Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors

Ocular Pharmacology

Treatment of ocular diseases presents unique challenges and opportunities for the clinician and for the clinical pharmacologist. Ophthalmic pharmaceuticals, typically given as liquids, require consideration of solubility, physiological pH, and osmolarity, as well as sterility and stability, which in turn requires optimal pharmaceutics. Ocular tissue levels are challenging to obtain in humans, and the clinical pharmacokinetics is typically blood levels, which are primarily related to safety, rather than efficacy. The eye is a closed compartment with multiple physiological barriers with esterases and transporters, but relatively little cytochrome oxidases. Delivery routes include topical, intravitreal, and systemic. Patient dosing involves not only adherence issues common to all chronic diseases, but also performance requirements on eye drop instillation. Therapeutically, ocular diseases and their pharmacological treatments include both those analogous to systemic diseases (e.g., inflammation, infection, and neuronal degeneration) and those unique to the eye (e.g., cataract and myopia).

Efficacy and Safety of Preoperative Prophylaxis in Cataract Surgery with Combined Topical Antiseptics: A Microbiological Study

INTRODUCTION

To evaluate the antimicrobial efficacy of an ophthalmic formulation containing hexamidine diisethionate (HD) 0.05%, polyhexamethylene biguanide (PHMB) 0.0001%, and edetate disodium (EDTA) 0.01% (Keratosept®, Bruschettini, Genova, Italy) on the microbial flora of a healthy ocular surface.

METHODS

Patients were enrolled consecutively. Each patient applied two drops of Keratosept® in the eye scheduled for cataract surgery (study eye) three times daily in the 2 days prior to surgery and one time in the morning of surgery. The contralateral eyes were considered as control (control eye). Bilateral conjunctival swabs were collected before the first administration (T0) and the morning of surgery (T1). The swabs were processed within 3 h from sampling for the automated detection of the presence of replicating microorganisms (colony-forming units, CFU/mL) and the provision of real-time growth curves.

RESULTS

Conjunctival swabs of 32 patients (n = 128) were examined. Six patients were excluded from the efficacy analysis because of microbial load < 50 CFU/mL at T0 in the study eye. No difference between study and control eyes was observed at T0 (p = 0.40). Compared with T0, 20 (76.9%) study eyes and 10 (38.5%) control eyes showed a ≥ 1 log reduction of the microbial load at T1, with a significant difference between groups (p = 0.005). Keratosept® showed good tolerability, and no adverse events or eye discomfort were recorded.

CONCLUSIONS

This study showed that the low-dose combination of antiseptic agents in the Keratosept® ophthalmic solution effectively reduces the bacterial load of healthy flora on the ocular surface.

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.

Microbiological Profile of Post-cataract Surgery Endophthalmitis with Usage of Prophylactic Intracameral Moxifloxacin

PURPOSE

To study the effect of prophylactic intracameral moxifloxacin (ICM) on microbiological profile and antimicrobial sensitivity of culture-proven postoperative endophthalmitis (POE).

METHODS

This study evaluated culture-proven POE diagnosed within 6 weeks of cataract surgery over two periods, period-1 (January 2010-March 2015) and period-2 (April 2015-December 2019), before and after introduction of prophylactic ICM, respectively.

RESULTS

In period-1, 100 cases of culture-positive POE were reported (1 in 4879, 0.02%), while 20 cases (1 in 24635, 0.004%) were reported in period-2 (5-fold reduction, p < .001). The cumulative culture positivity rate decreased from 27.6% to 17.1% (1.6-fold) . Coagulase-negative Staphylococci (CoNS) were significantly reduced (p = .005).

CONCLUSIONS

ICM reduced the incidence of culture-proven POE, CoNS in particular. In future, POE caused by rarer pathogens may become more prevalent due to reduction in the rate of commoner and more virulent pathogens with use of intracameral antibiotics. The moxifloxacin sensitivity of CONS did not show change with the use of ICM. Studies with larger population of POE will be more helpful to understand the trend better.

Endophthalmitis: a bibliometric study and visualization analysis from 1993 to 2023

Aims

This study is designed to generalize and depict the research hotspots of endophthalmitis through bibliometric methods and software and analyze the evolutive tendency of the work on this severe disease over the past 30 years.

Methods

This study employed a rigorous bibliometric approach. We identified all endophthalmitis-related literature by conducting a comprehensive search of the Science Citation Index Expanded database under the Web of Science Core Collection. The data was then analyzed and visualized using CiteSpace and VOSviewer, two widely recognized software tools in the field of bibliometrics. CiteSpace was used to analyze the country distributions, dual map overlay of journals, keyword bursts, and co-cited references. VOSviewer was employed to describe the authors and co-cited authors, the journals, the co-cited journals, and the keywords co-occurrence network. This robust methodology ensures the reliability and validity of the study's findings.

Results

A total of 2960 publications, including 2695 articles and 265 reviews, were included in this bibliometric study. There has been no shortage of endophthalmitis-related publications since 1993, with an apparent upward trend during recent years. Possible correlations with the COVID-19 pandemic are also analyzed. These studies were finished by 11,048 authors from 75 countries worldwide, with the United States in the lead. In the keyword co-occurrence network, except for the endophthalmitis term, cataract surgery becomes the keyword with the highest frequency. Different categories of endophthalmitis, including postoperative, post-injection, post-traumatic, and endogenous endophthalmitis, and antibacterial and anti-inflammatory therapies of infectious endophthalmitis, are discussed by categories. From the perspective of the timeline, postoperative and post-injection endophthalmitis were the dominant forms before and after the year 2000, respectively. Co-citation analyses reveal that the Endophthalmitis Vitrectomy Study (EVS) conducted in 1995 provides pivotal guidance for later research. Diverse pathogenic bacteria (e.g., Coagulase-negative Staphylococci, Propionibacterium acnes, Viridians Streptococci, and Bacillus cereus) or fungi (e.g., Candida, Aspergillus, and Fusarium) contribute to varying treatment principles and clinical prognosis, which should be taken seriously. In addition, intravitreal and intracameral antibiotics are the mainstay for treating and preventing infectious endophthalmitis, respectively.

Conclusion

Our bibliometric analysis provides an overview of dynamic evolution and structural relationships in the research field of endophthalmitis. The displayed hotspots and developmental directions have reference values for future investigation.

Incidence of Postsurgical Intraocular Inflammation 6 Months After Implantation with a Multifocal Intraocular Lens

Purpose

This study assessed the incidence of postsurgical intraocular inflammation after cataract extraction by phacoemulsification and implantation with AcrySof IQ ReSTOR intraocular lenses (IOLs) produced using an updated manufacturing process. Incidence rates were compared with historical rates of postsurgical intraocular inflammation.

Methods

This was a prospective, multicenter, post-approval study at 34 sites. Patients aged ≥22 years received a study lens in at least 1 eye. Postsurgical intraocular inflammation (aqueous cell grade ≥3+ within 14 days after surgery, aqueous cell ≥2+ at 14 to ≤60 days after surgery, or aqueous cell ≥1+ at >60 days) was assessed within a 180-day period after implantation. Rates of toxic anterior segment syndrome (TASS), acute postoperative endophthalmitis, chronic postoperative endophthalmitis, and uncategorized cases of postsurgical intraocular inflammation were assessed. Ocular adverse events (AEs) and ocular adverse device effects (ADEs) were evaluated. Historical rates of postsurgical intraocular inflammation were determined from the 2011-2013 Medicare Limited Data Set files (a 5% sample of the Medicare data set representative of patients aged ≥65 years).

Results

Final safety analysis set included 3357 eyes (1792 patients; mean age, 68.6 ± 7.9 years). Postsurgical intraocular inflammation (any type) rate was 5.1 per 1000 attempted IOL implants (95% CI, 2.95, 8.10). TASS, acute postoperative endophthalmitis, and uncategorized inflammation rates were 0.6 (95% CI, 0.07, 2.15), 0.3 (95% CI, 0.01, 1.66), and 4.2 (95% CI, 2.28, 6.99) per 1000 attempted IOL implants, respectively. There were no events of chronic postoperative endophthalmitis. Ocular AEs and ADEs were reported in 17% and 1.5% of eyes, respectively. Most common ADEs were halo (0.63%) and glare (0.51%). The historical postsurgical inflammation rate from 221,519 cataract procedures was 10.3/1000 cataract surgeries, and the endophthalmitis rate was 1.2/1000 surgeries.

