Use Of Intracameral Cefuroxime Research Articles

Acute bilateral blindness due to diffuse outer retinopathy following clear lens exchange: a case report

BackgroundAs the trend of refractive lens exchange for presbyopia continues to grow, our case report shows the first occurrence of an acute bilateral outer retinopathy following uncomplicated sequential clear lens extraction in an otherwise healthy individual.Case presentationA 54-year-old male without significant medical history benefited from a sequential bilateral lens exchange for presbyopia. He then experienced a rapid vision loss in both eyes, accompanied by photopsias and myodesopsias, with symptoms appearing respectively 4 and 3 weeks after the surgeries. Multimodal imaging revealed a fulminant outer retinopathy, leading to a total loss of light perception within a few days. Immediate intravenous corticosteroid therapy was administered, permitting to recover a small area of central visual function in both eyes, enabling shape and color distinction. The primary diagnostic hypothesis is a presumed autoimmune retinopathy, triggered by the cataract extraction, while an alternative diagnosis could be a toxic reaction secondary to the use of intracameral cefuroxime and lidocaine during the surgery.ConclusionIn this report, the authors describe the first recorded instance of outer retinopathy following cataract surgery. This occurrence raises the possibility of auto-immunization leading to retinal atrophy and vision loss as a potential outcome after undergoing cataract surgery.

Effect of Intracameral Cefuroxime on Graft Endothelial Cells in Descemet Membrane Endothelial Keratoplasty: A Comparative Study

ABSTRACT Purpose: To evaluate the effect of intracameral cefuroxime on graft endothelial cell loss after simple Descemet Membrane Endothelial Keratoplasty (DMEK) and combined DMEK and cataract surgery. Materials and Methods: Single-center retrospective comparative analysis. One hundred and three patients were included, 31 in the cefuroxime group and 72 in the non-cefuroxime (NC) group. Best Spectacle-Corrected Visual Acuity (BSCVA), endothelial cell density (ECD) of the graft measured by specular microscopy, and the recipient’s pachymetry were recorded pre-operatively and at 1, 3, and 6 months after surgery. Results: In the cefuroxime group, BSCVA was 0.22 ± 0.27 LogMAR, 0.15 ± 0.24 LogMAR and 0.07 ± 0.22, respectively, at 1, 3, and 6 months after surgery with no significant differences found when compared to the NC group (p > .05). Anatomical outcomes were similar as mean pachymetry decreased from 599 ± 51 µm preoperatively to 511 ± 30 µm at 6 months after surgery in the cefuroxime group and from 607 ± 67 µm preoperatively to 519 ± 32 µm at 6 months in the NC group (p = .25). Endothelial cell loss was comparable between both groups: 33.4% versus 33.6% at 1 month (p = .97), 37.4% versus 34.9% at 3 months (p = .68) and 41.6% versus 38.3% at 6 months (p = .42) in the cefuroxime and NC groups, respectively. The rates of rebubbling, graft rejection, and cystoid macular edema were not significantly higher in the cefuroxime group. Conclusion: The use of intracameral cefuroxime during simple or combined DMEK did not lead to higher graft endothelial cell loss.

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.

Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery.

