Intracameral antibiotics: Safety, efficacy, and preparation

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.

Toxic anterior segment syndrome (TASS): A review and update

Toxic anterior segment syndrome (TASS) is an acute, sterile, postoperative inflammatory reaction of the anterior segment without vitreous involvement, following an uncomplicated and uneventful ocular surgery, having broad and multiple etiologies. The symptoms of decreased visual acuity and ocular discomfort generally occur within the first 12-48 h after intraocular surgery. The clinical signs include prominent limbus-to-limbus corneal edema, anterior chamber cells, aqueous flare, fibrinous inflammation, and/or keratic precipitates. There can be sight-threatening complications of TASS, such as permanent corneal decompensation, intractable glaucoma, and cystoid macular edema. The causes of TASS are emerging and being reported, so are the newer treatment options for managing the inflammation and its complications. Prevention guidelines for TASS are being updated, and a traceability system for surgical instruments and intraocular fluids used during the surgery is being perpetually developed. It is important to recognize TASS and start treatment on an immediate effect. Hereby, we review the literature on TASS, emphasizing its etiology, pathophysiology, management, prognosis, complications, and the importance of prevention as well as prompt recognition.

Safety of intracameral injection of levofloxacin 0.5% eye drops single dose 0.6 ml preservative free on rabbit eye

Background

This was an experimental, parallel, and randomized study to evaluate the safety of single intracameral injection of 0.6 ml 0.5% preservative-free levofloxacin eye drops on rabbit eye.

Methods

In total, 24 eyes of 12 New Zealand white rabbits were divided into three groups. The first group (LFX) was treated with 0.1 ml intracameral injection of levofloxacin 0.5% eye drops of 0.6 ml preservative-free (n = 6), the second group (CRAV) was treated with 0.1 ml intracameral injection of levofloxacin 0.5% eye drops 5 ml commercially available eye drops preservative-free (n = 6), and the third group (BSS) were treated with 0.1 ml intracameral injection of balanced salt solution (n = 12). All groups received a single dose. The clinical evaluation was performed on the 1 st, 3 rd, 5 th, and 7 th day after injection. Each eye was enucleated on the 7 th day and underwent a histopathology examination.

Results

The clinical scores among the three groups did not show any significant difference on days 1 st, 2 nd, 3 rd, and 7 th (p>0.05). The only ones noted in clinical scores were mild corneal opacity, mild cells, and flares in the anterior chamber. The histopathology score demonstrated no statistically significant difference between the three groups (p>0.05). Vacuolization of corneal endothelial cells was noted in all groups but was not statistically significant.

Conclusions

A single intracameral injection of 0.6 ml 0.5% preservative-free levofloxacin eye drops was safe for rabbit eye, according to clinical and histopathology scores, similar to levofloxacin 0.5% eye drops in 5 ml bottle preservative free.

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

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

Nanotechnology-based ocular drug delivery systems: recent advances and future prospects

Ocular drug delivery has constantly challenged ophthalmologists and drug delivery scientists due to various anatomical and physiological barriers. Static and dynamic ocular barriers prevent the entry of exogenous substances and impede therapeutic agents' active absorption. This review elaborates on the anatomy of the eye and the associated constraints. Followed by an illustration of some common ocular diseases, including glaucoma and their current clinical therapies, emphasizing the significance of drug therapy in treating ocular diseases. Subsequently, advances in ocular drug delivery modalities, especially nanotechnology-based ocular drug delivery systems, are recommended, and some typical research is highlighted. Based on the related research, systematic and comprehensive characterizations of the nanocarriers are summarized, hoping to assist with future research. Besides, we summarize the nanotechnology-based ophthalmic drugs currently on the market or still in clinical trials and the recent patents of nanocarriers. Finally, inspired by current trends and therapeutic concepts, we provide an insight into the challenges faced by novel ocular drug delivery systems and further put forward directions for future research. We hope this review can provide inspiration and motivation for better design and development of novel ophthalmic formulations.

