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

Prophylactic Intracameral Antibiotics and Endophthalmitis After Cataract Surgery

Importance

Although the effectiveness of intracameral antibiotics to prevent postoperative endophthalmitis is described, selective use of antibiotics combined with 1% povidone iodine disinfection might be equally effective and could lead to cost reduction and avoidance of unnecessary use of antibiotics.

Objective

To compare the incidence of postoperative endophthalmitis when 1% povidone iodine disinfection is applied in combination with selective intracameral antibiotics with the incidence after routine use of intracameral antibiotics in combination with 5% povidone iodine.

Design, Setting, and Participant

This was a retrospective cohort study using incidence data from the ongoing endophthalmitis register of the Rotterdam Eye Hospital, a specialized hospital providing both secondary and tertiary ophthalmological care, when intracameral antibiotics were used only during cataract procedures with occurrence of a posterior capsular tear in comparison with results from cohorts described in the literature where routine antibiotics were used. All patients who had cataract (phacoemulsification) surgery at the Rotterdam Eye Hospital between 1993 and 2022 were included. No cataract surgical procedures combined with other intraocular procedures were included.

Exposure

Povidone iodine disinfection and intracameral antibiotics during cataract surgery either routinely or only in case of posterior capsular tears.

Main Outcome and Measure

Postoperative endophthalmitis incidence.

Results

Postoperative endophthalmitis incidence after 56 598 cataract (phacoemulsification) surgical procedures in the Rotterdam Eye Hospital between 2016 and 2022 was 0.000 (95% CI, 0.000-0.000). A PubMed literature search until September 2023 with respect to the incidence of postoperative endophthalmitis after routine antibiotic prophylaxis yielded 37 publications with an overall postoperative endophthalmitis incidence of 0.000 (95% CI, 0.000-0.000).

Conclusions and Relevance

No difference was observed between the postoperative endophthalmitis incidence during the last 7 years in the Rotterdam Eye Hospital and the overall postoperative endophthalmitis incidence after routine intracameral antibiotics prophylaxis as described in the literature. Disinfection with 1% povidone iodine in combination with selective antibiotic prophylaxis may be equally effective as routine antibiotic use and 5% povidone iodine.

Literature- and Experience-Based Consensus for Acute Post-operative Endophthalmitis and Endogenous Endophthalmitis in Taiwan

Clinical practices on acute post-operative and endogenous endophthalmitis (EnE) are highly variable among clinicians due to a lack of up-to-date, high-quality evidential support. An expert consensus is thus much needed. A panel consisting of ten retinal specialists in Taiwan was organized. They evaluated relevant literature and developed key questions regarding acute post-operative and EnE that are cardinal for practice but yet to have conclusive evidence. The panel then attempted to reach consensus on all the key questions accordingly. There were eight key questions proposed and their respective consensus statements were summarized as follows: Gram staining and culture are still the standard procedures for the diagnosis of endophthalmitis. Vitrectomy is recommended to be performed earlier than the timing proposed by the Endophthalmitis Vitrectomy Study (EVS). Routine intracameral antibiotic injection for post-cataract surgery endophthalmitis prophylaxis is not recommended because of potential compounding error hazards and a lack of support from high-quality studies. Routine fundus examination is recommended for all patients with pyogenic liver abscess. In EnE, vitrectomy is recommended if diffused and dense vitritis is present, or if the disease progresses. These consensus statements may work as handy guidance or reference for clinical practices of acute post-operative and EnE.

Susceptibility of Ocular Surface Bacteria to Various Antibiotic Agents in a Romanian Ophthalmology Clinic

Periodic assessment of bacterial contamination is necessary as it allows proper guidance in cases of eye infections through the use of appropriate antibiotics. Due to the extensive use of antibiotic treatment, many strains of the microbiota that cause infections are resistant to the usual ophthalmic antibiotics. The present study provides an updated assessment of the susceptibility of Gram-positive and Gram-negative bacteria found on the ocular surface to the most commonly used antibiotic agents in patients undergoing cataract surgery. A total of 993 patients were included in the study with ages between 44 and 98 years old. Conjunctival cultures were collected 7 days before cataract surgery. The response of Gram-positive and Gram-negative bacteria to various antibiotic classes, such as glycopeptides, cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, phenicols, tetracyclines, rifamycins, macrolides and penicillins, was assessed. From the tested antibiotics, vancomycin had 97.8% efficacy on Gram-positive bacteria. In the cephalosporin category, we observed a high level of resistance of the cefuroxime for both Gram-positive and negative bacteria. Antibiotics that have more than 90% efficacy on Gram-positive bacteria are meropenem, imipenem, netilmicin, amikacin and rifampicin. On Gram-negative bacteria, we found 100% efficacy of all tested fluoroquinolones, i.e., aminoglycosides (except for tobramycin), doxycycline, azithromycin, clarithromycin and chloramphenicol. The current study illustrates patterns of increased resistance in certain bacteria present on the ocular surface to some of the commonly used antibiotics in ophthalmological clinical practice. One such revealing example is cefuroxime, which has been highly used as an intracameral antibiotic for the prevention of bacterial endophthalmitis after cataract surgery.

