Assessing the accuracy of intracameral antibiotic preparation for use in cataract surgery

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.

Intraoperative Cefuroxime Irrigation Prophylaxis for Acute-Onset Endophthalmitis After Phacoemulsification Surgery

Purpose

Acute-onset postoperative endophthalmitis usually compromises the visual function and anatomical integrity of the eye. The aim of this study was to evaluate the efficacy of intraoperative cefuroxime use in irrigating solution on prevention of acute-onset endophthalmitis after phacoemulsification.

Methods

This retrospective, comparative, interventional cohort study included patients who underwent phacoemulsification between January 1, 2012, and December 31, 2019. Under a uniform perioperative protocol, the patients who had surgery from January 1, 2012, to December 31, 2014, received irrigating infusion fluid containing balanced salt solution (BSS) only (group 1), and those from January 1, 2015, to December 31, 2019, received BSS with cefuroxime (1500 μg/mL) during surgery (group 2). All eyes were evaluated postoperatively, and the eyes suspected to have endophthalmitis were assessed and treated by a consultation team. The rates of postoperative endophthalmitis in these two groups were calculated.

Results

A total of 61,299 eyes were included over the eight years. Among these eyes, 11 in group 1 (0.07% of 15,948 eyes) and 5 in group 2 (0.01% of 45,351 eyes) developed endophthalmitis, and the difference was significant (P < 0.01). Five among 16 patients (31.25%) with endophthalmitis were positive in bacterial culture. The positive rate of bacterial culture was not significantly different between group 1 (4/11) and group 2 (1/5) (P > 0.05). No adverse events related to the irrigation of cefuroxime were found.

Conclusion

Intraoperative cefuroxime irrigation (1500 μg/mL) could decrease the rate of postoperative endophthalmitis after phacoemulsification by 7-fold. This study provides evidence that intraoperative irrigation with cefuroxime is effective as an antibiotic prophylaxis for endophthalmitis.

[Complications of intracameral cefuroxime in cataract surgery]

Intracameral injection of cefuroxime during phacoemulsification is considered effective in preventing endophthalmitis. Its widespread usage has led to the accumulation of data on local and systemic adverse reactions. The analysis of complications of cataract surgery with cefuroxime injections described in literature has allowed identifying a few different clusters of toxic and allergic reactions to intracameral cefuroxime for the first time. These clusters included toxic anterior segment syndrome, serous retinal detachment with macular edema, retinal hemorrhagic infarction and anaphylactic reaction. The first two types develop in the cases of both correct and incorrect dosages, and both have favorable prognosis. Retinal hemorrhagic infarction was observed in cases with more than 50 mg intracameral antibiotic injected in the anterior chamber and was accompanied by persistent irreversible visual deterioration. Anaphylactic shock in response to a standard dose of intracameral cefuroxime was described in patients allergic to penicillin. Every clinical variant has specific complication mechanisms, prevention and treatment options. Antibiotic dilution done by medical staff accounts for the risk of incorrect dosage and related complications. Clinical manifestations of the complications of antibiotic prophylaxis should be considered when specifying the causes of decreased vision in the early postoperative period.

[Serous retinal detachment after phacoemulsification with intracameral cefuroxime (a case-control report)]

Serous retinal detachment is a rare postoperative complication of phacoemulsification with intracameral antibiotics. Diagnostic and therapeutic strategy in such cases is not well known.

PURPOSE

To present a case of serous retinal detachment after phacoemulsification with intracameral cefuroxime.

MATERIAL AND METHODS

A retrospective analysis of the medical record of one patient who had underwent cataract phacoemulsification on both eyes; the follow-up period was 5 months.

RESULTS

Phacoemulsification of noncomplicated cataract with implantation of intraocular lens in the right eye was completed uneventfully; 1 mg of cefuroxime was administered into the anterior chamber at the end of the surgery. In the first day after the surgery visual acuity decreased to 0.2. Serous detachment of retinal pigment and sensory epithelia in the macula area was revealed by optical coherence tomography (OCT). Fluorescein angiography showed no pathological vascular activity. The patient received standard post-surgery therapy supplemented with subtenon triamcinolone, intravenous dexamethasone injections and systemic acetazolamide ingestion. The retinal detachment status was monitored daily by OCT. By day 6 of the follow-up visual acuity recovered to 1.0. After 5 months, inner retinal profile deformation was revealed. The patient's left eye was considered the 'control' eye; phacoemulsification without cefuroxime was performed on it 5 months after the initial surgery, and no complication occurred during the follow-up.