Endophthalmitis is a severe inflammation of the anterior and/or posterior chambers of the eye that may be sterile or associated with infection. It is a potentially vision-threatening complication of cataract surgery. Prophylactic measures for endophthalmitis are targeted against various sources of infection.The objective of this review was to evaluate the effects of perioperative antibiotic prophylaxis for endophthalmitis following cataract surgery.We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to October 2012), EMBASE (January 1980 to October 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to October 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 25 October 2012. We also searched for additional studies that cited any included trials using the Science Citation Index.We included randomized controlled trials that enrolled adults undergoing cataract surgery (any method and incision type) for lens opacities due to any origin. Trials that evaluated preoperative antibiotics, intraoperative (intracameral, subconjunctival or systemic) or postoperative antibiotic prophylaxis for acute endophthalmitis were included. We did not include studies that evaluated antiseptic preoperative preparations using agents such as povidone iodine, nor did we include studies that evaluated antibiotics for treating acute endophthalmitis after cataract surgery.Two review authors independently reviewed abstracts and full-text articles for eligibility, assessed the risk of bias for each included study, and abstracted data.Four studies met the inclusion criteria for this review, including 100,876 adults and 131 endophthalmitis cases. While the sample size is very large, the heterogeneity of the study designs and modes of antibiotic delivery made it impossible to conduct a formal meta-analysis. Interventions investigated in the studies included the utility of adding vancomycin and gentamycin to the irrigating solution compared with standard balanced saline solution irrigation alone, use of intracameral cefuroxime and/or topical levofloxacin perioperatively, periocular penicillin injections and topical chloramphenicol-sulphadimidine drops compared with topical antibiotics alone, and mode of antibiotic delivery (subconjunctival versus retrobulbar injections). Two studies with adequate sample sizes to evaluate a rare outcome found reduced risk of endophthalmitis with antibiotic injections during surgery compared with topical antibiotics alone: risk ratio (RR) 0.33, 95% confidence interval (CI) 0.12 to 0.92 (periocular penicillin versus topical chloramphenicol-sulphadimidine) and RR 0.21, 95% CI 0.06 to 0.74 (intracameral cefuroxime versus topical levofloxacin). Another study found no significant difference in endophthalmitis when comparing subconjunctival versus retrobulbar antibiotic injections (RR 0.85, 95% CI 0.55 to 1.32). The fourth study which compared irrigation with balanced salt solution (BSS) alone versus BSS with antibiotics was not sufficiently powered to detect differences in endophthalmitis between groups. The risk of bias among studies was low to unclear due to information not being reported.Multiple measures for preventing endophthalmitis following cataract surgery have been studied. One of the included studies, the ESCRS (European Society of Cataract and Refractive Surgeons) study, was performed using contemporary surgical technique and employed cefuroxime, an antibiotic commonly used in many parts of the world. Clinical trials with rare outcomes require very large sample sizes and are quite costly to conduct; thus, it is unlikely that additional clinical trials will be conducted to evaluate currently available prophylaxis. Practitioners should rely on current evidence to make informed decisions regarding prophylaxis choices.

Endophthalmitis Prophylaxis in Cataract Surgery: Overview of Current Practice Patterns Around the World.

Acute-onset postoperative endophthalmitis after cataract surgery remains a rare but important cause of visual loss. There is no global consensus regarding the optimal strategies for prophylaxis of endophthalmitis and practices vary substantially around the world, especially with respect to the use of intracameral antibiotics. The European Society of Cataract & Refractive Surgeons in a randomized clinical trial (2007) reported an approximately 5-fold reduction in endophthalmitis rates associated with the use of intracameral cefuroxime. Despite this report, the use of intracameral antibiotics has not been universally adopted. Various endophthalmitis prophylaxis patterns around the world (including the United States, Canada, Australia/New Zealand, Japan, China, India, Indonesia, South Africa, Argentina, Russia, Sweden and Mexico) are compared. Each contributing author was asked to provide similar information, including endophthalmitis rates based on published studies, current practice patterns, and in some cases original survey data. Various methods were used to obtain this information, including literature reviews, expert commentary, and some new survey data not previously published. Many different practice patterns were reported from around the world, specifically with respect to the use of intracameral antibiotics. There is no worldwide consensus regarding endophthalmitis prophylaxis with cataract surgery.

Intracameral cefuroxime in the prevention of postoperative endophthalmitis: an experience from Hong Kong.

