Prophylactic intracameral cefuroxime. Evaluation of safety and kinetics in cataract surgery

Efficacy of intracameral and subconjunctival cefuroxime in preventing endophthalmitis after cataract surgery

PURPOSE

To compare the efficacy of intracameral cefuroxime versus subconjunctival cefuroxime in reducing the rate of endophthalmitis after cataract surgery.

SETTING

Single-specialty eye hospital, Sunderland, United Kingdom.

METHODS

A retrospective analysis of all presumed infectious endophthalmitis cases from January 1,2000, to December 31,2006 was performed. The rate of presumed infectious endophthalmitis in patients receiving subconjunctival cefuroxime was compared with those receiving intracameral cefuroxime at the end of surgery.

RESULTS

This study included 36743 phacoemulsification cataract procedures. The mean rate of presumed infectious endophthalmitis was 0.95 per 1000 cases. The incidence of endophthalmitis was higher in the subconjunctival cefuroxime group than in the intracameral cefuroxime group; the difference was statistically significant with an odds ratio of 3.01 (95% confidence interval, 1.37-6.63).

CONCLUSION

Intracameral cefuroxime was a safe alternative to subconjunctival cefuroxime and led to a lower rate of endophthalmitis.

Perspectives on antibiotics for postoperative endophthalmitis prophylaxis: Potential role of moxifloxacin

To aid the cataract surgeon's understanding of rational approaches to antimicrobial prophylaxis and place the European Society of Cataract & Refractive Surgeons (ESCRS) postoperative endophthalmitis study in perspective, a review was conducted of published and unpublished data on intracameral antibiotic use during cataract surgery and the antimicrobial efficacy, pharmacodynamics, ocular penetration, and safety of moxifloxacin. The ESCRS-sponsored study of postoperative endophthalmitis prophylaxis reported rates of presumed infectious postoperative endophthalmitis of 0.07% with intracameral cefuroxime treatment and 0.34% in control groups. Postoperative endophthalmitis after cefuroxime use was mostly due to cefuroxime-resistant gram-positive bacteria. Intracameral cefuroxime also requires extemporaneous compounding, has short-term stability, and carries a risk for hypersensitivity. Moxifloxacin, a fourth-generation fluoroquinolone, has potent and rapid bactericidal activity against the most common gram-positive postoperative endophthalmitis pathogens, has excellent ocular penetration after topical administration, and is available in a self-preserved ophthalmic formulation that has been shown safe and effective in preventing endophthalmitis when administered intracamerally in an animal model. Available data suggest that the optimum antibiotic regimen and route of delivery for cataract surgery antimicrobial prophylaxis require further study. Moxifloxacin offers many theoretical advantages that make it an attractive first-line choice for topical use and of interest for intracameral administration.

Pharmacokinetics of vancomycin following intracameral bolus injection in patients undergoing phacoemulsification cataract surgery

AIM

To determine the elimination kinetics of intracameral vancomycin administered as a bolus injection at the end of phacoemulsification cataract surgery.

METHODS

Vancomycin 1 mg/0.1 ml saline solution was administered to 19 patients by intracameral bolus injection at the end of routine cataract surgery. The aqueous concentration of vancomycin was determined in nine patients 1 minute after administration and in 10 patients 18-24 hours postoperatively. Aqueous samples were obtained by inserting a Rycroft cannula into the anterior chamber via the side port incision. Fluorescence polarisation immunoassay was used to calculate the aqueous vancomycin concentration.

RESULTS

The median (interquartile range) vancomycin concentration was 5458 (4756-6389) mg/l at 1 minute and 40.6 (25.9-47.1) mg/l 18 to 24 hours (median 19 hours) postoperatively. The vancomycin concentration exceeded the minimum inhibitory concentration (MIC) of endophthalmitis-causing gram-positive bacteria by a factor of 4 for up to 26 hours postoperatively. No adverse event or reaction was noted.

CONCLUSION

Following bolus intracameral injection at the end of cataract surgery the concentration of vancomycin in the anterior chamber vastly exceeds its MIC for at least 24 hours but is predicted to fall below the MIC after 33 hours.

A case of inadvertent anterior chamber and corneal stromal injection with antibiotics during cataract operation

PURPOSE

To report a case of inadvertent anterior chamber and cornea stromal injection with high dose antibiotics and steroids during cataract operation.