CONCLUSION

Serous detachment of retinal pigment and sensory epithelia during the early postoperative period after cataract surgery may be caused by a toxic reaction to intracameral cefuroxime even when it's administered in standard dosage. This complication has a favorable prognosis, but requires long term monitoring.

Assessing the accuracy of intracameral phenylephrine preparation in cataract surgery

PURPOSE

Unpreserved phenylephrine is often used as an off-licence intracameral surgical adjunct during cataract surgery to assist with pupil dilation and/or stabilise the iris in floppy iris syndrome. It can be delivered as a neat 0.2 ml bolus of either 2.5 or 10% strength, or in a range of ad-hoc dilutions. We wished to assess the accuracy of intracameral phenylephrine preparation in clinical practice.

METHODS

Phenylephrine 0.2 ml was analysed both neat (2.5 and 10%) and in diluted form (ratio of 1:1 and 1:3). Samples were analysed using the validated spectrophotometric method.

RESULTS

A total of 36 samples were analysed. The standard curve showed linearity for phenylephrine (R² = 0.99). Wide variability was observed across all dilution groups. There was evidence of significant differences in the percentage deviations from intended results between dilutions (p < 0.001). Mean percentage deviation for 1:3 dilution was significantly greater than neat (p = 0.003) and 1:1 dilution (p = 0.001). There was no evidence of a significant difference between 1:1 and neat (p = 0.827).

CONCLUSIONS

Current ad-hoc dilution methods used to prepare intracameral phenylephrine are inaccurate and highly variable. Small volume 1 ml syringes should not be used for mixing or dilution of drug. Commercial intracameral phenylephrine products would address dosage concerns and could improve surgical outcomes in cases of poor pupil dilation and/or floppy iris syndrome.

Effects of intracameral cefuroxime on corneal endothelial cell counts and its morphology after cataract surgery

Background

Endophthalmitis is one of the most important complications after cataract surgery and in case event can cause many symptoms, such as severe decrease in eyesight and/or even the loss of vision. Employing methods to reduce this problem is very important. The aim of this study was to evaluate the effect of intracameral cefuroxime after cataract surgery on corneal endothelial cell counts and its morphology.

Methods

In this study, 32 eyes of 30 patients underwent endothelial cell count and morphology assessment by ConfoScan III device before and 1 month after cataract surgery. All patients undertaken cataract surgery by one surgeon and by one method. Intracameral cefuroxime (1 mg/0.1 ml) was used as prophylaxis of postoperative endophthalmitis at the end of operation.

Results

In this study, the rate of corneal endothelial cell loss 1 month after cataract surgery was 8.4%, and the rate of endothelial cells polymegathism before and after cataract surgery did not differ statistically. During the follow-up period, there were no cases of endophthalmitis or other complications.

Conclusion

With regard to the importance of the intracameral cefuroxime in a reduction in the rate of endophthalmitis after cataract surgery and that harmful effects on the endothelial cells were not seen, this method can be considered as a suitable method for endophthalmitis prophylaxis.

Risks of Cefuroxime Prophylaxis for Postcataract Endophthalmitis

BACKGROUND:

Endophthalmitis after cataract surgery is a rare but vision-threatening complication. Intracameral cefuroxime (ICC) has been reported to be effective at reducing the risk, but concerns regarding the risks associated with this intervention remain.

METHODS:

Systematic review and synthesis of the literature on ICC, with a focus on the risks of therapy.