Conclusion

The updated IOL manufacturing process resulted in postoperative intraocular inflammation rates that were substantially lower than the historic rate.

Ocular Manifestations and Complications of Patent Foramen Ovale: A Narrative Review

Patent foramen ovale (PFO) is a prevalent congenital cardiac anomaly associated with a persistent opening between the atrial septum, allowing communication between the left and right atria. Despite often being asymptomatic, PFO can lead to various clinical presentations, including cryptogenic stroke and other embolic events. Transient visual disturbances, alterations in the visual field, migraine with aura, impaired eye movement and endogenous eye infections may prompt patients to seek ophthalmological consultation. Understanding these diverse clinical scenarios is crucial for early detection, appropriate management and mitigating the morbidity burden associated with PFO. This narrative review aims at examining the spectrum of clinical presentations of ocular pictures associated with PFO. The pathophysiology, diagnosis and treatment methods for PFO will be described, emphasizing the importance of a multidisciplinary approach involving ophthalmologists, cardiologists, neurologists and imaging specialists. In the future, prospective studies and clinical trials are warranted to provide further insights into the preventive role and optimal therapeutic strategies for managing PFO-related ocular complications, ultimately guiding clinical decision making and optimizing patient care.

A retrospective pharmacovigilance study of post-marketing safety concerns with cefuroxime

Background

Cefuroxime has played a crucial role in the prevention and treatment of bacterial infections. However, the differences in adverse events across formulations and routes remain unclear.

Objectives

This study aimed to investigate the post-marketing safety of cefuroxime, particularly concerning formulations and routes.

Design

A retrospective pharmacovigilance study of cefuroxime was conducted using the data from Food and Drug Administration Adverse Event Reporting System database.

Methods

The clinical characteristics and concomitant drugs reported with cefuroxime were investigated. Adverse event signals of cefuroxime were identified based on four disproportionality algorithms. The signal differences of cefuroxime across formulations and routes were further examined.

Results

A total of 1810 adverse event reports associated with cefuroxime were identified, and 181 cefuroxime-associated signals were detected. Compared with tablets, injections were more likely to cause preferred terms 'blood pressure decreased' and 'anaphylactic shock'. In addition, system organ class 'eye disorders' significantly increased when cefuroxime was administered intraocularly, underscoring the importance of exercising caution regarding ocular toxicity.

Conclusion

The adverse events associated with cefuroxime were significantly different across formulations and routes, which deserve special attention in clinical use.

Immediate Sequential Bilateral Cataract Surgery in Patients with Bilateral Visually Significant Cataracts

Purpose

To report our experience of performing immediate sequential bilateral cataract surgery (ISBCS) in patients with visually significant cataracts and reduced preoperative corrected distance visual acuity (CDVA).

Methods

Data of patients who underwent ISBCS for visually significant cataracts and had preoperative CDVA ≤20/32 (≤0.2 logMAR) in each eye were retrospectively reviewed. Refractive and visual outcomes were evaluated for the last available postoperative visit. Intraoperative and serious postoperative adverse events occurring within the first three months of surgery were reviewed.

Results

A total of 1335 patients (2670 eyes) were included in the analysis, with a mean age of 71.9 ± 9.5 years. On the last visit, 50.2% and 89.1% of eyes achieved uncorrected distance visual acuity (UDVA) ≥20/20 (0.0 logMAR) and ≥20/32 (0.2 logMAR), respectively. Of all eyes, 83.8% were within ±0.50D, and 96.4% were within ±1.00 D of emmetropia. Ten patients had postoperative bilateral ametropia of more than 1.00D in each eye, but eight of them still achieved binocular UDVA ≥20/40. Intraoperative events occurred in 14 eyes of 13 patients (per-eye incidence: 0.524% or 1 in 191 eyes). A total of 86 postoperative adverse events occurred in 80 eyes of 53 patients (per-eye incidence 2.996% or 1 in 33 eyes), of which cystoid macular edema was the most common. Only three eyes had CDVA reduced by more than two Snellen lines compared to preoperative CDVA, two of which were not related to cataract surgery. There was no patient with bilateral CDVA loss.

Conclusion

In our cohort of patients with visually significant cataracts, ISBCS resulted in good refractive predictability and a low incidence of serious adverse events.

Expert consensus on the management of patients undergoing cataract surgery: A Delphi study

PURPOSE

To define the management of patients undergoing cataract surgery.

SETTING

Panel of experts on cataract surgery and members of the Italian Association of Cataract and Refractive Surgery (AICCER) participated in the Delphi study.

DESIGN

A restricted panel of experts defined the statements concerning the topic and identified a larger panel of experts who voted the statements. The statements concerned a series of practical issues concerning the management of patients undergoing cataract surgery.

METHODS

An initial web round-table served to develop the statements. The larger panel was constituted by 15 experts which anonymously voted the statements, presented in a web platform, using a 5- point Likert scale. Consensus was defined as at least 80% of agreement.

RESULTS

All participants completed the questionnaire. Globally, the total percentage of agreement of all statements was 90.4%. The total mean score was 4.5. Score 4 and score 5 accounted for the 27% and the 68% of the total votes, respectively.

CONCLUSIONS

The participants felt they could largely agree with and approve the statements proposed by the board. In addition, the Delphi study identified some points that are highly shared and endorsed. In particular, a new model approach can be based on a seven-day course using a fixed high-potency corticosteroid combination with a broad-spectrum antibiotic. At the end of this cycle, the patient should be re-evaluated in some way to continue any treatment in the most appropriate and personalized way possible.

Antimicrobials and antiseptics: Lowering effect on ocular surface bacterial flora - A systematic review

Topical antimicrobials and antiseptics are used perioperatively to reduce the ocular surface bacteria flora (OSBF) that are involved in the development of post-operative infectious complications. However, their effectiveness is still a controversial topic. This systematic review, performed according to the PRISMA guidelines and registered in PROSPERO, aims to provide an overview of the efficacy of the agents currently used in peri-cataract surgery and -intravitreal injections (IVI) in lowering the OSBF. Although effective in lowering OSBF, perioperative topical antimicrobials are associated with the risk of resistance development, with no obvious additional benefit compared with topical antisepsis. Conversely, the effectiveness of topical antiseptics before cataract surgery and IVI is strongly supported. Based on the available evidence, perioperative antimicrobials are not recommended, whereas the perioperative use of antiseptics is strongly recommended as prophylactic treatment for lowering the infection due to OSBF. Post-operative antimicrobials may be considered in eyes at higher risk for infection.

Noninfectious Outcomes of Intravitreal Antibiotic Steroid Injection and Topical Nonsteroidal Antiinflammatory Drugs Versus Triple Drop Therapy After Cataract Surgery

PURPOSE

To compare noninfectious outcomes of intravitreal antibiotic steroid (IVAS) injection (moxifloxacin-triamcinolone) and postoperative topical nonsteroidal antiinflammatory drugs (NSAID) with a standard 3-drop therapy (TDT) regimen (topical antibiotic, steroid, and NSAID) in patients after cataract surgery.

DESIGN

Retrospective comparative clinical cohort study.

METHODS

In 3 study centers in the United States, a total of 2143 eyes (N = 2143 patients) underwent cataract surgery with IVAS-NSAID or TDT between 2017 and 2022. Preoperative data were included, including patients' age, iris color, medical history, and ocular history. Postoperative data, including best-corrected visual acuity, intraocular pressure (IOP), and the need for IOP-lowering medications, were recorded at 1-week, 1-month, and 6-month time points. The primary outcome measures were postoperative complications, defined as persistent anterior chamber inflammation, persistent corneal edema (PCE), rebound inflammation, and cystoid macular edema, were compared between the 2 groups.

RESULTS

There were 1079 eyes in the IVAS-NSAID group and 1064 eyes in the TDT group. Best-corrected visual acuity and IOP were similar between IVAS-NSAID and TDT eyes at all time points. A portion (11.6%) of TDT eyes experienced postoperative complications compared with 6.5% in IVAS-NSAID eyes (P < .001). Femtosecond laser-assisted cataract surgery was associated with increased rates of PCE in IVAS-NSAID eyes, and eyes with dark irides had a higher incidence of cystoid macular edema, PCE, and rebound inflammation in the IVAS-NSAID group.