Evaluation of the effect of gentamicin in surgical perfusion solution on cataract postoperative endophthalmitis

Objective

To evaluate the effect of gentamicin in surgical perfusion solution on endophthalmitis incidence after cataract surgery.

Methods

A retrospective analysis of endophthalmitis incidence was conducted in two groups of patients who underwent cataract surgery, with (Group B) or without gentamicin (Group A) in the surgical perfusion solution. Endophthalmitis incidence, the isolated pathogenic bacteria strains and their antibiotic sensitivity, and the drug-resistant genotype of the pathogens were examined.

Results

The incidence of endophthalmitis in patients of group A was 0.8‰. Thirteen pathogenic bacterial strains were isolated from the patient samples in group A, including 8 strains of Staphylococcus epidermidis, 1 Staphylococcus aureus, 1 Streptococcus pneumoniae, 1 Streptococcus bovis, 1 Enterococcus faecium and 1 Morganella sp. The incidence of endophthalmitis in group B patients was 0.2‰, which was significantly lower than that in group A (P<0.05). Five strains of pathogenic bacteria were successfully isolated, including 2 strains of Enterococcus faecium, 1 Enterococcus faecalis, 1 Staphylococcus epidermidis and 1 Staphylococcus aureus. There was no significant difference in the proportion of Staphylococcus strains in all isolated bacteria between the two groups (P > 0.05). However, the proportion of Enterococci isolated in group B samples was higher than that in group A (P < 0.05). There were more gentamicin-sensitive strains than levofloxacin-sensitive strains identified (P < 0.05). Interestingly, aminoglycoside-inactivating enzyme resistance gene was detected in Enterococcus strains.

Conclusion

Our data suggest that gentamicin-containing perfusion solution can reduce the incidence of postoperative endophthalmitis in cataract patients. However, the selective pressure imposed by gentamicin may facilitate the development of aminoglycoside-resistant Enterococcos strains.

Controlled Release of Multiple Therapeutics From Silicone Hydrogel Contact Lenses for Post-Cataract/Post-Refractive Surgery and Uveitis Treatment

Purpose

This work demonstrates seven-day controlled and extended in vitro physiological flow dual release of multiple post-ocular surgery therapeutics from extended-wear contact lenses as a dropless alternative for treatment of uveitis and corneal inflammation, pain, and infection. Lens replacement each week optimizes treatment matching patient recall time with the ability to increase or decrease dosage.

Methods

Lenses were synthesized using molecular imprinting to create lenses with macromolecular memory for diclofenac sodium (DS) and dexamethasone sodium phosphate (DMSP), as well as bromfenac sodium (BS) and moxifloxacin (MOX). Drug uptake and release were analyzed, and physical properties were measured and compared to commercial standards.

Results

DS + DMSP–loaded lenses demonstrated seven-days-plus release of each, whereas controls released more than 85% of their payload within the first day. Lenses loaded with BS + MOX demonstrated release of BS and MOX for 11 and eight days, respectively. Structural analysis demonstrated statistically similar mesh size and average molecular weight between crosslinks between imprinted lenses and controls, suggesting that release extension was due to formation of macromolecular memory sites rather than a tighter polymer architecture.

Conclusions

Lenses demonstrated in this work have significant clinical applications as an eye drop alternative, possessing the ability to be worn continuously for one week while delivering a consistent amount of therapeutic for the duration of wear.

Translational Relevance

In vitro physiological flow release results demonstrate the clinical potential of therapeutic contact lenses as a dropless vehicle for ocular drug delivery.

Preoperative antisepsis in ophthalmic surgery (a review)

Endophthalmitis remains a serious complication following intraocular procedures. Preoperative prophylactic measures for endophthalmitis decrease the morbidity associated with this disease and represent a standard of care prior to ophthalmic surgery. The literature supports as measures for ocular antisepsis: povidone-iodine solution for ocular surface preparation, chlorhexidine in patients with iodine allergy and application of topical antibiotics. Povidone-iodine is regarded as the most effective antiseptic associated with significant reduction in ocular surface bacterial counts. Currently, the recommended preoperative management is the application of 5% povidone-iodine solution in the conjunctival fornix, prior to surgery. This paper reviews the preoperative measures for ocular antisepsis, used in order to decrease the risk of culture-proven endophthalmitis.

Surveillance of post-cataract endophthalmitis at a tertiary referral center: a 10-year critical evaluation

BACKGROUND

Acute post-cataract endophthalmitis (APE) is a rare complication potentially causing irreversible visual loss. A 10-year study of APE was conducted to determine its incidence, microbiological spectra and antibiotic resistance profile of APE-related pathogens at a major tertiary referral center in Brazil.

METHODS

APE cases reported between January 2010 and December 2019 were included. Phacoemulsification and extracapsular cataract techniques were eligible; combined procedures, traumatic and congenital cataract were excluded. Vitreous samples were cultured and antimicrobial resistance was compared for the periods of 2010-2014 and 2015-2019. The results were analyzed with Fisher's exact test.