The purpose was to study the effect of introducing intracameral cefuroxime, which was compounded by a hospital pharmacy, on postoperative endophthalmitis in a tertiary eye centre in Hong Kong. All cases that underwent cataract surgeries over a 12-year period (January 2004 to December 2015) were included. The routine use of intracameral cefuroxime at the end of cataract surgery was introduced at our centre after April 2010. All cefuroxime aliquots were prepared by the hospital pharmacy using an aseptic compounding technique. The rates of postoperative endophthalmitis before April 2010 (Group 1, no intracameral cefuroxime) and after April 2010 (Group 2, routine use of intracameral cefuroxime) were compared. A total of 30,428 eyes (7,332 in Group 1 and 23,096 in Group 2) were studied. Eight cases developed postoperative endophthalmitis (1.09 in 1000; 0.11%) in Group 1 whereas no cases developed endophthalmitis (0%) in Group 2. The rate of reduction was statistically significant (p < 0.0001). Seven out of eight cases of endophthalmitis were confirmed by positive culture. Organisms identified were Group G Streptococcus (two cases), Group B Streptococcus, Staphylococcus aureus, Serratia marcescens, and coagulase-negative Staphylococcus (two cases). Antibiotic susceptibility testing results were available in six cases. Four out of six organisms were susceptible to the penicillin group. No adverse events related to the use of intracameral cefuroxime were encountered. The use of intracameral cefuroxime could significantly reduce the rate of postoperative endophthalmitis in a tertiary centre in Hong Kong. The use of aseptic compounding to prepare cefuroxime aliquots by hospital pharmacy appeared to be safe and efficacious.

Antibiótico intracameral para prevenção de endoftalmite aguda pós-cirurgia de catarata no Brasil

Acute endophthalmitis is a serious complication of cataract surgery that, given its infectious etiology, can be prevented using antiseptics and antibiotics. Various drugs and different formulations and routes of administration have been tested for this purpose; however, thus far, besides the well-established preoperative topical application of povidone-iodine, the use of intracameral cefuroxime at the end of surgery is the most effective measure to prevent acute endophthalmitis. However, in Brazil, as in the United States, cefuroxime is not available for intraocular use. This necessitates a search for feasible alternatives to reduce the incidence of this serious surgical complication.

Increased Uptake of Intracameral Antibiotic Prophylaxis in Europe

PurposeTo determine the use of intracameral cefuroxime at the end of cataract surgery across Europe since the beneficial results were first reported by the ESCRS Endophthalmitis Study Group in 2007 and examine the reasons for the different practice patterns identified.MethodsThe ESCRS conducted a survey of 250 ophthalmic surgeons across Europe regarding their awareness of the ESCRS study and seeking the reasons for their current use or non‐use of i/c antibiotics in their cataract surgery. Simultaneously, data on practice patterns for prophylaxis were searched in the main European countries concentrating on the uptake of the i/c route and the reasons for the switch.ResultsIn the ESCRS survey, 74% always/usually use i/c antibiotics and 82% of these use cefuroxime. Lack of need, protocol, or concerns re adverse events related to the absence of an approved product, accounted for non‐use. Only 8% would not use i/c cefuroxime whether commercially available or not. Germany has the lowest use and the highest cataract volume whilst France has the next highest volume and the most rapid conversion due to Government guidelines introduced in 2011. The approval of a product of i/c cefuroxime for use in cataract surgery by the EMA (European Medicines Agency) in 2012 eliminated the risks of errors of dilution, diluent, contamination or TASS and is largely responsible for the major shift to the i/c route.ConclusionsThe landmark ESCRS Study results of 2007 heralded a worldwide increase in the use of i/c antibiotic for the prevention of postoperative endophthalmitis following cataract surgery. Subsequent studies all over the world have validated these results ‐ where the rate was high it got much lower, where it was low it got even lower with almost no adverse events.

Intracameral cefuroxime and the incidence of post-cataract endophthalmitis: an Israeli experience.

The European Society of Cataract & Refractive Surgeons (ESCRS) study reported a decrease in endophthalmitis rates from 0.34 % to 0.08 % with the use of intracameral cefuroxime. The purpose of this study was to compare the endophthalmitis rates before and after the introduction of intracameral cefuroxime (ICC) routinely at the end of cataract surgery. A retrospective consecutive cohort study. We compared the rates of endophthalmitis between the years 2000-2006, and the years 2007-2014, after the pivotal publication of the ESCRS. Data collected included age, gender, culture results, initial and final visual acuity, and complications. Only patients that presented with endophthalmitis following cataract surgery performed at the two centers were included. Twenty-two cases of endophthalmitis occurred between the years 2000 and 2006, out of 26,663 cataract operations performed at the two centers, a rate of 0.083 %. Ten cases occurred between the years 2007 and 2014 out of 29,431 cataract operations, a rate of 0.034 %. The difference was statistically significant (p = 0.03) CONCLUSIONS: The introduction of prophylactic use of intracameral cefuroxime was associated with a significant reduction in post-operative endophthalmitis rates in our centers. We strongly recommend adoption of this routine by for all cataract operations except when contraindicated.