METHODS

During cataract operation on a 78 year-old female patient, high dose gentamicin (20 mg/0.5 ml) and dexamethasone (2 mg/0.5 ml) were inadvertently injected into the anterior chamber and cornea stroma when making cornea edema for sealing of the incision sites. Anterior chamber irrigation with balanced salt solution (BSS) was immediately administered. On postoperative day one, extensive cornea edema was noted, and best-corrected visual acuity was 0.2. Descemet's membrane folds were observed around the corneal incision sites. Topical 5% NaCl and 1% prednisolone were started.

RESULTS

Four weeks postoperatively, corneal edema began to reduce significantly. At four months postoperatively, corneal edema fully resolved, and best-corrected visual acuity was 0.8. However, some Descemet's membrane folds still remained, and a decrease in the number of endothelial cells was noted by specular microscope.

CONCLUSIONS

In this case involving anterior chamber and cornea stromal injection with high dose antibiotics and steroids, immediate anterior chamber irrigation with balanced salt solution seemed an appropriate management, and the patient's long-term visual acuity appears good. To prevent such mistakes, precise labeling of all solutions and use of different syringe needles should be considered.

Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location

PURPOSE

To establish the nationwide rate of postoperative endophthalmitis (PE) after cataract extraction (CE) and to study the relationship between PE and type of incision and other possible risk factors.

DESIGN

Prospective, multicenter, comparative, nonrandomized, observational study.

PARTICIPANTS

All cataract surgeries in Sweden performed from January 2002 through December 2004 and all endophthalmitis cases in the same period that were reported to the Swedish National Cataract Register (NCR).

METHODS

Through a standard reporting form sent to the NCR, patient and operation technique data were recorded. In addition, PE cases with a traceable number to the main register were collected. Various parameters with a possible impact on endophthalmitis development were evaluated. Univariate analyses and logistic regression were statistical methods.

MAIN OUTCOME MEASURES

The rate and etiology of PE; possible risk factors pertaining to patient history and operation technique, with a special emphasis on incision type and location; use of injector for the intraocular lens implantation; kind of prophylaxis; and presence of peroperative communication between the anterior chamber and vitreous.

RESULTS

The overall rate of PE was 0.048% (109 cases in 225 471 CEs). Incidences of PE were 0.053% with clear corneal incisions and 0.036% with sclerocorneal incisions (P = 0.14, logistic regression analysis). The corresponding results were 0.040% for superior incisions and 0.055% for temporal incisions (P = 0.14). Communication between the anterior segment and vitreous was found to be a highly significant independent risk factor for PE (P<0.001), as were patient age > or = 85 years (P<0.001) and the nonuse of intracameral cefuroxime (P<0.001).

CONCLUSIONS

The overall rate of PE after cataract surgery is low in Sweden, which may be a consequence of the widespread use of prophylactic intracameral cefuroxime. Only a trend for an increased risk of PE was detected for clear corneal and temporal wounds. The present data indicate that the use of clear corneal and/or temporal approaches will result in 1 additional PE case in approximately 5500 procedures on top of the PE rate after sclerocorneal or superior incisions, which was approximately 1 case in 2400 operations.

Safety of prophylactic intracameral moxifloxacin 0.5% ophthalmic solution in cataract surgery patients

PURPOSE

To determine the safety of prophylactic intracameral moxifloxacin 0.5% ophthalmic solution (Vigamox) in patients having cataract surgery.

SETTING

American Eye Center, Manila, Philippines.

METHODS

Preoperative and 1-month postoperative anterior chamber reaction, corneal endothelial cell density, and corneal thickness were assessed in 65 eyes that had cataract surgery with intracameral moxifloxacin. All eyes received 0.1 mL intracameral moxifloxacin 0.5% ophthalmic solution containing 500 mug of moxifloxacin as the last step of phacoemulsification. Different ophthalmologists conducted the postoperative evaluation in an observer-masked fashion. A P value less than 0.05 was considered significant.

RESULTS

All 65 eyes completed the study. The mean age was 69.5 years +/- 9.13 (SD) (range 48 to 84 years). All eyes had a postoperative best corrected visual acuity of 20/30 or better. All eyes had trace to +2 cells and flare anterior chamber reaction only on the first day after surgery. The mean endothelial cell count was 2491.52 cells/mm(2) preoperatively and 2421.58 cells/mm(2) postoperatively. The mean difference was 70 cells/mm(2), which not statistically significant (P = .737). The increase of 17.80 microm in postoperative pachymetry 1 month after surgery was not statistically significant (P>.65).