RESULTS:

Level 2a evidence was found to support the use of cefuroxime in penicillin-allergic patients. Compounding or dilutional errors are associated with ocular toxicity, but the incidence and risk of this occurrence are unknown. Level 4 evidence supports interventions that reduce the risk of dilutional errors. The association of cefuroxime injection with toxic anterior segment syndrome (TASS) is not established; Level 5 evidence supports standard measures to reduce the incidence of TASS related to cefuroxime administration.

CONCLUSION:

Cefuroxime can be administered safely to penicillin-allergic patients, and steps should be taken to reduce the risk of compounding or dilutional errors to avoid negating the benefits of this intervention. Recommended practice patterns for endophthalmitis prophylaxis should consider the risks and benefits of ICC.

Surgical, antiseptic, and antibiotic practice in cataract surgery: Results from the European Observatory in 2013

PURPOSE

To report the results from the first iteration of the European Observatory of Cataract Surgery, which was initiated to track changes in surgical, antiseptic, and antibiotic practices in cataract surgery over the coming years.

SETTING

Practicing European cataract surgeons (n = 479).

DESIGN

Internet-based declarative questionnaire or telephone questionnaire.

METHODS

The questionnaire comprised 37 questions divided into 8 categories as follows: screening, surgeon profile, surgical procedure used, product use before arrival at the operating room, techniques for mydriasis and anesthesia, product use during the surgery, product use after the patient leaves the operating room, and surgeon's attitude to guidelines.

RESULTS

Cataract surgeons (n = 2700) were initially contacted, of whom 479 (17.7%) were included in the survey. The current baseline survey revealed considerable variation between countries in their implementation of infectious postoperative endophthalmitis (IPOE) prophylaxis. In some countries, adoption of intracameral cefuroxime is almost universal, whereas in others, the use of such prophylaxis is below one half. When intracameral cefuroxime is used, it is generally cefuroxime powder designed for parenteral use. A preparation specifically registered for intracameral use is now available, and this formulation is more commonly used in countries in which intracameral cefuroxime was most widely adopted.

CONCLUSION

The baseline results from this ongoing survey suggest a considerable level of heterogeneity between European countries in IPOE prophylaxis. Further iterations of this survey will monitor whether a consensus begins to emerge.

FINANCIAL DISCLOSURES

This work was supported by Laboratoires Théa, under the supervision of the expert group. Members of the expert group were remunerated by Laboratoires Théa. J.F. Stolz, MD, PhD, provided editorial assistance in manuscript preparation, for which he was remunerated by Laboratoires Théa. Anders Behndig, Rita Mencucci, and Jacek P. Szaflik report no relevant conflicts of interest.

Incidence of Acute Postoperative Endophthalmitis after Cataract Surgery: A Nationwide Study in France from 2005 to 2014

PURPOSE

To report the incidence of acute postoperative endophthalmitis (POE) after cataract surgery from 2005 to 2014 in France.

DESIGN

Cohort study.

PARTICIPANTS

Patients undergoing operation for cataract surgery by phacoemulsification and presenting acute POE.

METHODS

We identified acute POE occurring within 6 weeks after phacoemulsification cataract surgery and the use of intracameral antibiotic injection during the surgical procedure by means of billing codes from a national database.

MAIN OUTCOME MEASURES

Incidence of acute POE.

RESULTS

From January 2005 to December 2014, 6 371 242 eyes in 3 983 525 patients underwent phacoemulsification cataract surgery. The incidence of acute POE after phacoemulsification decreased from 0.145% to 0.053% during this 10-year period; the unadjusted incidence rate ratio (IRR) (95% confidence interval) was 0.37 (0.32-0.42; P < 0.001). In multivariate analysis, intracameral antibiotic injection was associated with a lower risk of acute POE 0.53 (0.50-0.57; P < 0.001), whereas intraoperative posterior capsule rupture, combined surgery, and gender (male) were associated with a higher risk of acute POE: 5.24 (4.11-6.68), 1.77 (1.53-2.05), and 1.48 (1.40-1.56) (P < 0.001), respectively.

CONCLUSIONS

Access to a national database allowed us to observe a decrease in acute POE after phacoemulsification cataract surgery from 2005 to 2014. Within the same period, the use of intracameral antibiotics during the surgical procedures increased.

