Has the Time Come for All to Routinely Use Intracameral Antibiotic Prophylaxis at the Time of Cataract Surgery?

Antibiotic prophylaxis in cataract surgery - An evidence-based approach

Various protocols are being followed for endophthalmitis prophylaxis in cataract surgery, and this subject continues to be a matter of debate. We summarize the most recent evidence-based studies on this topic with additional stress on intracameral (IC) antibiotic prophylaxis. Here, we discuss several large, international clinical studies which discuss the efficacy, adoption, safety, cost, and newer trends in antibiotic prophylaxis. Majority of these studies report a significant reduction in endophthalmitis rates with IC antibiotic prophylaxis. Efficacy data have been reported for IC cefuroxime, vancomycin, and moxifloxacin. Surgeons are now looking for alternatives to vancomycin for IC prophylaxis because of its association with the rare but sight-threatening complication of hemorrhagic occlusive retinal vasculitis. A recent large clinical study shows convincing efficacy with IC moxifloxacin prophylaxis. Two large studies have also reported significant endophthalmitis reduction following use of IC antibiotic prophylaxis, in eyes with posterior capsule tear which are at highest risk for infection. Except for one randomized controlled trial, there is a lack of prospective data on this subject; however, considering the complexity of performing such studies, surgeons have to rely on the mounting evidence from other recent big data studies. Availability of approved intraocular antibiotic formulations will see a much higher adoption in the future.

Antibiotic prophylaxis in cataract surgery in the setting of penicillin allergy: A decision-making algorithm

Cataract surgery is the most commonly performed surgical procedure in many developed countries. Postoperative endophthalmitis is a rare complication with potentially devastating visual outcomes. Currently, there is no global consensus regarding antibiotic prophylaxis in cataract surgery despite growing evidence of the benefits of prophylactic intracameral cefuroxime at the conclusion of surgery. The decision about which antibiotic regimen to use is further complicated in patients reporting penicillin allergy. Historic statistics suggesting crossreactivity of penicillins and cephalosporins have persisted into modern surgery. It is important for ophthalmologists to consider all available antibiotic options and have an up-to-date knowledge of antibiotic crossreactivity when faced with the dilemma of choosing appropriate antibiotic prophylaxis for patients undergoing cataract surgery with a history of penicillin allergy. Each option carries risks, and the choice may have medicolegal implications in the event of an adverse outcome. We assess the options for antibiotic prophylaxis in cataract surgery in the setting of penicillin allergy and provide an algorithm to assist decision-making for individual patients.

Endophthalmitis after cataract surgery: epidemiology, risk factors, and evidence on protection

PURPOSE OF REVIEW

After publication of the results of the European Society of Cataract and Refractive Surgery (ESCRS) study, there is a lot of enthusiasm for using intracameral antibiotics for the prevention of postcataract endophthalmitis. However, despite level 1 evidence, the practice has not been adopted universally. The aim of this review is to present a summary of the articles published in the last 18 months on this topic.

RECENT FINDINGS

The published literature highlights that the incidence rate of endophthalmitis declined after 2007. Simultaneously, there is a rising trend for using intracameral injection of antibiotics at the conclusion of cataract surgery. Although various drugs have been used for this purpose, nearly all provide comparable protection. Industry has started manufacturing formulations for commercial availability of intracameral injection. Innovations are also ongoing to use intraocular lens for drug delivery and developing other intraocular drug delivery devices.

SUMMARY

Endophthalmitis prevention is at an interesting crossroad. Although there is hesitation the intracameral injection of antibiotics is increasingly being adopted by physicians, which is likely to grow further with commercial availability of formulations. However, it will be important to be cautious and report all adverse reactions associated with this practice.