Challenges in the diagnosis and management of simultaneous, bilateral, toxic anterior segment syndrome after phacorefractive surgery

A 59-year-old woman presented with a 24-hour history of severe, bilateral, painless vision loss starting 1 day after immediately sequential, bilateral, phacorefractive surgery with multifocal intraocular lens (IOL) implantation at another institution. Best-corrected visual acuity was counting fingers at 1 foot in the right eye and 20/100 in the left eye. Slit-lamp evaluation showed a dense fibrin membrane on the anterior surface of the IOL and significant anterior chamber inflammation in both eyes. B-scan ultrasound revealed bilateral vitreous haze, without membrane formation. The rapid onset, absence of sharp pain, ciliary injection, conjunctival chemosis, eyelid edema, and erythema raised suspicion for bilateral toxic anterior segment syndrome. Significant clinical improvement after high-dose prednisone and hourly prednisolone acetate eye drops supported the diagnosis. After 6 months of tapering anti-inflammatory therapy, optical coherence tomography of the macula showed no pathologic changes, and the patient's best-corrected visual acuity improved to 20/25 in both eyes.

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.

Lipid Nanoparticles as a Promising Drug Delivery Carrier for Topical Ocular Therapy-An Overview on Recent Advances

Due to complicated anatomical and physical properties, targeted drug delivery to ocular tissues continues to be a key challenge for formulation scientists. Various attempts are currently being made to improve the in vivo performance of therapeutic molecules by encapsulating them in various nanocarrier systems or devices and administering them via invasive/non-invasive or minimally invasive drug administration methods. Biocompatible and biodegradable lipid nanoparticles have emerged as a potential alternative to conventional ocular drug delivery systems to overcome various ocular barriers. Lipid-based nanocarrier systems led to major technological advancements and therapeutic advantages during the last few decades of ocular therapy, such as high precorneal residence time, sustained drug release profile, minimum dosing frequency, decreased drug toxicity, targeted site delivery, and, therefore, an improvement in ocular bioavailability. In addition, such formulations can be given as fine dispersion in patient-friendly droppable preparation without causing blurred vision and ocular sensitivity reactions. The unique advantages of lipid nanoparticles, namely, solid lipid nanoparticles, nanostructured lipid carriers, nanoemulsions, and liposomes in intraocular targeted administration of various therapeutic drugs are extensively discussed. Ongoing and completed clinical trials of various liposome-based formulations and various characterization techniques designed for nanoemulsion in ocular delivery are tabulated. This review also describes diverse solid lipid nanoparticle preparation methods, procedures, advantages, and limitations. Functionalization approaches to overcome the drawbacks of lipid nanoparticles, as well as the exploration of new functional additives with the potential to improve the penetration of macromolecular pharmaceuticals, would quickly progress the challenging field of ocular drug delivery systems.

Distribution of Gold Nanoparticles in the Anterior Chamber of the Eye after Intracameral Injection for Glaucoma Therapy

In glaucoma therapy, nanoparticles (NPs) are a favorable tool for delivering drugs to the outflow tissues of the anterior chamber of the eye where disease development and progression take place. In this context, a prerequisite is an efficient enrichment of NPs in the trabecular meshwork with minimal accumulation in off-target tissues such as the cornea, lens, iris and ciliary body. We evaluated the optimal size for targeting the trabecular meshwork by using gold NPs of 5, 60, 80 and 120 nm with a bare surface (AuNPs) or coated with hyaluronic acid (HA-AuNPs). NPs were compared regarding their colloidal stability, distribution in the anterior chamber of the eye ex vivo and cellular uptake in vitro. HA-AuNPs demonstrated an exceptional colloidal stability. Even after application into porcine eyes ex vivo, the HA coating prevented an aggregation of NPs inside the trabecular meshwork. NPs with a diameter of 120 nm exhibited the highest volume-based accumulation in the trabecular meshwork. Off-target tissues in the anterior chamber demonstrated an exceptionally low gold content. Our findings are particularly important for NPs with encapsulated anti-glaucoma drugs because a higher particle volume would be accompanied by a higher drug payload.

Toxic Anterior Segment Syndrome with Intracameral Moxifloxacin: Case Report and Review of the Literature

A case of severe anterior segment toxicity secondary to high-volume, undiluted intracameral moxifloxacin for endophthalmitis prophylaxis is reported. We examine the other reported cases of toxicity after intracameral moxifloxacin, as well as iris depigmentation and transillumination syndromes after oral and topical fluoroquinolone exposure. Additionally, we review the literature on safety, efficacy, and appropriate dosing of intracameral antibiotics with a focus on moxifloxacin.

Endophthalmitis after cataract surgery: an update on recent advances

PURPOSE OF REVIEW

Prevention and management of postcataract endophthalmitis remain quite relevant for anterior segment and vitreoretinal surgeons. Although the Endophthalmitis Vitrectomy Study, published in 1996, remains the only level 1 evidence for the management of postcataract endophthalmitis, recent advances have resulted in an evolution of practice patterns. The aim of this review is to summarize the literature regarding postcataract endophthalmitis with a focus on the last 18 months.