CONCLUSION

The IVAS-NSAID regimen overall had similar postoperative outcomes and fewer complications compared with the TDT regimen. IVAS-NSAID may be considered a safe alternative to topical regimens in non-femtosecond laser-assisted cataract surgery and patients with light irides.

Natural Product Isolation of the Extract of Cleome rupicola Fruits Exhibiting Antioxidant Activity

Cataracts are the leading cause of blindness worldwide, however, there is currently no drug-based treatment. Plants that exhibit antioxidant properties have shown promising anticataract effects, likely because they supplement the activity of glutathione, the major antioxidant in lens cells. An extract of Cleome rupicola, a desert plant found in the United Arab Emirates, has traditionally been used to treat cataracts. Phytochemical screening of the aqueous extract established the presence of flavonoids, tannins, steroid derivatives, and reducing sugars. Fractioning of extracts from the fruits using high-performance liquid chromatography (HPLC) yielded the isolation of the anthelmintic compound cleomin, and its structure was confirmed using mass spectrometry (MS) and nuclear magnetic resonance (NMR) spectroscopy.

Topical Antibiotic Therapy in the Ocular Environment: The Benefits of Using Moxifloxacin Eyedrops

Moxifloxacin is a fourth-generation fluoroquinolone antibiotic available for ophthalmic use. It inhibits two enzymes involved in bacterial DNA synthesis, covering Gram-positive and Gram-negative pathogens. This spectrum allows for the formulation of self-preserving bottle solutions, while its interesting pharmacological profile is distinguished by efficacy at low tissue concentrations and by an infrequent dose regimen due to its long duration on ocular tissues. This enhances patient compliance, promoting its use in children. The human eye hosts several microorganisms; this collection is called the ocular microbiota, which protects the ocular surface, assuring homeostasis. When choosing an antibiotic, it is appropriate to consider its influence on microbiota. A short dose regimen is preferred to minimize the impact of the drug. Moxifloxacin eyedrops represent an effective and safe tool to manage and prevent ocular infections. As healthcare providers face the complexity of the ocular microbiota and microbial resistance daily, the informed use of moxifloxacin is necessary to preserve its efficacy in the future. In this regard, it is well known that moxifloxacin has a lower capacity to induce resistance (an optimal WPC and MPC) compared to other quinolones, but much still needs to be explored regarding the impact that fluoroquinolones could have on the ocular microbiota.

New Approaches to Overcoming Antimicrobial Resistance in Endophthalmitis

Endophthalmitis is a rare but vision-threatening infection characterized by marked inflammation of intraocular fluids and tissues, uncommonly seen following surgery and intravitreal injection. Antimicrobials are used worldwide in the prophylaxis and treatment of bacterial and fungal infections of the eye and are standard treatment in the preoperative and postoperative care of surgical patients. However, antimicrobials are reported to be overprescribed in many parts of the world, which contributes to antimicrobial resistance (AMR). AMR complicates the prophylaxis and treatment of endophthalmitis. This article examines the prevalence and mechanisms of AMR in ocular microorganisms, emphasizing the importance of understanding AMR patterns for tailored treatments. It also explores prophylaxis and management strategies for endophthalmitis, with a discussion on the use of intracameral antibiotic administration. The use of prophylactic intracameral antibiotics during cataract surgery is common in many parts of the world but is still controversial in some locations, especially in the US. Finally, it highlights the role of stewardship in ophthalmology and its benefits in the treatment of endophthalmitis.

Clinical Profile, Antibiotic Resistance and Outcomes in Bacterial Endophthalmitis: Coagulase-Negative Staphylococcus Endophthalmitis as Compared to Other Organisms

BACKGROUND

To evaluate the clinical profile, outcomes and antibiotic resistance in bacterial endophthalmitis.

METHODS

This was a post-hoc analysis of a study conducted at a tertiary centre, where 60 consecutive cases of culture-proven bacterial endophthalmitis were included prospectively. Group 1 included coagulase-negative Staphylococcus endophthalmitis (CNSE), while group 2 included the remaining cases. Clinical features, antibiotic resistance and visual outcomes were compared. Visual acuity >3/60 at six months of follow-up was defined as a good visual outcome.

RESULTS

Group 1 had 31 cases, while group 2 had 29. Group 2 included 12 gram-positive and 17 gram-negative isolates. Among the groups, group 2 had more patients with presenting visual acuity below hand motions close to the face (25 vs. 12, p<0.001), poor visual outcomes (26 vs. 3, p<0.001) and retinal detachment (RD) (10 vs. 2, p=0.007). Pseudomonas was most commonly resistant to antibiotics, and ceftazidime (p=0.005) and cefazolin (p=0.009) resistance were higher in group 2 isolates. In group 1, five isolates were resistant to any one of the antibiotics, whereas in group 2, 13 isolates were resistant to any one of the antibiotics (p=0.024).

CONCLUSIONS

In the current study, eyes in the group of endophthalmitis caused by CNSE achieved better visual acuities at the last follow-up compared to eyes with endophthalmitis caused by other bacteria. Antibiotic resistance in isolates other than CNSE is a cause of concern.

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.

Evaluating the safety and operability of asymmetric trapezoid and near-square side-port incision in cataract surgery

PURPOSE

To compare the accuracy, safety, and consistency of asymmetric trapezoid and near-square side-port incision in cataract surgery.

SETTING

Aier Eye Hospital of Wuhan University, Wuhan, Hubei Province, China.

DESIGN

Prospective pilot study.

METHODS

This study included patients who underwent phacoemulsification between January 2022 and August 2022. They were divided into Group A and Group B using the random number table method. Group A was given a near-square side-port incision and Group B was given an asymmetric trapezoid side-port incision. We contrasted the differences in incision length, width, and shape; surgical time; and postoperative intraocular pressure (IOP) between the 2 groups.

RESULTS

220 eyes of 220 patients were included. The mean external width of the incision in Group A was much smaller than that in Group B ( P < .01), and the consistency of the incision diameter in Group A was better than that in Group B. There was no statistically significant difference in incision length between the 2 groups ( P = .75). 1 day after surgery, there was no statistically significant difference in incision morphology between the 2 groups ( P = .72). The operating time for Group A was significantly shorter than that of Group B ( P < .01). There was no obvious incision leakage in both groups after surgery, and the IOP was generally elevated after surgery, but there was no significant statistical difference between the 2 groups ( P = .98).

CONCLUSIONS

The present study suggests that a near-square side-port results in better consistency of incision width and shorter surgical time.

Immediate sequential bilateral cataract surgery: a 13-year real-life report of 56 700 cataract operations

BACKGROUND/AIMS

To assess the frequency of immediate sequential bilateral cataract surgery (ISBCS) and endophthalmitis during 13-year period in Tays Eye Centre, Tampere University Hospital, Tampere, Finland.

METHODS

All cataract surgeries performed between 1 January 2008 and 31 December 2020, and all endophthalmitis cases during the same period were searched from electronic patient records. Numbers and frequencies of ISBCS, and complications, including endophthalmitis and vitreous loss, were recorded and compared with unilateral operations.

RESULTS

The study included 56 700 cataract surgeries in 34 797 patients of whom 39% (n=13 445) had ISBCS. The median age of the patients was 75 (IQR 68-80, range 0.08-99) years at the time of surgery. The proportion of ISBCS patients increased from 4.2% in 2008 to 46% in 2020. Vitreous loss occurred in 480 (0.9%) of cataract surgeries. There were no postoperative endophthalmitis after cataract surgery (n=0) during the 13-year period.

CONCLUSION

The proportion of patients undergoing ISBCS increased from 4.2% in 2008 to 46% in 2020. No endophthalmitis were found to be associated with ISBCS.

Safety of intracameral application of moxifloxacin and dexamethasone (Vigadexa®) after phacoemulsification surgery

BACKGROUND

Intracameral antibiotics, such as moxifloxacin and cefuroxime, are safe to corneal endothelial cells and effective prophylaxis of endophthalmitis after cataract surgery. Corneal endothelial cells decrease in density after cataract surgery. Any substance used in the anterior chamber may affect corneal endothelial cells and lead to a greater decrease in density. This study wants to determine the percentage of endothelial cell loss after cataract extraction by phacoemulsification with off-label intracameral injection of moxifloxacin and dexamethasone (Vigadexa®).

