore the occurrence of endophthalmitis does not necessarily imply a break in technique or that the surgeon somehow “did something wrong”. Endophthalmitis cannot be prevented, but its rate can be reduced using evidence‐based measures. Endophthalmitis prophylaxis techniques include more than the use of antibiotics; specifically, prep/drape, speculum use, wound construction, etc.In the US, intracameral antibiotics are not universally used. The decision to use routine intracameral antibiotics appears to depend on many “non‐medical” factors, including internal health system policies, local standards of care, and other concerns. In the US, there is no packaged antibiotic that is specifically approved for intracameral use so all such agents are used “off‐label”; this factor appears to be suppressing the use of intracameral antibiotics at least in some locations.In the US, intravitreal injections are almost always performed in the clinic rather than in an operating room or similar setting. (In fact, it can be difficult to get reimbursed for anti‐VEGF drugs injected in an operating room.) Many practices use a standard examination room rather than a minor procedure room or a room dedicated to performing injections. Eyelid speculums are very widely used, although there is a growing acceptance of the use of bimanual retraction from a skilled assistant, rather than an eyelid speculum. In many practices, topical antibiotics are not used.It is the author's opinion (although there is little or no evidence from randomized clinical trials to support this opinion) that post‐surgical endophthalmitis differs from post‐injection endophthalmitis in how the microorganisms gain access to the intraocular space. Following cataract surgery, it seems most likely that microorganisms enter the eye through the incision in the postoperative period; this would explain the relatively later onset of infection, as well as the apparent benefits of postoperative topical antibiotics, proper wound construction, and suturing the incision when necessary. Following intravitreal injection, it seems most likely that microorganisms enter the eye at the moment of the injection; this would explain the relatively sooner onset of infection, as well as the apparent lack of benefit of postoperative topical antibiotics.

Incidence of endophthalmitis after phacoemulsification cataract surgery: a Meta-analysis.

To evaluate the overall endophthalmitis incidence and the effectiveness of potential prophylaxis measures following phacoemulsification cataract surgery (PCS). The PubMed and Web of Science databases were searched from inception to April 30th, 2021. We included studies that reported on the incidence of endophthalmitis following PCS. The quality of the included studies was critically evaluated with the Newcastle-Ottawa quality assessment scale. The random effect or the fixed-effects model was used to evaluated the pooled incidence based on the heterogeneity. The publication bias was assessed by Egger's linear regression and Begg's rank correlation tests. A total of 39 studies containing 5 878 114 eyes were included and critically appraised in the Meta-analysis. For overall incidence of endophthalmitis after PCS, the Meta-analysis yielded a pooled estimate of 0.092% (95%CI: 0.083%-0.101%). The incidence appeared to decrease with time (before 2000: 0.097%, 95%CI: 0.060%-0.135%; 2000 to 2010: 0.089%, 95%CI: 0.076%-0.101%; after 2010: 0.063%, 95%CI: 0.050%-0.077%). Compared with typical povidone-iodine solution (0.178%, 95%CI: 0.071%-0.285%) and antibiotics subconjunctival injections (0.047%, 95%CI: 0.001%-0.095%), the use of intracameral antibiotics significantly reduced the incidence of endophthalmitis after PCS (0.045%, 95%CI: 0.034%-0.055%, RR: 7.942, 95%CI: 4.510-13.985). Due to the advancement of phacoemulsification technology and the widespread use of intracameral antibiotics, the incidence of endophthalmitis following PCS shows a decreasing trend over time. The use of intracameral antibiotics administration will significantly reduce the risk of endophthalmitis.

Immediately sequential bilateral cataract surgery: pros and cons

This review presents the main pros and cons of immediately sequential bilateral cataract surgery versus delayed sequential bilateral cataract surgery. The main arguments against immediately sequential bilateral cataract surgery are the likelihood of postoperative bilateral endophthalmitis and refractive errors. At the same time, a careful selection of patients, implementation of safety recommendations and the use of intracameral antibiotics, combined with the improvement of formulas for calculating intraocular lenses, provide the advantages of immediately sequential bilateral cataract surgery associated with the rapid rehabilitation of patients after surgery and economic reasons.