CONCLUSION

Intracameral Vigamox 0.5 mg/mL appeared to be nontoxic in terms of visual rehabilitation, anterior chamber reaction, pachymetry, and corneal endothelial cell density.

A survey of measures used for the prevention of postoperative endophthalmitis after cataract surgery in the United Kingdom

PURPOSE

This study investigates the current practice of United Kingdom (UK) ophthalmologists in perioperative antibiotic and antiseptic use in cataract surgery.

MATERIALS AND METHODS

A telephone interview survey was conducted with ophthalmic staff at all ophthalmic training units in the UK in October and November 2005.

RESULTS

The practices of a total of 800 consultants were ascertained. Preoperatively, 795 (99.4%) surgeons used povidone-iodine to prepare the skin. In all, 558 (69.8%) instilled 5 or 10% povidone-iodine in the conjunctival sac; 47 (5.9%) gave preoperative antibiotic eyedrops. Intraoperatively, intracameral antibiotics were given either as a bolus [80 (10.0%) intracameral cefuroxime, 29 (3.6%) intracameral vancomycin] or in the irrigating fluid [33 (4.1%) vancomycin]. 48 (6.0%) gave subconjunctival gentamycin only routinely, 531 (66.4%) gave subconjunctival cefuroxime, and 39 (4.9%) gave other subconjunctival antibiotics. A single dose of topical antibiotics was given by 134 (16.8%) surgeons. Postoperatively, 515 (64.4%) used a combination steroid and neomycin eyedrop, and 213 (26.6%) gave a separate steroid and chloramphenicol eyedrop.

CONCLUSIONS

This study reveals wide variations in the choice and duration of antibiotics used by UK ophthalmologists. The predominant methods of intraoperative prophylaxis are subconjunctival cefuroxime and intracameral cefuroxime. Most surgeons used a neomycin eyedrop for postoperative prophylaxis.

ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study

PURPOSE

To report results in the European Society of Cataract & Refractive Surgeons (ESCRS) multicenter study of the prophylaxis of endophthalmitis after cataract surgery.

SETTING

Twenty-four ophthalmology units and eye clinics in Austria, Belgium, Germany, Italy, Poland, Portugal, Spain, Turkey, and the United Kingdom, with an administrative office in Ireland, coordinating center in England, and data management and statistical unit in Scotland.

METHODS

This partially masked randomized placebo-controlled multinational clinical study to evaluate prospectively the prophylactic effect of intracameral cefuroxime injection and/or perioperative levofloxacin eyedrops on the incidence of endophthalmitis after phacoemulsification cataract surgery began in September 2003 and was terminated early in January 2006. The study used random allocation of patients in a 2 x 2 factorial design.

RESULTS

By the end of 2005, complete follow-up records had been received for 13 698 study patients. Such a clear beneficial effect from the use of intracameral cefuroxime had been observed that it was agreed it would be unethical to continue the study and to wait for the completion of all follow-up procedures before reporting this important result. If total reported cases of endophthalmitis are considered, the incidence rate observed in those treatment groups not receiving cefuroxime prophylaxis (23 cases in 6862 patients) was almost 5 times as high (odds ratio [OR], 4.59; 95% confidence interval [CI], 1.74-12.08; P = .002) as that in the groups receiving this treatment (5 cases in 6836 patients). If only cases proved to be due to infection are considered, the rate was more than 5 times as high (OR, 5.32; 95% CI, 1.55-18.26; P = .008) in the treatment groups not receiving cefuroxime. Although the use of perioperative levofloxacin eyedrops as prophylaxis was also associated with a reduction in the observed incidence rate of postoperative endophthalmitis, this effect was smaller and was not statistically significant, whether total reported cases or only cases proven to be due to infection are used in calculating the rates. As not all follow-up procedures are complete, it is possible that further cases of endophthalmitis may be reported; however, it is not expected that this will alter the main conclusion. Nevertheless, it is anticipated that successful completion of follow-up procedures in all patients will increase the total number in the study to approximately 16,000.

CONCLUSION

Intracameral cefuroxime administered at the time of surgery significantly reduced the risk for developing endophthalmitis after cataract surgery.

Intracameral cefazolin as prophylaxis against endophthalmitis in cataract surgery

PURPOSE

To evaluate the efficacy of prophylactic intracameral cefazolin in preventing endophthalmitis in cataract surgery.

SETTING

Service of Ophthalmology, St. Joan Hospital, Reus, Spain.