RESULTS

Our sample consisted of 40,491 cataract surgeries and 51 (0.126%) APE cases. Culture was positive in 35 cases (71.4%), of which 31 (88.6%) Gram-positive, 3 (8.6%) Gram-negative, and 1 (2.9%) fungal. The most frequently isolated organism was Staphylococcus epidermidis (n = 17/35, 48.6%), followed by Staphylococcus aureus (n = 4/35, 11.4%). From 2010-2014 to 2015-2019, antimicrobial resistance increased against moxifloxacin (11.1-54.5%, p = 0.07), ciprofloxacin (54.5-72.7%, p = 0.659) and oxacillin (66.7-93.3%, p = 0.13).

CONCLUSIONS

The observed incidence and microbial spectra were compatible with previous studies. A trend towards growing moxifloxacin and ciprofloxacin resistance was observed. Surveillance remains crucial to prevent treatment failure from antimicrobial resistance.

The Anterior Chamber Injection of Moxifloxacin Injection to Prevent Endophthalmitis after Cataract Surgery: A Meta-analysis

Purpose

A meta-analysis was performed to compare the efficacy of an anterior chamber injection of moxifloxacin in the prevention of endophthalmitis after cataract surgery.

Methods

A computer-based search of PubMed, Embase, the Cochrane Library, and the Clinical Trial database for articles related to anterior intraventricular injection of moxifloxacin for the prevention of endophthalmitis after cataract surgery was performed through April 2019. Study selection, data exclusion, and quality assessment were performed by two independent observers. Statistical analysis for the meta-analysis was performed by RevMan5.3 software.

Results

Eight studies were included, with a total of 123,819 eyes. The meta-analysis showed that an anterior chamber injection of moxifloxacin can prevent the incidence of endophthalmitis after cataract surgery (OR = 0.29, 95% CI (0.15, 0.56), P=0.0002), and the difference was statistically significant. There were no significant differences between the moxifloxacin injection and nonmoxifloxacin injection groups in regard to UCVA (log MAR) (SMD = −0.13, 95% CI (−0.62, 0.35), P=0.60), BCVA (log MAR) (SMD = −0.27, 95% CI (−1.28, 0.74), P=0.60), IOP (SMD = −0.04, 95% CI (−0.02, 0.01), P=0.22), corneal edema (OR = 1.03, 95% CI (0.23, 4.69), P=0.97), CCT (SMD = −0.01, 95% CI (−0.07, 0.05), P=0.77), or ECD (SMD = 0.00, 95% CI (−0.06, 0.07), P=0.94).

Conclusion

An anterior chamber injection of moxifloxacin can effectively prevent the incidence of endophthalmitis after cataract surgery, while the moxifloxacin injection and nonmoxifloxacin injection groups had similar results in regard to UCVA (log MAR), BCVA (log MAR), IOP, corneal edema, CCT, and ECD.

Cataract management in children: a review of the literature and current practice across five large UK centres

Congenital and childhood cataracts are uncommon but regularly seen in the clinics of most paediatric ophthalmology teams in the UK. They are often associated with profound visual loss and a large proportion have a genetic aetiology, some with significant extra-ocular comorbidities. Optimal diagnosis and treatment typically require close collaboration within multidisciplinary teams. Surgery remains the mainstay of treatment. A variety of surgical techniques, timings of intervention and options for optical correction have been advocated making management seem complex for those seeing affected children infrequently. This paper summarises the proceedings of two recent RCOphth paediatric cataract study days, provides a literature review and describes the current UK 'state of play' in the management of paediatric cataracts.

Commonly used intracameral antibiotics for endophthalmitis prophylaxis: A literature review

Endophthalmitis is a serious complication of cataract surgery that occurs in thousands of patients each year. To decrease the incidence of postoperative endophthalmitis, many surgeons inject intracameral antibiotics (cefuroxime, moxifloxacin, and vancomycin) routinely at the end of surgery. A large number of recently published retrospective studies and large database analyses have reported decreased endophthalmitis rates with routine antibiotic use, and the only prospective, multicenter, randomized trial performed by the European Society of Cataract and Refractive Surgery demonstrated that intracameral cefuroxime decreases the incidence of postoperative endophthalmitis. Routine cefuroxime use has become common in many European countries, whereas moxifloxacin is the most commonly used drug in India, and vancomycin use predominates in Australia. The decision regarding whether or not to use intracameral prophylaxis and the drug that is selected varies considerably throughout the world because of antibiotic availability and cost, and the spectrum of causative organisms. Adverse events due to intracameral antibiotics are infrequent, but complications such as hemorrhagic occlusive retinal vasculitis have been reported. Because additional prospective, comparative trials have not been performed, a consensus regarding best practices to prevent postoperative endophthalmitis has not been reached. Additionally, many surgeons do not routinely use intracameral antibiotics because they believe them unnecessary with modern aseptic techniques, small incision surgery, and shorter operating times. We discuss the most commonly used intracameral antibiotics, present the risks and potential benefits of this approach, and highlight challenges with drug compounding and safety.

Noncompliance with Prescribed Eyedrop Regimens Among Patients Undergoing Cataract Surgery—Prevalence, Consequences, and Solutions

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