Resident Perspectives 56-5

Resident Perspectives 56-5

Incidence of post-cataract surgery endophthalmitis: a chronological review and intercontinental comparison

Purpose: This review aimed to investigate the global incidence of postoperative endophthalmitis (POE) after cataract surgery over the last three decades, with a particular focus on the use of prophylactic intracameral antibiotics. Study design: Literature review. Methods: A literature search was performed in PubMed and Scopus. Data was collected from included studies and analyzed in IBM SPSS v27. Results: A total of 63 studies from 20 regions were included. The use of prophylactic intracameral antibiotics significantly reduced POE incidence. The baseline POE incidence in studies that involved intracameral prophylaxis tended to be high. A downward linear trend in POE incidence was observed in studies that did not involve intracameral antibiotic prophylaxis. Interestingly, a study in Japan reported the use of intracameral antibiotic prophylaxis in only 10.4% of cataract surgeries with an overall POE incidence of 0.025%, which is comparable to countries that use intracameral prophylaxis routinely. Within studies from Australia, China, Europe, India, Singapore and United States, Australia had the highest POE incidence with and without intracameral prophylaxis, while China had the lowest POE incidences. Conclusion: Intracameral antibiotics are an effective prophylaxis against POE. However, the incidence of POE is decreasing worldwide even without intracameral prophylaxis. The benefits of intracameral antibiotics should be weighed against its risks prior to its implementation as routine prophylaxis protocol for cataract surgery.

Subconjunctival antibiotics: an alternative to intracameral antibiotics for endophthalmitis prophylaxis in cataract surgery

Background: There has been an increase in the use of routine intracameral antibiotics for endophthalmitis prophylaxis in cataract surgery. However, this can be associated with serious adverse events. Previously, subconjunctival antibiotics were the preferred route but there is minimal literature directly comparing the two. Hence, the safest and most efficacious route of prophylactic antibiotic administration remains controversial. Purpose: To evaluate the efficacy and safety of subconjunctival with intracameral antibiotics for postoperative endophthalmitis (POE) prophylaxis in patients undergoing uncomplicated cataract surgery. Methods: A literature review was conducted in Cochrane and PubMed for studies that compared the efficacy of prophylactic subconjunctival and intracameral antibiotics for post-cataract endophthalmitis. Searches were not limited to English or study design. Results: Three observational studies showed that subconjunctival and intracameral antibiotics both reduced POE rates. Intracameral antibiotics demonstrated a high efficacy (OR = 0.25, 95% CI 0.13-0.46, p < 0.0001) but was also associated with increased potential complications. All studies were conducted in a sequential nature during which cataract surgery techniques and instrumentation have improved in recent years. Conclusion: In institutions with a high incidence of endophthalmitis, routine intracameral antibiotic use would be more appropriate. However, in facilities with lower rates of POE, the subconjunctival route of delivery can be an alternative due to its better safety profile.

Commentary: Improving the cataract surgery efficiency and clearing the cataract surgery backlog due to COVID-19 pandemic.

Commentary: Improving the cataract surgery efficiency and clearing the cataract surgery backlog due to COVID-19 pandemic.

Efficacy of intracameral antibiotics following manual small incision cataract surgery in reducing the rates of endophthalmitis: A meta-analysis.

Manual small incision cataract surgery (MSICS) is a widely used technique for cataract surgery in the developing world. Higher rates of postoperative endophthalmitis have been reported with this technique compared with phaco-emulsification. The purpose of this study was to evaluate the efficacy of prophylactic intracameral (IC) antibiotics in reducing the rates of postoperative endophthalmitis following MSICS. Systematic review and meta-analysis of patients undergoing MSICS. A literature search in PubMed and EMBASE databases was performed to identify studies published from October 1992 to April 2020 evaluating MSICS with a minimum of 500 eyes reported. Two authors independently assessed eligibility, extracted data and assessed the risk of bias. Heterogeneity was assessed using the I2 test. Twelve studies enrolling 1 494 307 eyes were included. IC antibiotics were used in 725 324 (48.5%) eyes. The risk ratio of developing endophthalmitis was 2.94 (95% CI, 1.07-8.12; P = .037) in eyes that did not receive IC antibiotics. Routine use of IC antibiotics may help to reduce the rates of endophthalmitis following MSICS and significantly improve the safety of this effective form of cataract surgery.

Dropless cataract surgery: modernizing perioperative medical therapy to improve outcomes and patient satisfaction.