METHODS

An observational retrospective study was performed. The clinical records of patients undergoing cataract surgery by phacoemulsification plus intracameral injection of Vigadexa® were analyzed. Endothelial cell loss (ECL) was calculated using preoperative and postoperative endothelial cell density. The relation of endothelial cell loss with cataract grade using LOCS III classification, total surgery time, total ultrasound time, total longitudinal power time, total torsional amplitude time, total aspiration time, estimated fluid usage, and cumulative dissipated energy (CDE) was studied using univariate linear regression analysis and logistic regression analysis.

RESULTS

The median loss of corneal endothelial cells was 4.6%, interquartile range 0 to 10.4%. Nuclear color and CDE were associated with increased ECL. ECL>10% was associated with age and total ultrasound time in seconds.

CONCLUSIONS

The endothelial cell loss after the intracameral use of Vigadexa® at the end of cataract surgery was similar to the reported in other studies of cataract surgery without the use of intracameral prophylaxis for postoperative endophthalmitis (POE). This study confirmed the association of CDE and nuclear opalescence grade with postoperative corneal endothelial cell loss.

A survey of Asian Eye Institutions on perioperative antibiotic prophylaxis in cataract surgery

PURPOSE

To determine current institutional practice patterns for the use of perioperative antibiotics and other measures to prevent infection after cataract surgery in Asia.

METHODS

An online survey-based study of leading eye institutions in China, Hong Kong, India, Indonesia, Japan, Malaysia, Pakistan, Philippines, Singapore, South Korea, Taiwan, Thailand and Vietnam was conducted. The survey was administered to 26 representative key opinion leaders from prominent tertiary eye institutions that are also national academic teaching institutions in Asia. Survey responses were collated and anonymized during analysis.

RESULTS

All surveyed institutions used povidone iodine for the preoperative antiseptic preparation of the eye, with notable variations in the concentration of povidone iodine used for conjunctival sac instillation. Preoperative topical antibiotics were prescribed by 61.5% and 69.2% of institutions in low-risk and high-risk cases, respectively. Regarding the use of intra-operative antibiotics, 60.0% and 66.7% of institutions administered intracameral antibiotics in low-risk and high-risk patients, respectively. Postoperative topical antibiotics use patterns were generally very similar in low-risk and high-risk patients. Over half of the institutions (52.2% and 68.0% in low-risk and high-risk patients, respectively) also indicated prolonged postoperative use of topical antibiotics (> 2 weeks). Not all surveyed institutions had established policies/protocols for perioperative antibiotic use in cataract surgery, endophthalmitis surveillance, and/or a monitoring program for emerging antimicrobial resistance.

CONCLUSION

There are variations in antimicrobial prophylaxis approaches to preoperative, intra-operative and postoperative regimens in cataract surgery in Asia. More evidence-based research is needed to support the development of detailed guidelines for perioperative antibiotic prophylaxis to reduce postoperative infections.

Consensus and controversies in the science of endophthalmitis management: Basic research and clinical perspectives

Infectious endophthalmitis is a severe intraocular infection caused by bacteria, or less commonly by fungi. It can occur after penetrating eye procedures, trauma, or the spread of infection from contiguous structures or via emboli from distant organs. Because of the time-critical nature of the treatment, endophthalmitis is treated with the clinical diagnosis and modified by the microbiological report of the intraocular contents. The current strategy for managing endophthalmitis relies on pre-clinical literature, case series, and one large multi-center randomized clinical trial on post-cataract surgery endophthalmitis. Culture-susceptibility of the microorganisms from undiluted vitreous guides the definitive treatment in non-responsive cases. Strategies to reduce the incidence of endophthalmitis after penetrating eye procedures have been developed concurrently with refined means of treatment. Despite these advances, outcomes remain poor for many patients. Although consensus articles have been published on managing endophthalmitis, treatment patterns vary, and controversies remain. These include (1) the use of newer methods for early and precise microbiological diagnosis; (2) the choice of intravitreal antibiotics; (3) the need for systemic therapy; (4) early and complete vitrectomy. Here, we review the current consensus and address controversies in diagnosing and managing endophthalmitis. This review is intended to familiarize physicians and ophthalmologists with different aspects of endophthalmitis management to make informed decisions.

The impact of antibiotic prophylaxis with intracameral cefuroxime on postoperative infectious endophthalmitis rates in a high-volume cataract surgery center

Our purpose was to compare postoperative infectious endophthalmitis rates before and after the introduction of antibiotic prophylaxis via intracameral with cefuroxime (ATB-P IC) in a high-volume cataract surgery service. Retrospective cohort study considering patients who underwent cataract surgery at Ophthal Hospital Especializado, São Paulo, Brazil, from January/2011 to December/2019. Patients operated from 2013 to 2019 comprised the ATB-P IC group while those operated from 2011 to 2013 formed the control group without the ATB-P IC protocol. A total of 23,184 cataract surgeries were included, with 6,207 in the Control Group and 16,977 in the ATB-P Group. A significantly higher rate of endophthalmitis was observed in the control group (0.0967%) when compared to the ATB-P group (0.0177%) (p = 0.014). Surgeries performed with ATB-P showed 80% less chance of reported endophthalmitis (OR = 0.20; 95% CI 0.05-0.72; p = 0.014) than those without ATB-P. Of the six cases confirmed by culture in the control group, all tested positive for Pseudomonas aeroginosa and the only case confirmed by culture in the ATB-P group was positive for Staphylococcus epidermidis. Our findings strongly support the use of intracameral antibiotic prophylaxis with cefuroxime to reduce postoperative infectious endophthalmitis rates, and we recommend its incorporation into cataract surgery protocols.

Safety of office-based lens surgery: U.S. multicenter study

PURPOSE

To evaluate the rate of adverse events after office-based lens surgery performed across multiple private practices in the United States.

SETTING

36 private practices across the U.S.

DESIGN

Retrospective multicenter study.

METHODS

This analysis included case records of all consecutive patients who underwent office-based lens surgery for visually significant cataract, refractive lens exchange, or phakic intraocular lens implantation between August 2020 and May 2022 at 36 participating sites across the U.S. The study outcome measures included the assessment of intraoperative and postoperative complications such as the incidence of unplanned vitrectomy, iritis, corneal edema, and endophthalmitis after lens surgery. The frequency of patients requiring a return to the operating room (OR) or referral to a retina surgeon and the frequency of patients requiring hospitalization or calling emergency services (911) for any reason were also evaluated.

RESULTS

The study reviewed 18 005 cases of office-based cataract or refractive lens surgery performed at 36 clinical sites. The rates of postoperative endophthalmitis, toxic anterior segment syndrome, and corneal edema were 0.028%, 0.022%, and 0.027%, respectively. Unplanned anterior vitrectomy was performed in 0.177% of patients. Although 0.067% of patients needed to return to the OR, 0.011% of patients were referred to the hospital.

CONCLUSIONS

The rate of adverse events for office-based cataract or refractive lens surgery is similar to or less than the reported adverse event rate for modern cataract surgery in the ambulatory surgery center setting.

Antibiotic prophylaxis for cataract surgery - Practice patterns amongst Indian Ophthalmologists

Purpose

To assess the current trends in use of perioperative antibiotic prophylaxis, especially intracameral antibiotics (ICAB), for cataract surgery in India.

Methods

This was an E-survey using a previously validated questionnaire carried out by the All India Ophthalmological Society (AIOS) in August 2022. An E-mail invitation to complete an online 40-point survey was sent to all members of the AIOS using a digital E-mail service (Survey Monkey) and social media platforms.