METHODS

In this noncontrolled retrospective observational study, all patients had uncombined cataract surgery from January 2001 to December 2004. All cases of postoperative endophthalmitis were related. The patients were classified into 2 groups. The first (n = 3650) had surgery between January 2001 and December 2002, and the second (n = 3618) had surgery between January 2003 and December 2004; the second group received a bolus of intracameral cefazolin instilled at the end of surgery.

RESULTS

The rate of postoperative endophthalmitis was lower in the cases with intracameral injection at the end of surgery (0.055%) than in those without cefazolin injection (0.63%). No patients in the group with intracameral cefazoline developed corneal endothelium or retinal toxicity.

CONCLUSIONS

Intracameral bolus injection of cefazolin (1 mg in 0.1 mL solution) in cataract surgery demonstrated prophylactic efficacy in diminishing the rate of postoperative endophthalmitis without toxic effects on the cornea or retina.

ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery

PURPOSE

To present the development and design of the European Society of Cataract & Refractive Surgeons multicenter study of the prevention of postsurgical infective endophthalmitis after phacoemulsification and to describe the process for its successful implementation and conduct.

SETTING

Twenty-four ophthalmology units and eye clinics in Austria, Belgium, Germany, Italy, Poland, Portugal, Spain, Turkey, and the United Kingdom, with an administrative office in Ireland, coordinating center in England, and data management and statistical unit in Scotland.

METHODS

This partially masked randomized placebo-controlled multinational clinical study was designed to evaluate prospectively the prophylactic effect of intracameral cefuroxime and/or perioperative topical levofloxacin on postoperative endophthalmitis after cataract surgery. Random allocation was based on a 2 x 2 factorial design that included participating centers as a class variable. Real-time electronic data collection monitored study progress and provided weekly outcome tables, monthly recruitment summaries, and quarterly analytical reports for the study's Data Monitoring Committee, which evaluated the safety and efficacy by Internet-based conferences.

RESULTS

A 2-year lead time was required to meet harmonized standards of clinical research in the European Union, obtain ministerial authorization in 3 countries, gain institutional approvals at 24 hospitals, and procure indemnity insurance for surgical centers. Informed consent instruments, designed to comply with national health policies, were translated into 8 languages. The use of information technology to collect study data enabled the organizers to evaluate individual eligibility at enrollment, adherence with study medications during and after surgery, and postoperative status during follow-up.

CONCLUSION

This international cooperative study provided the opportunity to estimate the current incidence of endophthalmitis after cataract surgery in Europe and determine whether 1 or both of 2 antimicrobial regimens reduces the risk for postsurgical intraocular infection.

Effect of vancomycin, teicoplanin, and cefuroxime on Staphylococcus epidermidis adherence to intraocular lenses

PURPOSE

To compare the adherence of Staphylococcus epidermidis on AcrySof (Alcon) and poly(methyl methacrylate) (PMMA) intraocular lenses (IOLs) treated with vancomycin, teicoplanin, and cefuroxime.

SETTING

Kocaeli University, School of Medicine, Kocaeli, Turkey.

METHODS

The lenses were contaminated with S epidermidis solutions containing 10(8) colony-forming units. Intraocular lenses were placed in sterile triptic soy broth after being held in antibiotic solutions for 15 minutes. After that, sonication and vortex procedures were performed to remove all the attached bacteria that could not be removed by antibiotics. Ten microliters from each broth were taken and inoculated into sheep blood agar. The colonies were counted overnight. The statistical analyses were made using Mann-Whitney U and Kruskal-Wallis tests, and a P value less than 0.05 was considered statistically significant.

RESULTS

Regarding the inhibitory effect of antibiotics on bacterial adhesion, there was no statistically significant difference between AcrySof and PMMA lenses. In the cefuroxime group, the mean numbers of colony-forming units on AcrySof and PMMA lenses were 35.2 +/- 6.94 and 30.8 +/- 18.69, respectively (P>.05). In the teicoplanin group, the mean number of colony-forming units on AcrySof lenses was 100.1 +/- 20.97 and 70.6 +/- 43.75 on the PMMA lenses. The adherence in the vancomycin group was 245 +/- 273.74 colony-forming units for AcrySof lenses and 159.8 +/- 101.94 for PMMA lenses (P>.05). Regarding the inhibitory effect of antibiotics, cefuroxime was the most effective, followed by teicoplanin and vancomycin, respectively. Overall, the mean numbers of colony-forming units on the lenses that were held in cefuroxime, teicoplanin, and vancomycin solutions were 33.0 +/- 13.90, 85.35 +/- 36.66, and 202.4 +/- 205.74, respectively (P = .000).