RECENT FINDINGS

The IRIS registry indicates the rates of endophthalmitis are decreasing in the United States, and the outcomes appear to be improving. Intracameral moxifloxacin has become more widely accepted and intracameral vancomycin has been shown to be associated with retinal vasculitis. The role of systemic antibiotics and vitrectomy is unclear and practice patterns vary widely.

SUMMARY

Although practice patterns vary, prevention and treatment of endophthalmitis after cataract surgery continues to improve. More uniform guidelines regarding surgical and medical therapy are necessary but the standard of prompt referral to a vitreoretinal specialist for immediate intravitreal antibiotics remains the most important intervention in the management of postcataract endophthalmitis.

Vancomycin-associated retinal hemorrhages in pediatric age group: A case report

Purpose

To report a case of possible post-lensectomy vancomycin-induced retinal hemorrhages in a 9-month-old infant to raise awareness of this rare postoperative complication in the pediatric age group.

Observation

A retinal vascular occlusion-like findings were noted bilaterally after sequential uneventful parsplicata lensectomy in a 9-month-old infant during the very early postoperative follow-up (1–2 days). The case was recorded with no remarkable intraoperative events and received intraoperative vancomycin 20μg/ml in irrigating solution (a routine endophthalmitis prophylactic protocol).

Conclusions and Importance

Vancomycin-associated hemorrhagic occlusive retinal vasculitis (HORV) is a rare reported postoperative complication of intraocular prophylactic vancomycin injection. Although all documented cases were reported in elderly patients aged 50 years and above, all presented with almost common findings of occlusive retinal vasculitis. To the best of author's knowledge, this is the first reported case of presumed HORV in pediatric age group. The author finds this of utmost importance to demonstrate the case to expand awareness of this possible complication in the pediatric age group as well.

Comparison of the local effects of different intracameral cefuroxime solutions on rabbit cornea

PURPOSE

We aimed to compare the local effects of intracameral cefuroxime diluted in normal saline (SF groups) against those of cefuroxime in balanced salt solution (BSS group) on the cornea of rabbits.

MATERIALS AND METHODS

Fourteen New Zealand albino rabbits were randomised into two groups. The right eyes of the rabbits in the SF group I were injected intracamerally with 1 mg cefuroxime diluted with 0.1 mL normal saline (n = 7), whereas the right eyes of the BSS group II were injected with 1 mg intracameral cefuroxime diluted with 0.1 mL with balance salt solution, and the left eyes of all rabbits received no treatment group III (control group). Corneal thickness was measured with pachymetry before and 1 week after the injection. Corneal samples were evaluated with light, specular and electron microscopy.

RESULTS

Mean endothelial cell count was lower in the SF than in the BSS and control groups. Although an increase in corneal thickness was found in both treatment groups, this was not the case for the control group. The corneal endothelium preserved its hexagonal structure in all groups. Although both treatment groups showed a loss of endothelial microvilli, this was more prevalent in the SF group. However, microvilli were preserved in the control group. Dissolution of tight junctions in corneal endothelium was observed in the SF group only. Mitochondrial swelling, coarsening of endoplasmic reticulum, cytoplasmic vacuolisation, and increased endothelial cell sizes were the same in both treatment groups but was not observed in the control group. Thicker and more oedematous corneal stroma were observed in the SF group compared with the BSS and control groups.

CONCLUSION

Dilution of intracameral cefuroxime in BSS yielded superior results compared with dilution in normal saline owing to toxicity to the endothelial cells and decline in the endothelial cell number, resulting in intracellular and intercellular morphological changes. BSS or any other solution with proven safety should be used in clinical studies.

Ocular Disease Therapeutics: Design and Delivery of Drugs for Diseases of the Eye

The ocular drug discovery field has evidenced significant advancement in the past decade. The FDA approvals of Rhopressa, Vyzulta, and Roclatan for glaucoma, Brolucizumab for wet age-related macular degeneration (wet AMD), Luxturna for retinitis pigmentosa, Dextenza (0.4 mg dexamethasone intracanalicular insert) for ocular inflammation, ReSure sealant to seal corneal incisions, and Lifitegrast for dry eye represent some of the major developments in the field of ocular therapeutics. A literature survey also indicates that gene therapy, stem cell therapy, and target discovery through genomic research represent significant promise as potential strategies to achieve tissue repair or regeneration and to attain therapeutic benefits in ocular diseases. Overall, the emergence of new technologies coupled with first-in-class entries in ophthalmology are highly anticipated to restructure and boost the future trends in the field of ophthalmic drug discovery. This perspective focuses on various aspects of ocular drug discovery and the recent advances therein. Recent medicinal chemistry campaigns along with a brief overview of the structure-activity relationships of the diverse chemical classes and developments in ocular drug delivery (ODD) are presented.