Results

Out of 1804 total respondents, 58% (n = 1022) reported using routine ICAB prophylaxis. Of those using ICAB, 89% (n = 909) reported using it for all cases, whereas the rest used it for specific indications such as post-PC rent (n = 43), one eyed patient (n = 19), and high-risk cases (n = 50). Commercially available moxifloxacin was by far the commonest agent used for ICAB (n = 686, 67%). Eighty respondents (8%) reported noticing occasional toxic reactions and nontoxic corneal edema (n = 64, 6%) with ICAB. Surgeons with >10 years' experience especially practicing in medical colleges used fewer ICAB (OR = 0.52, 95%CI = 0.38 - 0.72, P < 0,001) compared to younger surgeons (<5-year experience) in solo clinics. The commonest reason for nonadoption of IC antibiotics was "unconvinced of the need to use it in my setting" (n = 296, 52% of those who answered this question).

Conclusion

IC antibiotic prophylaxis for cataract surgery has significantly increased in India from 40% in 2017 to 58% in 2022. Commercially available moxifloxacin was preferred by the majority users. Intraocular inflammation may occur occasionally and needs safer formulations to avoid this.

Immediate sequential bilateral cataract surgery is a reasonable and safe option during a pandemic

PURPOSE

To evaluate the preoperative and intraoperative features, intraoperative and postoperative complications and postoperative satisfaction of patients who underwent immediate sequential bilateral cataract surgery (ISBCS) during the COVID-19 pandemic.

METHODS

The study included ISBCS patients from September 2021 through January 2022. Demographics, comorbidities, type of anesthesia (topical/general), intraoperative complications, postoperative refractive errors, and complications were examined. The one-month postoperative appointment included a patient satisfaction questionnaire.

RESULTS

ISBCS was performed in 206 eyes of 103 patients. Intraoperative complications did not occur in 99 (96.1%) of ISBCS patients. No patients had visually significant corneal edema, wound leakage, endophthalmitis, or toxic anterior segment syndrome during postoperative follow-up. Final manifest spherical equivalent refraction was less than 1.00 D in all patients and less than 0.50 D in 70.7% of patients. In the questionnaire given to the patients at the one-month follow-up, 96.1% of patients did not change their preference for surgery on the same day.

CONCLUSION

ISBCS provides an advantage during the pandemic period by reducing hospital visits, especially for the elderly population and patients with comorbidities. ISBCS is a safe and reasonable method that can be used during a pandemic due to the low rates of complications, the success of the refractive results, and the high patient satisfaction rates.

Exogenous Endophthalmitis

PURPOSE

Exogenous endophthalmitis (ExE) results from microbial infection as a complication of ocular surgery, penetrating ocular trauma, and intraocular foreign bodies. We herein review the classification of ExE, etiological agents, differential diagnosis and therapeutic challenges.

METHODS

Narrative Literature Review.

RESULTS

Identification of the causative agent through ocular fluid analysis is central in the diagnostic work-up of ExE. Prompt intravitreal antimicrobial therapy is key to successful management of ExE and vitrectomy is essential in severe cases. In culture-negative cases, and in the presence of specific features, a diagnosis of sterile intraocular inflammation or toxic syndrome should be suspected.

CONCLUSION

Strict adherence to treatment guidelines may improve outcomes of ExE, however the ultimate prognosis, especially in severe cases, may depend more on the virulence of the causative organism and associated ocular complications. Accurate differential diagnosis and effective treatment are crucial elements in the management and prognosis of non-infectious masquerades of ExE.

A Randomized, Prospective, Observer-Masked Study Comparing Dropless Treatment Regimen Using Intracanalicular Dexamethasone Insert, Intracameral Ketorolac, and Intracameral Moxifloxacin versus Conventional Topical Therapy to Control Postoperative Pain and Inflammation in Cataract Surgery

Purpose

To evaluate clinical efficacy and patient preference for a dropless treatment regimen compared to conventional topical therapy in patients undergoing cataract surgery.

Patients and Methods

In this prospective, contralateral eye study, patients with bilateral cataract were randomized to receive either intracanalicular dexamethasone insert, intracameral phenylephrine 1%/ketorolac 0.3%, and intracameral moxifloxacin (50 µg) (study group) or topical moxifloxacin 0.5%, ketorolac 0.5%, and prednisolone acetate 1.0% QID (control group). The second eye underwent cataract surgery 2 weeks later and was treated with the opposite treatment. All patients were evaluated at Days 1, 7, 14, 28, and 3 months. The primary outcome measure was postoperative ocular pain. Secondary outcomes included summed ocular inflammation score (SOIS; the sum of the mean anterior chamber cells and anterior flare score), the patient preference for medication protocol between the two eyes, and patient out-of-pocket cost of medications. Safety outcome measures included CDVA, intraocular pressure, central retinal thickness (CRT), and the incidence of reported AEs.

Results

The proportion of patients with no pain was similar in both groups at all postoperative visits (p>0.05). No statistically significant difference in SOIS score was observed between the two groups at any visit. A strong majority of the patients (94.7%) preferred the study eye's dropless regimen over the control eye's conventional topical therapy regimen. No statistically significant difference in mean intraocular pressure (IOP) was observed at any postoperative visit, except at Week 1. The mean CDVA was also similar in both groups at all postoperative visits (p>0.05). The postoperative mean CRT was comparable between the two groups.

Conclusion

A dropless treatment regimen is as effective as topical eyedrop administration. A higher proportion of patients who underwent bilateral cataract surgery preferred the dropless treatment regimen over the patient-administered eye drop regimen.

Role of Antimicrobial Resistance in Outcomes of Acute Endophthalmitis

BACKGROUND

This study explores local trends in antimicrobial resistance and its influence on long-term visual outcomes following treatment with broad-spectrum empiric intravitreal antibiotics.

METHODS

All patients undergoing intraocular sampling for endophthalmitis from Auckland between January 2006-May 2023 were included. The impact of antimicrobial resistance on the final visual outcome was analysed using logistic regression models.

RESULTS

389 cases of endophthalmitis were included, and 207 eyes (53.2%) were culture positive. When tested, all Gram-positive microorganisms were fully susceptible to Vancomycin, and all Gram-negative microorganisms demonstrated full or intermediate susceptibility to Ceftazidime. Resistance to at least one antimicrobial agent was present in 89 culture results (43.0%), and multidrug resistance (resistant to ≥3 antimicrobials) in 23 results (11.1%). No increase in resistance was observed over time. The primary procedure was a tap and inject in 251 eyes (64.5%), and early vitrectomy was performed in 196 eyes (50.3%). Severe vision loss (≤20/200) occurred in 167 eyes (42.9%). Antimicrobial resistance was associated with an increased risk of retinal detachment (OR 2.455 p = 0.048) but not vision loss (p = 0.288).

CONCLUSION

High sensitivity to Vancomycin and Ceftazidime was present in our population, reinforcing their role as first-line empiric treatments. Resistant microorganisms were associated with an increased risk of retinal detachment but no alteration in final visual outcome.

An intelligent decision support system for acute postoperative endophthalmitis: design, development and evaluation of a smartphone application

BACKGROUND

Today, clinical decision support systems based on artificial intelligence can significantly help physicians in the correct diagnosis and quick rapid treatment of endophthalmitis as the most important cause of blindness in emergency diseases. This study aimed to design, develop, and evaluate an intelligent decision support system for acute postoperative endophthalmitis.

METHODS

This study was conducted in 2020-2021 in three phases: analysis, design and development, and evaluation. The user needs and the features of the system were identified through interviews with end users. Data were analyzed using thematic analysis. The list of clinical signs of acute postoperative endophthalmitis was provided to ophthalmologists for prioritization. 4 algorithms support vector machine, decision tree classifier, k-nearest neighbors, and random forest were used in the design of the computing core of the system for disease diagnosis. The acute postoperative endophthalmitis diagnosis application was developed for using by physicians and patients. Based on the data of 60 acute postoperative endophthalmitis patients, 143 acute postoperative endophthalmitis records and 12 non-acute postoperative endophthalmitis records were identified. The learning process of the algorithm was performed on 70% of the data and 30% of the data was used for evaluation.

RESULTS

The most important features of the application for physicians were selecting clinical signs and symptoms, predicting diagnosis based on artificial intelligence, physician-patient communication, selecting the appropriate treatment, and easy access to scientific resources. The results of the usability evaluation showed that the application was good with a mean (± SD) score of 7.73 ± 0.53 out of 10.