Reevaluating intracameral cefuroxime as a prophylaxis against endophthalmitis after cataract surgery in India

To determine whether an intracameral injection of cefuroxime sodium at the conclusion of cataract surgery lowers the incidence of acute-onset postoperative endophthalmitis. Tertiary eye care center, Bhubaneswar, India. Prospective comparative interventional cohort study. Under a uniform protocol, cataract surgery with posterior chamber intraocular lens (PC IOL) implantation was performed from September 27, 2006, to July 31, 2010 (Group 1). All eyes were evaluated 1 day, 7 days, and 5 weeks ± 1 (SD) postoperatively. Treatment of eyes suspected to have developed infectious endophthalmitis was managed by retina-vitreous surgeons. From August 1, 2010, to August 31, 2012, the same surgeons performed cataract surgery with PC IOL implantation in another group of eyes, in which they administered intracameral cefuroxime prophylaxis (Group 2). All other protocols of postoperative care and microbiological investigation of the vitreous samples were similar. The rate of clinical and culture-positive endophthalmitis was compared between the 2 study groups: eyes without intracameral cefuroxime (Group 1) and eyes with intracameral cefuroxime (Group 2). The incidence of clinical endophthalmitis in Group 1 (0.155% [12/7756 eyes]) and in Group 2 (0.108% [8/7366 eyes]) was not significantly different (P = .57). The culture positivity rate in Group 1 (0.09 % [7 eyes]) and in Group 2 (0.04% [3 eyes]) was also not significantly different (P = .38). In the treatment without intracameral cefuroxime, there was a minimal, statistically insignificant increase in postoperative acute endophthalmitis (odds ratio, 1.42; 95% confidence interval, 0.53-4.02; P = .506). There is not strong evidence to support use of intracameral cefuroxime to reduce the rate of acute endophthalmitis after cataract surgery; however, the marginal benefit might justify its use. No author has a financial or proprietary interest in any material or method mentioned.

Ocular Toxıcıty after High Dose Cefuroxime Injection to the Anterior Chamber

Sefalosporinler beta-laktam turevi antibiyotiklerdir ve bakteri hucre duvari sentezini bozarak bakterisidal etki gosterirler (1). Sefuroksim 2. kusak sefalosporindir ve ozellikle intrakamaral yolla sefuroksim kullanimi katarakt cerrahisi profilaksisinde yaygin olarak kullanilmaktadir. Ulkemizde bircok ticari preparati mevcuttur. Intrakamaral sefuroksimin uygulanmasi sonrasinda en az 1 saat terapotik duzeyde kalabilmektedir (2). Bu yazida, intraokuler cerrahi sonrasinda sefuroksimin on kamaraya, olmasi gereken dozun 2,5 kati Abstract Cephalosporins are beta-lactam antibiotics and, like penicillin derivatives, they show bacteriostatic effect by disrupting bacterial cell wall synthesis. Cefuroxime is a second generation cephalosporin and the use of intracameral cefuroxime after cataract surgery has been widely used in the endophthalmitis prophylaxis. A 78-year-old male patient was operated for cataracts in both eyes about 8 years ago. Ocular trauma has occurred in the left eye nine months ago. Vitrectomy surgery combined with intraocular lens extraction was performed and the patient was left aphakic. Secondary intraocular lens implantation was performed. In this paper, we present postoperative ocular findings in a patient who was given cefuroxime into the anterior chamber 2.5 times higher than the recommended dose (25 mg/ml) after secondary intraocular lens implantation.