Incurred sample reanalysis of cefuroxime in rabbit ocular tissues-A case study

In this paper, we present the incurred sample reanalysis (ISR) data for cefuroxime in various ocular tissues of rabbits. Based on the cefuroxime concentration vs. time profile in various ocular tissues, three chosen time points enabled ISR assessment. Cefuroxime was quantitated in the ocular tissues using a published liquid chromatography-electrospray ionization/tandem mass spectrometry method operated under the multiple reaction-monitoring mode in positive ion mode. Regardless of the ocular tissue, the linearity range was 12.7-2760 ng/ml with a correlation coefficient (r² ) of ≥0.996. All of the ISR samples representing various ocular tissues met the acceptance criteria. To the best of our knowledge, this is the first report showing the ISR of ocular tissues in any species.

Rapid and progressive decline despite early intervention in a case of bilateral hemorrhagic occlusive retinal vasculitis

Purpose

To present a case of severe bilateral hemorrhagic occlusive retinal vasculitis (HORV) after uncomplicated cataract surgery with intracameral vancomycin. We present a report of a single patient with bilateral presentation of HORV that demonstrated classic features of the disease and progressed to profound vision loss despite early and aggressive intervention.

Observations

On initial presentation, the patient had good Snellen visual acuity of 20/25 PH 20/20 OD and 20/60 PH 20/30 OS with retinal hemorrhages in both eyes and sub-hyaloid hemorrhage in the left eye. Early therapeutic intervention with intravitreal corticosteroids, anti-vascular endothelial growth factor (anti-VEGF) agents and oral steroids was pursued. Even with treatment, the clinical picture rapidly deteriorated with progression of occlusive and hemorrhagic complications in both eyes resulting in bilateral ischemic retinopathy and breakthrough vitreous hemorrhage. After a prolonged course of treatment including the aforementioned along with panretinal photocoagulation (PRP) in both eyes and vitreoretinal surgery in the left eye, the final visual acuity was light perception (LP) OD and 20/100 OS.

Conclusions and importance

Hemorrhagic occlusive retinal vasculitis remains a feared complication of uncomplicated cataract surgery utilizing intracameral vancomycin. Despite early recognition and appropriate intervention, our patient still had a poor visual outcome with significant ischemic damage.

[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.

Controlled Release of Vancomycin From a Thermoresponsive Hydrogel System for the Prophylactic Treatment of Postoperative Acute Endophthalmitis

Purpose

To investigate the efficacy of a poly(ethylene glycol) diacrylate and poly(N-isopropylacrylamide) based thermo-responsive hydrogel drug delivery system (DDS) to deliver prophylactic vancomycin (VAN) following ocular surgery.

Methods

VAN was encapsulated in a hydrogel DDS and characterized in terms of initial burst, release kinetics, bioactivity, and cytotoxicity. Long-Evans rats received an intravitreal injection of Staphylococcus aureus to produce acute endophthalmitis in four experimental groups. One of four treatments were then applied: (1) bolus subconjunctival injection of VAN, (2) blank DDS, (3) saline treatment, and (4) subconjunctival injection of VAN DDS. Animals were scored for infection (0–3) at 12, 24, 48, and 72 hours, and eyes were harvested at 24 and 48 hours for histology.

Results

Following a 36% initial burst, VAN release from the DDS continued at a steady rate for 2 weeks plateauing at 84% after 504 hours. Bioactivity was maintained for all release samples and cytotoxicity analysis for the DDS revealed cell viability >90%. Not until after 12 hours did any of the groups show evidence of infection; however, at 24 hours, animals that received the VAN DDS had significantly lower infection scores (0 ± 0) than those that received a bolus VAN injection, blank DDS, or saline (1.5 ±1.5, 2.3 ± 0.87, and 2.9 ± 0.25; respectively). At 48 and 72 hours, the VAN DDS and bolus VAN treatment groups performed comparably and showed significantly better infection scores than the control groups.

Conclusions

This DDS appears to have promise as a vehicle for short term, prophylactic antibiotic delivery.