CONCLUSION

A decision support system with accuracy, precision, sensitivity and specificity, negative predictive values, F-measure and area under precision-recall curve 100% was created thanks to widespread participation, the use of clinical specialists' experiences and their awareness of patients' needs, as well as the availability of a comprehensive acute postoperative endophthalmitis clinical dataset.

Postoperative Complications of True Dropless Cataract Surgery versus Standard Topical Drops

Purpose  Compare postoperative outcomes in cataract surgery between eyes with standard drop regimen versus dropless protocol by residents. Design  Retrospective cohort study between April 1, 2018 and March 31, 2020. Methods  The study was performed at Lyndon B. Johnson General Hospital in Houston, Harris County, Texas. A total of 547 eyes (234 dropless vs. 313 standard) with phacoemulsification cataract surgery and minimum of 1-month follow-up with best-corrected visual acuity (BCVA) were included. Dropless received 40 mg sub-Tenon's triamcinolone and intracameral moxifloxacin. Patients were followed at postoperative day 1 (POD1), week 1 (POW1), and month 1 (POM1). Postoperative rate of BCVA better than 20/40 (Good vision) and rate of complications were compared between groups. Results  Good vision on POM1 in dropless (77.8%) was noninferior to standard (75.1%, p  = 0.80). Complication rate in dropless (28.6%) was noninferior to standard (24.0%, p  = 0.13). Intraocular pressure (IOP) elevation on POD1 ( p  = 0.041) and anterior chamber (AC) cells on POW1 and POM1 ( p  < 0.001) were more frequent in dropless. Mean spherical equivalent at POM1 was better in dropless (-0.37 D [±0.81 D]) compared with standard (-0.61D [±0.77 D], p  = 0.001). Early posterior capsular opacification (early PCO) was more frequent in dropless ( p  = 0.042). Conclusions  Postoperative rate of BCVA better than 20/40 and rate of postoperative complications were noninferior, although dropless had higher rates of AC inflammation, IOP elevation, and early PCO.

Role of Prophylactic Oral Antibiotics in the Prevention of Post-cataract Surgery Acute Infective Endophthalmitis

Purpose To evaluate the role of perioperative oral antibiotics in the prevention of acute infective endophthalmitis (IE) after cataract surgery. Methods A prospective cohort study of patients older than 18 years of age undergoing uncomplicated phacoemulsification was conducted. Group A was given post-op oral ciprofloxacin for three days, whereas Group B was not. Both groups received 5% povidone-iodine (PVI) preparation for five minutes in the conjunctival cul-de-sac, and intracameral (IC) 0.5% moxifloxacin was administered at the end of the procedure as prophylaxis. The minimum post-op follow-up period was six weeks. Results Out of 2161 patients, 859 (39.8%) were included in Group A, and 1302 (60.2%) were included in Group B. No significant difference in anterior chamber (AC) reaction was found on day 1 (p = 0.67), day 14 (p = 0.03), or day 45 (p = 0.1). One patient developed acute post-op IE (0.04%) and two patients developed toxic anterior segment syndrome (TASS) from Group A. The non-oral antibiotic group had no serious complications. Conclusion Perioperative oral antibiotic use in routine clinical practice is not recommended for the prevention of acute post-op IE. Pre-op conjunctival PVI 5% for five minutes and IC moxifloxacin at the end of surgery were proven to be effective prophylactic measures in our study.

Managing low corneal astigmatism in patients with presbyopia correcting intraocular lenses: a narrative review

Cataract surgery has become a refractive procedure in which emmetropia is the goal, with the implantation of extended depth-of-focus or multifocal intraocular lenses (IOLs) being the commonly selected option to restore vision beyond the far distance. The selection criteria for implanting these lenses can differ from those for monofocal IOLs and even between technologies, as eye characteristics can affect postoperative visual performance. Corneal astigmatism is an eye characteristic that can affect visual performance differently, depending on the implanted IOL. The magnitude of corneal astigmatism, the tolerance of the IOL to this astigmatism, economic aspects, comorbidities, and the efficacy of astigmatism treatment are factors that can make surgeons' doubt as to what astigmatism treatment should be applied to each patient. This review aims to summarize the current evidence related to low astigmatism tolerance in presbyopia-correcting lenses, the efficacy achieved through corneal incisions, and their comparison with the implantation of toric IOLs.

Relative efficacy of intracameral moxifloxacin injection methods

PURPOSE

To determine the amount of moxifloxacin remaining in the anterior chamber (AC), immediately after its injection using 3 current injection methods, assuming mixing and fluid exchange with the AC contents during injection of the drug, and to determine the most desirable injection method.

SETTING

Department of Ophthalmology and Vision Sciences and Institute of Biomedical Engineering, University of Toronto, Toronto, Canada.

DESIGN

Mathematical modeling.

METHODS

Mathematical modeling using first-order mixing methods were used to assess mixing.

RESULTS

The Kaiser method of injecting 0.5 mL × 100 μg/0.1 mL does not achieve the desired 500 μg level of moxifloxacin in the AC. The "straight from the bottle" method of injecting 0.1 mL × 500 μg/0.1 mL is fraught with potential error, yielding a relatively unreliable final amount in the AC. Injecting 0.5 to 0.6 mL × 150 μg/0.1 mL yields a result closest to the desired goal.

CONCLUSIONS

Based on the calculation, the most accurate of current methods to deliver 500 μg moxifloxacin intracamerally is the method of 150 μg/0.1 mL × 0.5 to 0.6 mL.

Postoperative exogenous endophthalmitis caused by Escherichia coli: a rare case report and literature review

Aim: We report a rare case of postoperative endophthalmitis caused by Escherichia coli. Case description: The diagnosis of postoperative endophthalmitis in our patient was established based on the clinical signs of hypopyon along with vitritis. The patient underwent pars plana vitrectomy, anterior chamber washout, intraocular lens removal, and intravitreal antibiotics (amikacin and vancomycin) injection. The culture of both the vitreous sample and the intraocular lens, revealed a heavy growth of Escherichia coli. Conclusion: Escherichia coli is an unusual microorganism to cause postoperative endophthalmitis. A major breach in the sterilization may explain this infection. Proper sterilization and prophylactic measures are crucial to avoid this disastrous complication.

Intracameral Drug Delivery: A Review of Agents, Indications, and Outcomes

An intracameral (IC) injection directly delivers the drug into the anterior chamber of the eye. This targeted drug delivery technique overcomes the ocular barriers and offers a high therapeutic concentration of medication at the desired site and consequently better clinical outcomes. IC drug delivery is a safe and effective modality with many advantages over topical delivery. These include excellent bioavailability, reduced systemic risk, and minimal ocular toxicity. Agents delivered via IC injection have shown promising results against infection, inflammation, ocular hypertension, and neovascularization. Current literature shows that IC antibiotics, including cefuroxime, vancomycin, and moxifloxacin, are routinely used for prophylaxis of endophthalmitis. Other drugs available for IC use are steroids, anesthetics, mydriatics, miotics, antivascular endothelial growth factor, antiglaucoma, and alkylating agents. Introduction of sustained-release devices containing dexamethasone or Bimatoprost in anterior chamber via IC route has the potential in treating ocular inflammation and raised intraocular pressure. The complications such as hemorrhagic occlusive retinal vasculitis and toxic anterior segment syndrome have been documented with IC prophylaxis but are rare. In this review, we provide an overview of available IC drugs, their pharmacokinetics, the spectrum of activity, dosage and preparation, prophylactic and therapeutic usage, clinical efficacy, and safety profiles.

An update on immediate sequential bilateral cataract surgery

PURPOSE OF REVIEW

The aim of this study was to present an overview of recent publications and opinions in the field of same-day bilateral cataract surgery.

RECENT FINDINGS

A Cochrane review was published comparing immediate sequential bilateral cataract surgery (ISBCS) and delayed sequential bilateral cataract surgery (DSBCS) with regard to safety outcomes, costs and cost-effectiveness. In addition, several large database studies provided more information on incidences of rare complications such as unilateral and bilateral endophthalmitis rates.

SUMMARY

Recently available evidence showed that ISBCS is an effective and cost-effective alternative to DSBCS. Nonetheless, additional (randomized) registry studies, randomized controlled trials and cost-effectiveness studies are needed to evaluate bilateral endophthalmitis rates, refractive outcomes and cost-effectiveness of ISBCS compared with DSBCS.