Budget impact assessment of Aprokam® compared with unlicensed cefuroxime for prophylaxis of post-cataract surgery endophthalmitis

Background

Intracameral cefuroxime is recommended as prophylaxis against postoperative endophthalmitis (POE) following cataract surgery. Aprokam is the only licensed product for prophylaxis of POE, although unlicensed intracameral cefuroxime may be administered using pre-filled syringes (PFS), either prepared in hospital by reconstituting cefuroxime via serial dilution (prepared PFS), or commercially purchased (purchased PFS). This study aimed to estimate the potential budget impact of using Aprokam over unlicensed cefuroxime for intracameral administration.

Methods

A budget impact model (BIM) was developed from UK NHS hospital perspective to estimate the economic impact of adopting Aprokam compared with purchased PFS or prepared PFS for the prophylaxis of POE following cataract surgery over a 5-year time horizon. The BIM incorporated direct costs only, associated with the acquisition, delivery, storage, preparation, and administration of cefuroxime. Resource utilisation costs were also incorporated; resource utilisation was sourced from a panel survey of hospital pharmacists, surgeons, and theatre nurses who are involved in the delivery, storage, preparation, quality assurance, or administration of cefuroxime formulations. Unit costs were sourced from NHS sources; drug acquisition costs were sourced from BNF. The model base case used a hypothetical cohort comprising of 1000 surgeries in the first year and followed a 5.2 % annual increase each year.

Results

The model predicts Aprokam is cost saving compared with purchased PFS, with a modest increase compared prepared PFS over 5 years. There are total savings of £3490 with Aprokam compared with purchased PFS, driven by savings in staff costs that offset greater drug acquisition costs. Compared with prepared PFS, there are greater drug acquisition costs which drive an increased total cost over 5 years of £13,177 with Aprokam, although there are substantial savings in staff costs as well as consumables and equipment costs.

Conclusions

The lower direct costs of using Aprokam compared with purchased PFS presents a strong argument for the adoption of Aprokam where purchased PFS is administered. The additional benefits of Aprokam include increased liability coverage and possible reduction in dilution errors and contaminations; as such, in hospitals where unlicensed prepared PFS is used, modest additional resources should be allocated to adoption of Aprokam.

Toxic anterior segment syndrome after uncomplicated cataract surgery possibly associated with intracamaral use of cefuroxime

Purpose

To report toxic anterior segment syndrome (TASS) after cataract surgery possibly associated with intracameral use of cefuroxime.

Methods

We conducted a retrospective chart review and analysis on the pre- and postoperative conditions of the subjects who had developed TASS.

Results

The patient group consisted of 17 patients. Tyndallization and fibrin fibers were positive in all eyes. In four eyes, hypopyon formation developed. These reactions diminished on the third day and fully resolved 1 week after the operations with the use of intensive topical steroid and mydriatic therapy. To determine the etiology of TASS, infusion fluid, viscoelastics, and intracameral antibiotic agent were changed respectively. After changing intracameral antibiotic agent from cefuroxime axetile to moxifloxacin no new cases of TASS were diagnosed.

Conclusion

All agents injected into the anterior chamber can cause TASS. Ophthalmologists and operating room staff need to pay careful attention to all drugs and irrigating solutions.

Understanding medication compounding issues

The potential for contamination of compounded products and the resulting infections are a serious threat to patient safety. Immediate use products are used frequently in the perioperative department, and perioperative nurses should be familiar with the guidelines and practices that aim to reduce the contamination that can occur during the sterile compounding process. Four common themes lead to successful compounding: quality (eg, product identification, purity, stability, compatibility, risk level assessment), the environment (eg, using a segregated compounding area with specialized airflow capabilities, reducing particulate matter, practicing proper hand hygiene, performing gloved fingertip sampling, properly cleaning equipment and work areas), personnel activities (eg, familiarity with types of containers used and how often they can be accessed, following expiration dates and the number of times containers can be accessed), and the control process (eg, process monitoring, quality improvement). If a third-party vendor is contracted to handle compounding for a facility, perioperative personnel should be aware of the responsibilities for the facility and the vendor to ensure a quality compounding program.