Translational Relevance

This DDS may prevent the development of postoperative endophthalmitis.

Uptake and pharmacokinetics of cefuroxime in rabbits after intravitreal, intracameral, and topical dosing: relevance to human ocular injection of cefuroxime

Cefuroxime is one of the widely used antibiotics. The objective of this study was to determine pharmacokinetics and disposition in various ocular tissues following topical (TOP), intracameral (IC) and intravitreal (IVT) administration of cefuroxime to rabbits.Following TOP, IC and IVT dosing plasma and various ocular tissues (aqueous humor (AH), vitreous humor (VH), conjunctiva, trabecular mesh (TM), lens and retina-choroid (RC)) were collected and analyzed to understand the disposition of cefuroxime. Postintravenous administration plasma samples were collected to determine the systemic pharmacokinetics.Post-TOP dosing cefuroxime concentrations were observed only in conjunctiva up to 48 h. IC administration showed cefuroxime concentrations in AH up to 8 h; in conjunctiva, TM and plasma, the concentration lasted up to 4 h and in RC and VH till 1 h. IVT administration of cefuroxime showed concentrations in all ocular tissues (up to 8 h) and lasted up to 48 h except in conjunctiva and RC.There was evidence that the mechanism(s) of cefuroxime entry into the eye by via IVT, IC and TOP routes is clearly different. The present ocular tissue data may aid clinicians for considering appropriate choice in the treatment of post-operative ocular complications due to bacterial infections including endophthalmitis.

Toxic anterior segment syndrome: A review

Toxic anterior segment syndrome is a surgical complication characterized by a noninfectious anterior chamber inflammatory reaction having multiple etiologies. The clinical signs (prominent limbus-to-limbus corneal edema, anterior chamber inflammation) and symptoms (decreased visual acuity, discomfort) generally occur within the first 12-48 hours after intraocular surgery. Most patients achieve good clinical and visual outcomes when there is a prompt clinical diagnosis and adequate treatment. We review the literature on toxic anterior segment syndrome, emphasizing its etiology, pathophysiology, and clinical and surgical management, as well as prognosis and sequelae. Our goal is to reduce the frequency of toxic anterior segment syndrome by highlighting the importance of prevention, early recognition, and distinguishing toxic anterior segment syndrome from infectious endophthalmitis.

Endophthalmitis following cataract surgery and intracameral antibiotic: Moxifloxacin resistant Staphylococcus epidermidis

Purpose

To describe an immunosuppressed patient who developed acute-onset postoperative endophthalmitis caused by a moxifloxacin-resistant strain of Staphylococcus epidermidis after cataract surgery despite the use of intracameral moxifloxacin.

Observations

A 76-year old woman with a history of birdshot chorioretinopathy controlled on systemic immunosuppression underwent uneventful cataract surgery in her right eye. Compounded intracameral moxifloxacin 0.2 cc of 1mg/0.1mL (Edge Pharmacy, Syracuse, NY) was injected intraoperatively as prophylaxis, and the patient was placed on a standard regimen of trimethoprim-polymyxin b (10000-0.1unit/mL) and prednisolone acetate 1% postoperatively. Four days later, the patient experienced a sudden decrease in vision in the right eye. Anterior chamber inflammation, vitritis, and vasculitis were seen in the operated eye. The patient underwent a vitreous tap and intravitreal injections of vancomycin (1mg/0.1mL), ceftazidime (2.25mg/0.1mL), and dexamethasone (0.4mg/0.1mL). Cultures grew Staphylococcus epidermidis, resistant to moxifloxacin (MIC ≥8mg/L). The inflammation resolved over two months. Eight months later, the patient underwent uncomplicated cataract surgery in the left eye. Intracameral antibiotics were not used, however her systemic immunosuppressive therapy was held for several weeks perioperatively. One year after the initial surgeries, the patient had an uncorrected visual acuity of 20/20 in each eye.

Conclusions and Importance

S. epidermidis, the most common cause of postoperative endophthalmitis, is increasingly resistant to fluoroquinolones. Adequate concentrations of intracameral antibiotics need to be achieved in order to exceed minimal inhibitory concentration values of the targeted pathogen. Although intracameral moxifloxacin has been reported to decrease the rate of endophthalmitis after cataract surgery, it does not eliminate the risk.

Toxic anterior segment syndrome-an updated review

Background

Toxic anterior segment syndrome (TASS) can be a rare complication of anterior segment surgery. Here we reviewed the most recent advances in the understanding of TASS.