Intravitreal injections as a leading cause of acute postoperative endophthalmitis-a regional survey in England

BACKGROUND

To evaluate the characteristics, treatment patterns and outcomes of acute postoperative endophthalmitis.

METHODS

Patients presenting with acute postoperative endophthalmitis between January 2017 to December 2019 were identified from hospital records in this multicentre retrospective cohort study. Clinical records were reviewed for visual acuity (VA) at various timepoints, cause of endophthalmitis, microbiological results, treatments and complications.

RESULTS

Forty-six eyes of 46 patients were included. Intravitreal injections were the leading cause of acute postoperative endophthalmitis (n = 29; 63%), followed by cataract surgery (n = 8; 17%), vitreoretinal surgery (n = 7; 15%), and secondary intraocular lens insertion (n = 2, 4%). The absolute risk of endophthalmitis was 0.024% (1:4132) for intravitreal injections, 0.016% (1:6096) for cataract surgery, and 0.072% (1:1385) for vitreoretinal surgery. The majority of patients (n = 38; 83%) had better VA at 6 months compared to presentation, although fewer (n = 13; 28%) maintained similar or better VA compared to before the precipitating surgery. Twenty-four cases yielded positive culture results, of which staphylococcus epidermidis was the most commonly isolated organism. Microbiological yield was not associated with better final visual outcomes. Patients who underwent therapeutic vitrectomy (n = 15; 33%) had poorer VA at presentation, but subsequently achieved visual outcomes comparable to those who received medical treatment alone. There was no difference in time to presentation, visual outcome and retinal detachment rates among the different causative procedures.

CONCLUSION

Intravitreal injections were the most common cause of endophthalmitis in our region, primarily because of their higher frequency compared to other intraocular procedures. In this cohort, the primary procedure had no effect on presentation, management or visual outcomes.

Postoperative Endophthalmitis after Combined Cataract Extraction and iStent Inject Implantation

Purpose. To report a case of postoperative endophthalmitis after combined cataract extraction and iStent inject implantation. Observation. A 70-year-old male with a nuclear sclerotic cataract and primary open-angle glaucoma underwent an uneventful phacoemulsification cataract extraction with implantation of an intraocular lens and an iStent inject trabecular bypass stent. The patient was prescribed a postoperative regimen of ofloxacin 0.3% and prednisolone acetate 1%, 1 drop four times a day each. On postoperative day five, he presented to the emergency room for eye pain and had 4+ mixed cells in the anterior chamber (AC) without hypopyon or vitritis on exam. Prednisolone 1% eye drops were increased from four times a day to every two hours while awake. Overnight, he developed worsening vision and severe eye pain. The next morning, he was found to have increased AC cells, vitritis, and intraretinal hemorrhages and was diagnosed with endophthalmitis. The patient underwent a vitreous tap and intravitreal injections of vancomycin (1 mg/0.1 mL) and amikacin (0.4 mg/0.1 mL). Cultures grew Staphylococcus epidermidis. Lab work-up revealed underlying neutropenia. Visual acuity eventually recovered to 20/20. Conclusion and Importance. This report highlights a case of endophthalmitis associated with placement of the iStent inject. The infection was well-controlled after administration of intravitreal antibiotics without removal of the iStent inject, and visual acuity eventually recovered to 20/20. Surgeons should be aware of endophthalmitis risk following combined iStent inject placement, and good recovery is possible without removal of the implant.

Disturbances in the ocular surface microbiome by perioperative antimicrobial eye drops

We aimed to elucidate the effects of antimicrobial eye drops used in the perioperative period of ophthalmic surgery on the ocular surface microbiome by metagenomic analysis. Twenty-eight eyes from 15 patients (mean age 74.1 years) with no history of eye drop use within 3 months before cataract surgery were included in this study. Gatifloxacin eye drops were used in all patients in the perioperative period. The antimicrobial eye drops were started 3 days before surgery. They were discontinued after conjunctival sac specimen collection for 2 weeks after the surgery. Conjunctival sac specimens were collected to investigate the alterations in the ocular surface microbiome by meta-16S analysis targeting the V3-V4 region of the bacterial 16S rRNA gene. Principal coordinate analysis showed that the bacterial composition tended to be different before and 2 and 4 weeks after surgery. Individual observations on six eyes showed that the bacterial composition at 12 weeks after surgery was closer to that before surgery than to that at 4 weeks after surgery in two eyes, while the bacterial composition in the remaining four eyes was different at various time points. Before surgery, Firmicutes, Proteobacteria, and Bacteroidetes were predominant; however, 2 weeks after surgery, the proportion of Proteobacteria increased and that of Firmicutes decreased. A similar trend was noticed 4 weeks after surgery, although antibacterial eye drops had been discontinued 2 weeks after surgery. The Shannon-Weaver coefficient showed a decreasing trend at 2-, 4-, and 12-weeks post operation compared to that before operation. The diversity of the microbiome decreased significantly at 2- and 4-weeks after surgery when compared to that before surgery (p < 0.05). The ocular surface microbiome is easily disrupted by antimicrobial eye drops, and it needs recovery time. In such cases, the ocular surface microbiome is presumed to contain many antimicrobial-resistant bacteria. In some cases, it may not recover, and a new microbiome is formed.

Management of patients undergoing cataract surgery: An Italian survey

PURPOSE

To investigate the management of patients undergoing cataract surgery in Italy.

SETTING

Italian ocular surgeons, members of the Italian Association of Cataract and Refractive Surgery (AICCER), were invited to participate to this survey.

DESIGN

Participants had to respond to a questionary including a series of practical questions concerning the management of patients undergoing cataract surgery.

METHODS

A designed questionnaire explored the main issues concerning the practical problems involved in managing patients undergoing cataract surgery. The questionnaire was sent by e-mail and analyzed by descriptive statistics.

RESULTS

Preoperative prophylaxis was performed by most surgeons. After surgery, several products were used, even simultaneously. Fixed antibiotic-corticosteroid combination (87.2%; 89) and NSAIDs (88.2; 90) were chosen as the most commonly used drug classes. The average duration of prescribed post-surgical therapies was more than two weeks for 52.9% (54) of participants, two weeks for 29.4% (30), and only one week for 5.9% (6).

CONCLUSION

This survey confirmed a discrete adherence to the main guidelines but at the same time highlights a discrete inhomogeneity in the use of medications, duration of treatments, and follow-up visits. For this reason, it is appropriate to continue updating and implementing the guidelines and educational pathways. This thought is consistent with the Precision Medicine approach. Every patient should be carefully evaluated to determine the best medication, dosage, and duration. A Personalized Medicine strategy is used on a single patient to optimize treatment clinical efficacy while minimizing side effects.

Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: A Case Series and Systematic Review

This study describes three unilateral cases of hemorrhagic occlusive retinal vasculitis (HORV) after cataract surgery and a review of the literature until February 2022, including 21 articles reporting HORV cases. Altogether, 61 eyes (41 patients) were included. Twenty patients had bilateral and 21 patients had unilateral HORV. Prophylactic vancomycin was given to all patients. Additional vancomycin use was associated with the worst outcome. The mean time to HORV was 9 days post-cataract surgery. In bilateral cases, the median time between surgeries was 7 days. Visual acuity was < 20/400 in 48%, with no light perception in 20%. Neovascular glaucoma developed in 43%. Central macular thickening or hyperreflectivity of the inner retinal layers on optical coherence tomography was associated with worse outcomes. Corticosteroid treatment, early panretinal laser photocoagulation, or anti-vascular endothelial growth factor therapy, and prophylaxis alternative to vancomycin is recommended. [Ophthalmic Surg Lasers Imaging Retina 2022;53:702-712.].

