Endophthalmitis Prophylaxis Failures in Patients Injected With Intracameral Antibiotic During Cataract Surgery

Endophthalmitis after cataract surgery and effect of different intracameral antibiotic regimes in Sweden 2011-2017: national registry study

PURPOSE

To study the incidence, predictive factors, etiology, and visual consequences of postoperative endophthalmitis (PE) in relation to 3 intracameral (IC) antibiotic regimes.

SETTING

Swedish National Cataract Register entries from 2011 through 2017.

DESIGN

Observational retrospective study.

METHODS

PE incidence, influencing factors, bacteriology, and visual outcome were analyzed regarding the 3 major prophylactic IC protocols.

RESULTS

The overall incidence of PE was 0.023% or 177 cases in 764 513 cataract procedures. Analyzed per IC regime, the rates of PE were 0.024% (126 cases in 514 916 surgeries) for cefuroxime, 0.020% (25 cases in 122 340 surgeries) for moxifloxacin, and 0.017% (20 cases in 121 045 surgeries) for combined cefuroxime-ampicillin. Incidences were not statistically significantly different from one another. Gram-positive bacteria caused 89.0% of culture positive cases. Enterococci as pathogens were significantly more frequent with IC cefuroxime than with moxifloxacin, P = .006, or cefuroxime-ampicillin, P < .001, while streptococci other than enterococci were more common with moxifloxacin than with cefuroxime, P < .001. Bacterial susceptibility to the given antibiotics was demonstrated in 21.3% of PE cases treated with cefuroxime, which was statistically significantly lower than proportions found with cefuroxime-ampicillin, 60.0%, P = .015, or with moxifloxacin, 88.2%, P < .001. Visual outcome worse than 20/200 was similar in the groups ranging from 42.0% to 53.7%.

CONCLUSIONS

No statistically significant differences in PE incidence or visual outcome results between treatment groups were demonstrated. However, differences in etiology and bacterial sensitivity were found between the prophylactic IC treatments.

The Preventive Effect of Gentamicin in the Irrigating Solution on Endophthalmitis Caused by Methicillin-Resistant Staphylococcus epidermidis After Phacoemulsification with Intraocular Lens Implantation in Rabbits

OBJECTIVE

To analyze the effect of gentamicin in the irrigating solution on endophthalmitis caused by methicillin-resistant Staphylococcus epidermidis after phacoemulsification with intraocular lens implantation.

METHODS

Fifteen rabbits were randomly assigned into three groups. During surgery, group A was irrigated with gentamicin-free solution and injected with 100 μL of normal saline postoperatively, group B was irrigated with 80 μg/mL gentamicin and injected with 100 μl of MRSE suspension, group C was irrigated with gentamicin-free solution and injected with 100 μl of MRSE suspension. At different times, corneal endothelial cell count (CEC), inflammation grading，B-scan ultrasonography and histological examination were analyzed.

RESULTS

No endophthalmitis occurred in groups A and B. Group C developed severe endophthalmitis, with massive inflammatory exudation in the vitreous cavity.

CONCLUSION

Irrigating solution containing gentamicin is favorable to reduce the incidence of MRSE endophthalmitis after phacoemulsification with IOL in rabbits.

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.

ASCRS clinical advisory on intracameral moxifloxacin injection for infection prophylaxis

Moxifloxacin solution is frequently injected at the conclusion of cataract surgery for endophthalmitis prophylaxis. 2 different concentrations are most commonly available in the United States for intracameral (IC) use: 0.5% (5 mg/mL) and 0.1% (1 mg/mL). The recommended volume to be injected is different for the 2 concentrations, and incorrect dosing can increase the risk of toxic anterior segment syndrome or endophthalmitis. In addition, the U.S. Food and Drug Administration recently published an alert regarding potential adverse events associated with intraocular compounded moxifloxacin. This clinical advisory reviews the optimal dosing of IC moxifloxacin based on current evidence.