Advances in pharmacology offer freedom from topical medical therapy without compromise of anti-inflammatory and antimicrobial coverage in the perioperative period. In this review, we describe the basis for dropless cataract surgery with the goal of improving outcomes and the patient experience. Phacoemulsification outcomes depend largely on surgeon skill but also on adherence to a complex multidrug regimen of perioperative anti-inflammatory and antimicrobial therapy to prevent sight-threatening complications such as cystoid macular edema or endophthalmitis. Successful administration of this regimen can be limited by noncompliance, difficulty administering eye drops, bioavailability, and side effects, among others. The recent development of sustained-release formulations of dexamethasone - one an intracanalicular insert and the other an intraocular suspension - can provide sustained tapering doses of dexamethasone while reducing or eliminating the need for anti-inflammatory eye drop therapy. Similarly, mounting evidence compellingly demonstrates that intracameral antibiotic use intraoperatively is at least as effective as topical antibiotics in preventing endophthalmitis. Sustained-release dexamethasone coupled with intracameral antibiotics at the time of phacoemulsification can provide antimicrobial and anti-inflammatory prophylaxis without the need for topical eye drop medications. This approach has the potential to improve compliance with therapy, visual acuity outcomes, and the overall patient experience.

Review of Efficacy and Comparison of Intracameral Antibiotics for Postcataract Surgery Endophthalmitis Prophylaxis

Justify universal adoption of intracameral antibiotic for prophylaxis against postcataract endophthalmitis. Review of both placebo-controlled randomized clinical trials for intracameral cefuroxime and moxifloxacin as well as large retrospective studies demonstrate efficacy in reducing the risk of postcataract endophthalmitis when the intracameral antibiotic choice is targeted to the causative pathogens of the demographic studied. Clinical evidence demonstrates the benefit of intracameral antibiotic use from statistical, clinical, and cost-effective analyses. Cases with higher risk for endophthalmitis such as posterior capsule rupture, manual extracapsular cataract extraction, immunocompromised patients, and age > 85, warrant special attention and greater consideration for intracameral antibiotic use. Further research to identify the optimal drug, formulation, and concentration can improve patient outcomes.

Postoperative Endophthalmitis Before and After Preferred Utilization of Prophylactic Intracameral Antibiotics for Phacoemulsification Cataract Surgeries at Cole Eye Institute.

To compare the rate of endophthalmitis of intracameral versus topical antibiotic prophylaxis for patients undergoing phacoemulsification at a single-centered, multispecialty ophthalmological institute. A retrospective analysis of the rate of endophthalmitis by coding search within 90 days of cataract surgery in periods before (May 15, 2012-May 15, 2014) and after (April 30, 2015-April 30, 2017) intracameral antibiotics became the institution's preferred practice pattern for phacoemulsification. Clinical data were collected for each endophthalmitis case, including timing of onset, presenting symptoms and signs, culture results, treatment performed, and visual acuity outcome. The rate of postphacoemulsification endophthalmitis decreased from 0.18% (29 eyes among 16,201 cataract surgeries) to 0.07% (11 eyes among 16,325 surgeries) when the preferred method was changed from topical to intracameral antibiotics (P=0.004) with an odds ratio of 0.32. Endophthalmitis cases in the 2 groups had comparable visual acuity at initial presentation and at 3 months (P=0.86). The most commonly isolated organism in culture-proven cases of endophthalmitis in both groups was coagulase-negative staphylococcus. The rate of gram-positive endophthalmitis decreased from 0.08% to 0.02% with an odds ratio of 0.23 (P=0.012) while the rate of gram-negative cases remained similar. The use of intracameral antibiotics during cataract surgery was associated with a statistically significant reduction of postoperative endophthalmitis.

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.

Major ocular trauma in Taiwan: 2002\u20132004 versus 2012\u20132014

We investigated the temporal changes in major eye injuries in Taiwan by reviewing the medical records of all patients with ocular trauma hospitalized at the National Cheng Kung University Hospital during 2002–2004 and 2012–2014. A total of 169 eyes (161 patients) during 2002–2004 and 121 eyes (120 patients) during 2012–2014 were enrolled (mean ± SD age: 41.9 ± 20.8 years in 2002–2004, and 51.8 ± 19.3 years in 2012–2014). Males accounted for ~75% of patients. The most frequent injury-causing object was metallic material (~24%), and blunt traumas were most frequently attributable to traffic accidents and falls. The most common locations of injuries for males and females were the workplace and home, respectively. Open-globe injuries occurred in ~70% of eyes, requiring primary repair, cataract extraction, and/or intraocular lens implantation. The frequencies of fall injury, lacrimal system laceration, lens injury, corneal/scleral foreign bodies, and use of intracameral antibiotics increased from 2002–2004 to 2012–2014, while those of closed-globe injury, vitreous haemorrhage, optic nerve injury, and medical treatment decreased. The final visual acuity remained poor (≤20/200) in >1/3 of injured eyes. Despite therapeutic advancements, major eye injuries still pose a high risk for poor visual outcome.