Intracameral cefuroxime and moxifloxacin used as endophthalmitis prophylaxis after cataract surgery: systematic review of effectiveness and cost-effectiveness.

Postoperative endophthalmitis is one of the most serious potential complications of ocular lens surgery. Its incidence can be reduced by means of antibiotic prophylaxis. Although the prophylactic use of intracameral cefuroxime has been extended, other drugs, such as moxifloxacin, have arisen as alternatives. We performed a systematic literature review on the effectiveness and efficiency of intracameral cefuroxime and moxifloxacin for the prophylaxis of postoperative endophthalmitis after cataract surgery. Several bibliographic databases were searched up to October 2010 and were updated up to January 2013. Outcomes were the onset of endophthalmitis after surgery and the cost-effectiveness ratio of using both antibiotic prophylaxis alternatives. The following were included: a clinical trial reported in two papers, six observational studies, and an economic evaluation. All studies assessed cefuroxime compared with another antibiotic prophylaxis or no prophylaxis. The only randomized controlled trial performed by the European Society of Cataract and Refractive Surgery found that intracameral cefuroxime is significantly more effective than not using prophylaxis or the use of a topical antibiotic. The observational studies support these results. The economic evaluation compared different prophylaxis regimens and concluded that intracameral cefuroxime showed the best cost-effectiveness ratio. Both the observational studies and the economic evaluation have methodological limits that reduce their validity. This review confirmed that cefuroxime can prevent endophthalmitis after cataract surgery. Further randomized controlled trials, with large sample sizes, are required to compare different antibiotic prophylaxis regimens.

PP-011 Implementation of a process optimisation protocol for the preparation of ready-to-use (RTU) intracameral cefuroxime for endophthalmitis prophylaxis (EP) after cataract surgery

BackgroundThe use of intracameral cefuroxime is becoming more widely accepted for endophthalmitis prophylaxis (EP) after cataract surgery. Recently, the European Medicines Agency approved a single, sterile, unit dose of intracameral...

Adoption of intracameral antibiotic prophylaxis of endophthalmitis following cataract surgery: Update on the ESCRS Endophthalmitis Study

To determine the use of intracameral cefuroxime at the end of cataract surgery since the beneficial results were first reported by the European Society of Cataract and Refractive Surgeons Endophthalmitis Study Group in 2006, 250 ophthalmic surgeons affiliated with both public and private hospitals and clinics across Europe were surveyed. The questions regarded their awareness of the results of the ESCRS endophthalmitis study and their current use or non-use of intracameral antibiotics in their cataract procedures. Seventy-four percent of respondents said they always or usually use intracameral antibiotics in their cataract surgery procedures. The most frequently cited reasons for not using cefuroxime or other intracameral antibiotics was the lack of an approved commercial preparation and related anxieties regarding the risk of dilution errors and contamination. More than 90% of respondents said they would use cefuroxime if an approved single-unit dose product were commercially available.

Response to Nestel

Sir, We thank Dr Nestel1 for his interest in our study.2 We found some associations between the pathogenic conjunctival bacteria and the systemic co-morbidities of patients undergoing cataract surgery, which was the main purpose of the study. Among these associations, we found that enterococci prevalence is associated with age and diabetes. Owing to the current wide use of intracameral cefuroxime for the cataract surgery prophylaxis,3, 4 we introduced the example of the postoperative endophthalmitis (PE) caused by enterococci for illustrating the implications of our findings in the management of patients carrying conjunctival bacteria resistant to a particular prophylaxis, such as the enterococci to cefuroxime, as Dr Nestel pointed. The systemic co-morbidities associations with other bacteria (for instance multi-resistant Staphylococcus) could also help in choosing a prophylaxis. The answers to other comments are as follows: In the study design, polymyxin B plus trimethoprim eye drops is an empirical prophylaxis for all patients, except those having conjunctival pathogen bacteria resistant to these antibiotics, such as enterococci. We try not to increase the resistance to first-line antibiotic treatments. The occurrence of four PE cases in the first year of the study period2 was before using intracameral cefuroxime. This fact could point to streptococci as the most likely cause, as there was no case of Streptococci-PE in the ESCRS groups treated with cefuroxime,5 and no others prophylactic measures had changed in our study. The oral antibiotic for patients with conjunctival enterococci was chosen in accordance with their susceptibility tests;6 quinolones being the first choice, if possible. Finally, the ‘potential' risk of intraocular contamination by enterococci, in patients over 85 years, was calculated with respect to the conjunctival enterococci prevalence of patients younger than 86 years (Supplementary Table 3).2 This information is extended in Table 1. Table 1 Increasing potential risk of intraoperative contamination by enterococci according to age in patients operated on for cataract

Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery.

Endophthalmitis is a severe inflammation of the anterior and/or posterior chambers of the eye that may be sterile or associated with infection. It is a potentially vision-threatening complication of cataract surgery. Prophylactic measures for endophthalmitis are targeted against various sources of infection. The objective of this review was to evaluate the effects of perioperative antibiotic prophylaxis for endophthalmitis following cataract surgery. We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to October 2012), EMBASE (January 1980 to October 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to October 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 25 October 2012. We also searched for additional studies that cited any included trials using the Science Citation Index. We included randomized controlled trials that enrolled adults undergoing cataract surgery (any method and incision type) for lens opacities due to any origin. Trials that evaluated preoperative antibiotics, intraoperative (intracameral, subconjunctival or systemic) or postoperative antibiotic prophylaxis for acute endophthalmitis were included. We did not include studies that evaluated antiseptic preoperative preparations using agents such as povidone iodine, nor did we include studies that evaluated antibiotics for treating acute endophthalmitis after cataract surgery. Two review authors independently reviewed abstracts and full-text articles for eligibility, assessed the risk of bias for each included study, and abstracted data. Four studies met the inclusion criteria for this review, including 100,876 adults and 131 endophthalmitis cases. While the sample size is very large, the heterogeneity of the study designs and modes of antibiotic delivery made it impossible to conduct a formal meta-analysis. Interventions investigated in the studies included the utility of adding vancomycin and gentamycin to the irrigating solution compared with standard balanced saline solution irrigation alone, use of intracameral cefuroxime and/or topical levofloxacin perioperatively, periocular penicillin injections and topical chloramphenicol-sulphadimidine drops compared with topical antibiotics alone,and mode of antibiotic delivery (subconjunctival versus retrobulbar injections). Two studies with adequate sample sizes to evaluate a rare outcome found reduced risk of endophthalmitis with antibiotic injections during surgery compared with topical antibiotics alone: risk ratio (RR) 0.33, 95% confidence interval (CI) 0.12 to 0.92 (periocular penicillin versus topical chloramphenicol-sulphadimidine) and RR 0.21, 95% CI 0.06 to 0.74 (intracameral cefuroxime versus topical levofloxacin). Another study found no significant difference in endophthalmitis when comparing subconjunctival versus retrobulbar antibiotic injections (RR 0.85, 95% CI 0.55 to 1.32). The fourth study which compared irrigation with balanced salt solution (BSS) alone versus BSS with antibiotics was not sufficiently powered to detect differences in endophthalmitis between groups. The risk of bias among studies was low to unclear due to information not being reported. Multiple measures for preventing endophthalmitis following cataract surgery have been studied. One of the included studies, the ESCRS (European Society of Cataract and Refractive Surgeons) study, was performed using contemporary surgical technique and employed cefuroxime, an antibiotic commonly used in many parts of the world.Clinical trials with rare outcomes require very large sample sizes and are quite costly to conduct; thus, it is unlikely that additional clinical trials will be conducted to evaluate currently available prophylaxis. Practitioners should rely on current evidence to make informed decisions regarding prophylaxis choices.

Reduction in postoperative endophthalmitis with intracameral cefuroxime

Postoperative endophthalmitis is an uncommon complication of cataract surgery with grave consequences. This report describes the trend of endophthalmitis in a district general hospital in England over eight years, and attempts made to modify this trend. An outbreak of endophthalmitis in 2007 led to a detailed investigation and subsequent changes in practice. Intracameral cefuroxime (ICC) was introduced in place of subconjunctival cefuroxime. Use of ICC in patients with 'penicillin allergy' was explored, found to be safe and resulted in a change of policy. This led to a four-fold reduction in the rate of endophthalmitis.