Cohort study of intracameral moxifloxacin in postoperative endophthalmitis prophylaxis

We conducted a cohort study to evaluate post-cataract surgery endophthalmitis rates in relation to prophylactic intracameral moxifloxacin administration. A total of 2332 patients (2674 eyes) who underwent phacoemulsification by a single surgeon from January 2007 through December 2012 were included in the study. A total of 1056 eyes did not receive intracameral prophylactic moxifloxacin and the antibiotic was injected in 1618 eyes. The incidence of presumed postoperative endophthalmitis in the 2 groups was calculated. The rate of presumed infectious endophthalmitis after cataract surgery between January 2007 and June 2009 (without intracameral moxifloxacin) was 0.094%. The rate in the second period, from July 2009 to December 2012 (with prophylactic intracameral moxifloxacin), was 0%. In our patients, a decline in the incidence of presumed infectious postoperative endophthalmitis appeared to be associated with the application of intracameral moxifloxacin.

Intracameral cefuroxime: prophylaxis of postoperative endophthalmitis after cataract surgery

Results of the landmark European Society of Cataract and Refractive Surgeons trial and additional prospective and retrospective studies support the use of intracameral cefuroxime in the prophylaxis of endophthalmitis following cataract surgery. Prophylaxis with intracameral cefuroxime at the recommended dose appears to be well tolerated in patients undergoing cataract surgery. However, off-label use of intracameral cefuroxime usually requires a two-step dilution process with the potential for dilution errors, and there are also concerns regarding the risk of contamination. Aprokam® (intracameral cefuroxime) has been approved in the EU for the prophylaxis of postoperative endophthalmitis after cataract surgery. After reconstitution of Aprokam®, no further dilution is required and each vial is only indicated for single-patient use; this has the potential to reduce the risk of both dilution errors and contamination.

Incidence of endophthalmitis and impact of prophylaxis with cefuroxime on cataract surgery

PURPOSE

To evaluate the clinical and economic impact of prophylactic administration of intracameral cefuroxime on cataract surgery.

SETTING

Hospital Universitario Fundación Alcorcón, Madrid, Spain.

DESIGN

Quasi-experimental study with before and after analysis.

METHODS

The evolution of the cumulative incidence of endophthalmitis before and after (October 2005) administration of intracameral cefuroxime as endophthalmitis prophylaxis in cataract surgery was studied. The annual incidence adjusting to a Poisson distribution was compared. The effectiveness of the prophylaxis was evaluated with the relative risk (RR). The impact of cefuroxime was evaluated with the attributable risk fraction and the number of patients needed to treat to avoid a case of endophthalmitis.

RESULTS

Cataract surgery was performed in 19 463 patients, 6595 patients before and 12 868 patients after October 2005. Endophthalmitis was diagnosed in 44 cases (39 before and 5 after). Positive microbiology cultures were obtained in 29 patients (66%). The overall cumulative incidence was 0.23 cases per 100 patients. Cefuroxime protected against endophthalmitis (RR = 0.06; P<.05; 95% confidence interval [CI], 0.03-0.17); the impact or number needed to treat was 182, and the attributable risk fraction was -0.93% (P<.05; 95% CI, -0.82 to -0.97). The cost of a dose of cefuroxime was €1, and the cost of a case of endophthalmitis was €1358. The potential saving with cefuroxime was €1177 for every 182 patients treated.

CONCLUSION

Intracameral cefuroxime reduced the incidence of endophthalmitis in cataract surgery and had a high clinical and economic impact on its prevention.

Six-year incidence of endophthalmitis after cataract surgery: Swedish national study

PURPOSE

To report the nationwide incidence and risk factors for endophthalmitis after cataract surgery in Sweden.

SETTING

Swedish National Cataract Register containing reports on cataract operations from all Swedish ophthalmic surgical units.

DESIGN

Prospective epidemiologic study.

METHODS

Endophthalmitis case reports were collected from 2005 through 2010. Case and control parameters pertaining to patient characteristics and surgical technique were generated from the database. In addition, information from annual surveys regarding the topical prophylactic protocol was analyzed.