The Safety, Efficacy, and Potential Complications of Intracameral Antibiotics

The use of intracameral antibiotics (ICAs) as endophthalmitis prophylaxis after cataract surgery has increased in the past decade. The goal of this paper is to review the current literature arguing for and against ICAs. There is compelling evidence that ICAs have greater efficacy than topical antibiotics in preventing post-operative endophthalmitis. However, issues related to availability, cost, and safety have limited their widespread adoption in countries such as the USA. In countries without access to a commercially available prepackaged antibiotic for intracameral use, cataract surgeons will have to individually weigh the risks and benefits of ICAs in determining their method of endophthalmitis prophylaxis.

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...

Antibiotic prophylaxis in cataract surgery: Understanding the trends of the day.

Postoperative endophthalmitis (POE) remains the most dreaded complication for any cataract surgeon worldwide. Although with more stringent peri-operative prophylactic measures in place, the rates of POE have dropped to <0.1% all over the world, the perfect formula which would provide the maximum protection against ocular infection remains the Holy Grail. It is interesting to see the preferred practice patterns of cataract surgeons all over the world, and these surveys have often formed the recommendations in the absence of a fixed set of guidelines on this topic. The 2006 ESCRS study[12] had first recommended the routine use of intracameral (IC) cefuroxime at the end of the cataract surgery as a safe and effective measure against POE. Eight years down the line, the 2014 ESCRS survey[3] showed that 74% of its members had routinely inculcated IC antibiotic usage into their practice. However, this also means that approximately one-fourth of the respondents had not inculcated this effective measure in their practice in 8 years since the publication. Similarly, the endophthalmitis prophylaxis surveys of ASCRS, 2007 and 2014,[45] showed a growing trend of IC antibiotic use from 30% to 50% among its respondents. This again also indicates that 50% of respondents in 2014 were not using IC antibiotic. In the Indian subcontinent, the practice patterns of cataract surgeons have been seen to vary widely. Some robust studies from larger institutes such as by Haripriya et al. concluded that IC moxifloxacin prophylaxis is effective with a 3.5-fold reduction in the overall rate of POE.[6] This study acknowledges that, while this does not constitute Level 1 evidence and that there is no consensus that IC antibiotic prophylaxis should be the standard of care, IC moxifloxacin prophylaxis should be considered for high-risk eyes experiencing posterior capsule rupture with vitreous loss. Kelkar et al. in their article “Antibiotics prophylaxis practice patterns for cataract surgery in India – Results from an Online Survey”[7] could elicit responses from a small number of participants – 1228 respondents (8.2%), which may not be truly representative of the prevalent practices among cataract surgeons in India; however, it does provide insights into POE prevention. In this study, preoperative povidone-iodine antisepsis was adopted by 94% of the respondents. Unfortunately, this figure needs to be made 100%. Nearly 38% of the respondents reported IC antibiotic usage routinely after cataract surgery, but 68% believed that it is important to have a commercially approved drug for IC use. Nearly 48% of the respondents were not using intraocular antibiotics since they were not convinced of the need. The AIOS member survey by Maharana et al.[8] is a commendable effort in bringing out some glaring shortcomings, and we can hope it will be the step toward formulation of a recommended set of guidelines which every anterior-segment surgeon practicing in the country will be expected to adhere to. In addition, following up with repeated surveys with the same cohort in the future would help to assess the changes which could be brought by these recommendations. However, only 30.2% of participation in the survey is still a small number, and it can be hoped that this participation can be increased in future surveys. The revelation from the study that only 83% use of povidone-iodine is an eye-opener showing that <100% of the respondents perform mandatory preoperative preparations. Use of postoperative subconjunctival antibiotics by 46% of the respondents is another revelation highlighting rigid barriers to the changing protocols of postoperative antibiotic regimen. Thus, we do understand that preferred practice patterns should not only give mandatory protocols on specific disease issues from time to time, but the ophthalmological community must also institute measures to execute the same in the large interest of our patients. There is a strong need to educate our ophthalmologists across the country of the changed protocols of antibiotic prophylaxis in the current scenario. These are the interesting facts which prove that there is a major challenge in convincing the respondents on the use of safety measures.