Intracameral Cefuroxime

Results of the landmark European Society of Cataract and Refractive Surgeons trial and additional prospective and retrospective studies support the use of intracameral cefuroxime in the prophylaxis of endophthalmitis following cataract surgery. Prophylaxis with intracameral cefuroxime at the recommended dose appears to be well tolerated in patients undergoing cataract surgery. However, off-label use of intracameral cefuroxime usually requires a two-step dilution process with the potential for dilution errors, and there are also concerns regarding the risk of contamination. Aprokam® (intracameral cefuroxime) has been approved in the EU for the prophylaxis of postoperative endophthalmitis after cataract surgery. After reconstitution of Aprokam®, no further dilution is required and each vial is only indicated for single-patient use; this has the potential to reduce the risk of both dilution errors and contamination.

Intracameral antibiotics for the prevention of endophthalmitis in cataract surgery

Aim: To determine if there is enough evidence to support the use of intracameral antibiotics for the prevention of endophthalmitis post cataract surgery. Method: A systemic review of English language articles was conducted by performing a broad search using Medline/ProQuest, Science Direct, the Cochrane Library and Embase. The search was restricted to articles published between January 2005 and October 2010. The terms endophthalmitis and intracameral antibiotics were used to initiate the search but the term cataract was used for further exclusion. The population base incorporated adult patients undergoing cataract surgery. Limitations include one author as a reviewer of the titles resulting from the literature searches. A team review would give a more robust methodological quality. Results: Of the 493 results that were identified in the literature search 451 citations were excluded after screening titles and abstracts. Forty two publications were included for this review and were identified as being relevant after scrutiny. Publications showing retrospective data far exceeded the number of prospective case controlled studies negatively affecting the number of high quality articles reviewed. A randomized controlled study released by the European Society of Cataract and Refractive Surgeons (ESCRS) published results in 2006 showing a near _fivefold decrease in the rates of post-operative endophthalmitis with the use of intracameral cefuroxime. This study was discontinued due to ethical considerations. The study observed a clear benefit from the use of intracameral cefuroxime. Moxifloxacin has not been truly evaluated and has a potential for bacterial resistance. Topical antibiotics are unreliable relying on patient compliance and requiring frequent administration. From this review an effective solution for endophthalmitis prevention remains unclear. Conclusion: Intracameral cefuroxime administered at the time of surgery seems to work well for reducing the incidence of post-operative endophthalmitis as it is a broad spectrum and cost-effective antibiotic. The major barrier to its clinical use is the lack of a commercial preparation which increases the threat of dilution errors, which is known to be toxic to human endothelial cells.

Injections intracamérulaire de céfuroxime dans la prophylaxie des endophtalmies après chirurgie de cataracte : organisation et résultats

The European Society for Cataract and Refractive Surgery (ESCRS) endophthalmitis study demonstrated a significant decrease in the rates of postoperative endophthalmitis with the use of intracameral cefuroxime during cataract surgery. We report the organization of the implementation of this procedure in our departments and our results after 2 years. All patients operated on for cataract between January 2007 and December 2008 in the ophthalmology departments of the Pellegrin University Hospital in Bordeaux and Lariboisiere University Hospital in Paris received an intracameral injection of cefuroxime at the end of the surgery. The cefuroxime was prepared in ready-for-use syringes by the hospital's central pharmacy. A convenient method of preparation and conditioning cefuroxime with stable preservation lasting longer than 1 week was set up in our hospitals. Between January 2007 and December 2008, out of 3316 patients who had a cataract surgery, two presented an endophthalmitis (0.06%). The intracameral cefuroxime injection at the end of the cataract surgery is a means to consider to prevent endophthalmitis. It can be implemented as a part of regular practice with appropriate preparation rules. The major barrier to its further use appears to be the lack of a commercially available preformulated preparation.