Effect of cefuroxime intracameral injection antibiotic prophylactic on postoperative endophthalmitis wound post‐cataract: A meta‐analysis

To assess the impact of cefuroxime injection of intracameral prophylaxis antibiotic on after endophthalmitis operative wound following surgery of cataract, we conducted a meta-analysis. A thorough review of the literature up to July 2022 revealed that there were 1 167 197 participants with surgery of cataract at the start of the research; 1 004 425 of these subjects received an injection of intracameral of cefuroxime, while 162 772 did not get an antibiotic as a control. Using dichotomous approaches and a random or fixed-effect model, odds ratios (OR) with 95% confidence intervals (CIs) were estimated to evaluate the impact of cefuroxime injection of intracameral prophylaxis antibiotic on after endophthalmitis operative wound following surgery of cataract. When comparing no antibiotic in participants who had surgery of cataract, the cefuroxime injection of intracameral significantly reduced the after endophthalmitis operative wound (OR, 0.14; 95% CI, 0.07-0.29, P = 0.001) with high heterogeneity (I2 = 95%). When comparing participants who received no antibiotic after surgery of cataract, the after endophthalmitis operative wound from the cefuroxime injection of intracameral was considerably lower. Although none of the 22 studies encompassed in the meta-analysis had a study with a small sample size, it is nevertheless advisable to proceed with caution when analysing the results.

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.

Prospective evaluation of the prevalence of conjunctival and intraocular bacteria in dogs undergoing phacoemulsification following a standardized aseptic preparation with 0.5% povidone iodine

PURPOSE

To evaluate bacterial contamination of conjunctiva and aqueous humor in dogs undergoing phacoemulsification following asepsis with 0.5% povidone iodine and determine the influence of intravenous antibiotics on outcome of contamination.

METHODS

Client-owned dogs were prospectively enrolled and randomly assigned to a control group, receiving 22 mg/kg intravenous cefazolin at induction prior to sampling, or experimental group receiving no antibiotic prior to sampling, masked to the surgeon. Dogs receiving antimicrobials in the pre-operative period were excluded. Asepsis was performed on all operated eyes using 0.5% iodine with minimum 3 min contact time at induction of anesthesia and repeated before surgery. A conjunctival swab and aqueous humor sample were collected prior to incision and following incision closure, respectively. Samples were submitted for aerobic and anaerobic bacterial culture and susceptibility.

RESULTS

Seventy-one eyes of 42 dogs were included. Median age was 9 years. Thirty-nine and 32/71 eyes received intravenous cefazolin and no antibiotic, respectively. Median procedure time was 40 min per eye. Conjunctival cultures were positive in 6 eyes (8.5%): Serratia marcescens (5 eyes) and Cutibacterium acnes (1 eye). Aqueous humor cultures were positive in 5 eyes (7.0%): S. marcescens (2 eyes), Pseudomonas aeruginosa (2 eyes), Staphylococcus pseudointermedius (1 eye). Prevalence of positive culture did not differ between groups (p = .74), order of eyes for bilateral procedures (p = .74) and diabetic status (p = 1).

CONCLUSIONS

Bacterial contamination of the conjunctiva and aqueous humor was present in 8.5% and 7.0% of dogs undergoing phacoemulsification after asepsis. Lack of IV cefazolin was not significantly associated with positive culture.

Pars-plana-vitrectomy for endophthalmitis treatment and the role of standardized ultrasound

PURPOSE

Endophthalmitis is a severe inflammation following surgery or endogenous spread of pathogens. Besides clinical signs and symptoms, standardized ultrasound might help to confirm the diagnosis. Thus, we analyzed 172 cases of endophthalmitis for pathogens, visual acuity (VA) and the predictive value of standardized ultrasound.

METHODS

Retrospective analysis of patients treated with pars-plana-vitrectomy for endophthalmitis at the University Eye Hospital was performed. Sex, age, VA at presentation, first day after surgery, four weeks postoperatively, and at last follow-up, as well as pathogen culture, and presence of standardized ultrasound before vitrectomy were recorded. Mann-Whitney U and Chi-square tests were used for groupwise comparisons.

RESULTS

A total of 172 patients (male = 47.7%) with a median age of 76 years (IQR 65-82 years) treated for endophthalmitis (exogenous = 85.5%) were included. Median follow-up time was 65 days (IQR 12-274 days). Visual acuity at presentation was 2.30 logMAR (IQR 2.70-2.30 logMAR); it increased to 1.00 logMAR (1.4-0.40 logMAR) at last follow-up. A total of 79 patients (45.9%) underwent standardized ultrasound before vitrectomy. Patients with positive ultrasound criteria had a significantly decreased VA at presentation (p = 0.034). Positive microbiological cultures for Streptococcus spp. and Enterococcus faecalis were associated with decreased VA (p = 0.028) at last follow-up.

CONCLUSION

Standardized ultrasound is an easy and robust tool in the diagnosis of endophthalmitis. Positive criteria are significantly associated with decreased VA at presentation. The recovery of VA depends on pathogens and is significantly worse for certain species (Streptococcus spp., Enterococcus faecalis).

[Ophthalmologic Emergencies in the General Practice]

Ophthalmologic Emergencies in the General Practice Abstract. Even though ophthalmological care is now very well developed even in rural areas, many patients with an eye problem still consult their family doctor or general internist as a first step. The general internist must then decide on an ad-hoc basis if that he or she can manage the problem with a simple treatment available to him or her (tear substitutes, topical antibiotics or a combination of steroids and antibiotics) or if a referral to the nearest ophthalmologist is necessary.

Impact on corneal morphology after cataract surgery with intracameral moxifloxacin in neglected hard cataracts

AIM

To evaluate corneal morphology after use of 0.5% intracameral moxifloxacin (ICM) in cataract surgery in patients who presented late with hard cataracts.

METHODS

Cross-sectional study conducted from June-2021 to December-2021 at a tertiary eye-care center. 90 patients over 60 years with high-risk characteristics for Covid-19, who presented late with higher grades of nuclear-sclerosis (NS), were included. They underwent phacoemulsification and 0.5%moxifloxacin (0.1 ml) was injected intracamerally at the end of surgery. Best-corrected visual acuity (BCVA), intraocular pressures (IOP), endothelial cell density (ECD), coefficient of variation in cell-area (CoV), hexagonality (Hex) and central corneal thickness (CCT) were measured preoperatively and postoperatively on day1, day7 and day30. Statistical analysis was done by Anova test. p-value<0.05 was considered significant.

RESULTS

Mean age of presentation was 65.26±8.3 years. Mean preoperative BCVA (1/60-to-6/60), IOP (16.7±2.3 mm of Hg), CCT (523.93±39.6µ), ECD (2547±302.08cells/mm2), Hex (47.04±5.7%) and CoV (37.57±3.9) changed to BCVA (6/9-to-6/6), IOP (17.5±2.1 mm of Hg), CCT (538.42±36.9µ), ECD (2388.40±339.25cells/mm2), Hex (44.44±5.6%) and CoV (39.09±4.5) at day30 postoperative. Average rate of change at day30 was increase in CCT (2.89%), ECD loss (6.4%), decrease in Hex (4.9%) and increase in CoV (4.6%), though clinically insignificant. No case of endophthalmitis or toxic-anterior segment syndrome seen.

CONCLUSION

0.5% moxifloxacin (0.1 ml) is safe as intracameral antibiotic to prevent postoperative infection in high-risk patients. The reported changes in the corneal parameters were within the range of any routine surgeries of hard senile cataracts. No specific effect could be attributed to ICM.

Polygenic Risk Score Improves Cataract Prediction in East Asian Population

Cataracts, characterized by crystalline lens opacities in human eyes, is the leading cause of blindness globally. Due to its multifactorial complexity, the molecular mechanisms remain poorly understood. Larger cohorts of genome-wide association studies (GWAS) are needed to investigate cataracts’ genetic basis. In this study, a GWAS was performed on the largest Han population to date, analyzing a total of 7079 patients and 13,256 controls from the Taiwan Biobank (TWB) 2.0 cohort. Two cataract-associated SNPs with an adjustment of p < 1 × 10−7 in the older groups and nine SNPs with an adjustment of p < 1 × 10−6 in the younger group were identified. Except for the reported AGMO in animal models, most variations, including rs74774546 in GJA1 and rs237885 in OXTR, were not identified before this study. Furthermore, a polygenic risk score (PRS) was created for the young and old populations to identify high-risk cataract individuals, with areas under the receiver operating curve (AUROCs) of 0.829 and 0.785, respectively, after covariate adjustments. Younger individuals had 17.45 times the risk while older people had 10.97 times the risk when comparing individuals in the highest and lowest PRS quantiles. Validation analysis on an independent TWB1.0 cohort revealed AUROCs of 0.744 and 0.659.