Prophylactic antibiotics for postcataract surgery endophthalmitis: a systematic review and network meta-analysis of 6.8 million eyes

To reveal optimal antibiotic prophylactic regimen for postoperative endophthalmitis (POE), we conducted systematic review and network meta-analysis. A total of 51 eligible original articles, including two randomized controlled trials, were identified. In total, 4502 POE cases occurred in 6,809,732 eyes (0.066%). Intracameral injection of vancomycin had the best preventive effect (odds ratio [OR] 0.03, 99.6% confidence interval [CI] 0.00-0.53, corrected P-value = 0.006, P-score = 0.945) followed by intracameral injection of cefazoline (OR 0.09, 99.6% CI 0.02-0.42, corrected P-value < 0.001, P-score = 0.821), cefuroxime (OR 0.18, 99.6% CI 0.09-0.35, corrected P-value < 0.001, P-score = 0.660), and moxifloxacin (OR 0.36, 99.6% CI 0.16-0.79, corrected P-value = 0.003, P-score = 0.455). While one randomized controlled trial supported each of intracameral cefuroxime and moxifloxacin, no randomized controlled trial evaluated vancomycin and cefazoline. Sensitivity analysis focusing on the administration route revealed that only intracameral injection (OR 0.19, 99.4% CI 0.12-0.30, corrected P-value < 0.001, P-score = 0.726) significantly decreased the risk of postoperative endophthalmitis. In conclusion, intracameral injection of either vancomycin, cefazoline, cefuroxime, or moxifloxacin prevented POE.

Patient Experience and Satisfaction With Immediate Sequential and Delayed Sequential Bilateral Cataract Surgery

PURPOSE

In bilaterally pseudophakic patients who received immediate or delayed sequential bilateral cataract surgery (ISBCS or DSBCS), we sought to determine patient experience, particularly related to the loss of opportunity to modify the surgical plan for the second eye.

DESIGN

Cross-sectional.

METHODS

Patients who received ISBCS (n = 1818) and DSBCS (n = 1818) in the Kaiser Permanente Northern California system between 2017 and 2019 who actively used the electronic patient portal were randomly selected and sent a survey link. The survey inquired about reasons for choosing ISBCS or DSBCS, concerns about surgery, and whether the loss of opportunity to modify the surgical plan for the second eye affected the patient's decision to undergo ISBCS.

RESULTS

Participation was 18% among patients who received ISBCS and 17% among patients who received DSBCS. Of the patients who received ISBCS, 96% would choose ISBCS again while 80% of patients who received DSBCS would choose DSBCS again (P < .0001). Convenience was the leading reason patients chose ISBCS (65%), whereas surgeon recommendation was the primary reason patients chose DSBCS (68%). Sixteen percent of patients who received ISBCS and 38% of patients who received DSCBS reported that the possibility of modifying the surgical plan to reduce the need for corrective lenses in the second eye was an important consideration (P < .0001).

CONCLUSIONS

Compared with patient who chose DSBCS, patients who chose ISBCS were more likely to choose ISBCS again and to recommend ISBCS to a family member or friend. The option to modify the surgical plan for the second eye to reduce need for glasses or contact lenses was not an important consideration for most of either group.

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

AIM

To evaluate the overall endophthalmitis incidence and the effectiveness of potential prophylaxis measures following phacoemulsification cataract surgery (PCS).

METHODS

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.

RESULTS

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).

CONCLUSION

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.

Cataract Surgery by Intraoperative Surface Irrigation with 0.25% Povidone-Iodine

Postoperative endophthalmitis after cataract surgery is typically caused by the patient's own conjunctival normal bacterial flora. A three-step approach is recommended to prevent endophthalmitis: (1) "border control" to prevent microorganisms from entering the eye by disinfecting the ocular surface is the most important measure; (2) bacteria that have gained access into the anterior chamber are reduced by irrigation; (3) bacteria remaining in the anterior chamber and vitreous at the end of surgery are controlled by antibacterial drugs. We have devised a method, "the Shimada technique", for irrigating the ocular surface with povidone-iodine, a disinfectant with potent microbicidal effect and established effective and safe concentrations for eye tissues. Povidone-iodine exhibits a bactericidal effect for a wide concentration range of 0.005-10%, but 0.1% povidone-iodine has the highest activity and requires the shortest time of only 15 s to achieve microbicidal effect. When used to irrigate the ocular surface every 20-30 s during cataract surgery, 0.25% povidone-iodine is conceivably diluted to around 0.1%. Irrigation with 0.25% povidone-iodine during cataract surgery significantly reduced bacteria contamination rate in the anterior chamber compared with saline (p = 0.0017) without causing corneal endothelial damage.