CONCLUSIONS

The results suggest that cefuroxime, teicoplanin, and vancomycin significantly inhibit bacterial adherence to IOLs. The effect of cefuroxime on adherence inhibition was significantly higher than that of teicoplanin and vancomycin. Bacterial adherence is an important factor in bacterial virulence. Antibiotics, especially cefuroxime, can successfully inhibit bacterial adherence.

Cataracts in children

Bilateral congenital cataract is the most common cause of treatable childhood blindness. Nuclear cataract is usually present at birth and is nonprogressive, whereas lamellar cataract usually develops later and is progressive. Surgery must be performed promptly in cases with dense congenital cataract; if nystagmus has developed, the amblyopia is irreversible. A treatment regimen based on surgery within 2 months of birth combined with prompt optical correction of the aphakia and aggressive occlusion therapy with frequent follow-up has been successful in unilateral and bilateral cases. Both anterior and posterior capsulorhexes are performed in most children. Intraocular lens implantation can be performed safely in children older than 1 year. Anterior dry vitrectomy is recommended in preschool children to avoid after-cataract. Opacification of the visual axis is the most common complication of cataract surgery in children. Secondary glaucoma is the most sight-threatening complication and is common if surgery is performed early. Life-long follow-up is essential in these cases.

Macular thickness after cataract surgery with intracameral cefuroxime

PURPOSE

To determine whether the use of prophylactic intracameral cefuroxime during phacoemulsification cataract surgery is associated with increased macular thickening in the postoperative period.

SETTING

Hull and East Yorkshire Eye Hospital, Hull, United Kingdom.

METHODS

In this prospective randomized double-masked clinical study, the study group received 1 mg of intracameral cefuroxime and the control group received intracameral balanced salt solution only. Ocular coherence tomography was performed 5 (+/-1) weeks after surgery.

RESULTS

Intracameral cefuroxime did not have a statistically significant effect on postoperative macular thickness compared with nonadministration of intracameral antibacterials. All patients in both groups achieved a postoperative best corrected visual acuity of 6/9 or better.

CONCLUSION

Use of 1 mg of intracameral cefuroxime was not associated with increased macular thickness 4 weeks to 6 weeks postoperatively.

Severe anaphylactic reaction after intracameral antibiotic administration during cataract surgery

We report a severe anaphylactic reaction that occurred about 5 minutes after 1.0 mg of cefuroxime was injected into the anterior chamber after routine phacoemulsification and intraocular lens implantation. The patient was known to be allergic to penicillin. Immediate action was taken, and the patient recovered well. The presence of staff trained in resuscitation was essential in this case and raises questions about the trend to perform routine topical anesthesia cataract surgery without an anesthesiologist in the operating room.

Ocular surgical pharmacology: corneal endothelial safety and toxicity

The purpose of this review is to discuss the recently published literature related to corneal endothelial toxicity and safety. We discuss postoperative complications, such as toxic endothelial cell destruction syndrome and toxic anterior segment syndrome, that cause significant injury to the patient and anxiety to the physician. Additionally, we review recent papers related to intraocular medications, preservatives, and devices, including antibiotics, anesthetics, viscoelastics, and enzymatic sterilization detergents, that have potentially toxic effects on the corneal endothelium.

Prophylactic intracameral cefuroxime. Efficacy in preventing endophthalmitis after cataract surgery

PURPOSE

To evaluate the efficacy of prophylactic intracameral cefuroxime in preventing endophthalmitis in cataract surgery.

SETTING

Department of Ophthalmology, St. Eriks Hospital, Stockholm, Sweden.

METHODS

In a noncontrolled retrospective observational study, all cases of recorded postoperative endophthalmitis were related to the total number of uncombined cataract procedures from January 1996 to December 2000.

RESULTS

Twenty cases of postoperative endophthalmitis occurred in 32180 procedures, yielding an overall rate of 0.06%. Cefuroxime-resistant organisms accounted for 12 of 13 culture-positive cases, and enterococci were the most common etiology.

CONCLUSIONS

Intracameral cefuroxime 1 mg appeared to effectively inhibit sensitive bacterial strains and was associated with a low frequency of postoperative endophthalmitis. The causative organisms of future incidents of postoperative endophthalmitis will determine whether the present protocol must be reappraised.