RESULTS

The reports showed 135 endophthalmitis cases in 464,996 operations, equaling an incidence of 0.029%. Patient age over 85 years, perioperative communication with the vitreous and, above all, nonuse of intracameral cefuroxime showed a statistically significant association with endophthalmitis in the logistic regression. Short-term topical antibiotics given as add-on prophylaxis to the intracameral regimen before, after, or before and after the operation did not confer a clear-cut benefit. Groups with topical treatment were small, comprising 14% of the sample.

CONCLUSIONS

The incidence of endophthalmitis after cataract surgery in Sweden is declining, which appears to be explained by a fall in the frequency of major risk factors. Operating earlier in the cataract course, avoiding capsule breakage, and giving intracameral antibiotics universally should further reduce the endophthalmitis rate.

[Prophylaxis and therapy of postoperative endophthalmitis. Criticism of the ESCRS study and the Early Vitrectomy study]

Postoperative endophthalmitis often leads to a substantial loss of vision and sometimes to loss of the eye. Occasionally this results in legal disputes during which medical studies will be consulted for reaching a verdict. Both the European Society of Cataract and Refractive Surgeons (ESCRS) study on prophylaxis and the Early Vitrectomy study on the therapy of postoperative endophthalmitis suffer from substantial deficits in essential areas. These studies cannot therefore be utilized as standard operating procedures and guidelines as well as in legal disputes.

A European perspective on topical ophthalmic antibiotics: current and evolving options

BACKGROUND

Eye infections can be vision-threatening and must be treated effectively by appropriate and safe use of topical ophthalmic anti-infectives. This review will essentially consider the current and evolving treatment options for the various types of bacterial eye infections. Ocular surface bacterial infections affect subjects of all ages with a high frequency in newborns and children.

METHODS

This article presents a review of the peer-reviewed published scientific literature in order to define the well-established uses of anti-infective eye drops in the field of ocular infections. A comprehensive search of the recent published literature including topical ophthalmic anti-infectives effective in bacterial ocular infections was performed. Clinical studies provide relevant data concerning the characteristics and clinical efficacy of antibacterial eye drops in ocular anterior segment infections or for perioperative prophylaxis. Publications were included to cover the current options of antibacterial eye drops available in Europe.

RESULTS

Several recent publications identified effective topical ocular antibacterials requiring a reduced dose regimen and a short treatment course. Additional literature reviewed included data on novel perioperative prophylaxis, indications for topical fortified antibiotics and innovative research including the risk of resistance.

CONCLUSIONS

Safe and effective topical antibiotic eye drops for the treatment and prevention of ocular infections must be adapted to the type of bacteria suspected. Usual topical antimicrobials should be replaced by more recent and more effective treatments. The use of highly effective fluoroquinolones should be reserved for the most severe cases to avoid resistance. Short treatment courses, such as azithromycin, can be easily used in children, thereby improving quality of life.

Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis

This distillation of the peer-reviewed scientific literature on infection after cataract surgery summarizes background material on epidemiology, etiology, and pathogenesis, describes the roles of surgical technique and antibiotic prophylaxis in prevention, and discusses diagnostic and therapeutic interventions in cases of suspected endophthalmitis.

Randomized controlled trial on the safety of intracameral cephalosporins in cataract surgery

Objective:

To compare the safety profiles of intracameral cephalosporins in cataract surgery.

Patients and methods:

In this controlled trial, 129 patients were randomized to one of four groups to receive 1 mg of one of three cephalosporins – cefazolin, cefuroxime, or ceftazidime, or normal saline – given intracamerally during cataract surgery. Central endothelial cell density (ECD) and retinal center point thickness (CPT) were determined by specular microscopy and ocular coherence tomography, respectively, before and at 3 months after surgery.

Results:

There were no statistical significant differences in the changes of ECD and CPT between eyes receiving intracameral cephalosporin and control.

Conclusion:

The use of intracameral cefazolin, cefuroxime, or ceftazidime (1 mg in 0.1-mL solution) at the time of cataract surgery had no significant effect on ECD and CPT postoperatively.