Methods

English articles related to TASS were retrieved from “PubMed” using the following keywords; “toxic anterior segment syndrome” or “TASS”. The authors of this paper reviewed all the retrieved literature and critical findings were summarized.

Results

The onset of TASS can vary from hours to months. The clinical manifestations are also variable. The causes of TASS are broad and continue to expand and could not be elucidated in over half of the reported cases. Prompt and thorough investigation to explore the causes of TASS is critical. Surgeons should be fully aware and updated regarding possible etiologies and make ceaseless efforts to prevent TASS. This effort begins with establishing TASS prevention protocols and regularly training surgical staff. Proper cleaning of surgical instruments is critical and should follow the guidelines set by The American Society of Cataract and Refractive Surgery TASS Task Force. When TASS occurs, sharing information with other ophthalmologists and reporting new causes is crucial for the prevention of outbreaks.

Conclusions

Anterior segment surgeons should be reminded that TASS is mostly preventable by the establishment of TASS prevention protocols, regular surgical staff training and thorough adherence to recommendations for cleaning and sterilizing intraocular surgical instruments.

Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: A Clinical-Pathophysiological Analysis

PURPOSE

To derive novel insights into the pathophysiology of vancomycin-related hemorrhagic occlusive retinal vasculopathy (HORV) through a careful clinicopathologic correlation.

METHODS

We retrospectively reviewed the clinical and pathologic course of 2 consecutive patients who developed HORV. The clinical history, multimodal imaging, ultrasound biomicroscopy (UBM), and intraoperative and histologic findings are reported.

RESULTS

Both patients presented with decreased vision and eye pain within 1 week following otherwise uncomplicated cataract extraction and were diagnosed with HORV after endophthalmitis was ruled out. Both patients presented with significant ocular discomfort that progressively worsened, and both experienced a dismal visual outcome despite early aggressive medical and surgical therapy. One patient requested enucleation for a blind and painful eye. Upon histologic examination of this eye, the iris and ciliary body appeared to be infarcted with separation of the iris and ciliary epithelia from their adjacent stromal components. These findings were corroborated by UBM of the second patient. Histologic examination of the posterior segment demonstrated severe hemorrhagic necrosis of the neurosensory retina and an occlusive nonarteritic vasculopathy of the retina and choroid. The choroid was thickened by prominent nongranulomatous chronic inflammation accompanied by a glomeruloid proliferation of small vessels. The inflammatory infiltrate was almost exclusively confined to the choroid and consisted of predominantly T cells. There was conspicuous absence of inflammatory cells in the retina and no histologic evidence of leukocytoclastic vasculitis.

CONCLUSIONS

HORV is a rare condition that can lead to profound vision loss. Significant ocular pain can be a presenting sign of HORV in cases with severe iris and ciliary body ischemia. Although it has been suggested that HORV is a form of leukocytoclastic retinal vasculitis, the histologic findings herein indicate that the pathophysiology is more complex. It is grounded in a necrotizing retinal vasculopathy in the absence of retinal vasculitis, chronic nongranulomatous choroiditis, and an unusual glomeruloid proliferation of endothelial cells in the choroid and elsewhere in the eye.

Ocular delivery of proteins and peptides: Challenges and novel formulation approaches

The impact of proteins and peptides on the treatment of various conditions including ocular diseases over the past few decades has been advanced by substantial breakthroughs in structural biochemistry, genetic engineering, formulation and delivery approaches. Formulation and delivery of proteins and peptides, such as monoclonal antibodies, aptamers, recombinant proteins and peptides to ocular tissues poses significant challenges owing to their large size, poor permeation and susceptibility to degradation. A wide range of advanced drug delivery systems including polymeric controlled release systems, cell-based delivery and nanowafers are being exploited to overcome the challenges of frequent administration to ocular tissues. The next generation systems integrated with new delivery technologies are anticipated to generate improved efficacy and safety through the expansion of the therapeutic target space. This review will highlight recent advances in formulation and delivery strategies of protein and peptide based biopharmaceuticals. We will also describe the current state of proteins and peptides based ocular therapy and future therapeutic opportunities.

A Financial Evaluation of the Centralized Repackaging of Intracameral Moxifloxacin for Cataract Surgery and Its Impact on Cost Reduction

Background: Extensive evidence-based literature supports the use of intracameral (IC) moxifloxacin for the prevention of postoperative endophthalmitis after cataract surgery. The Aurora Pharmacy Packaging Center (APPC) has developed a process for centrally preparing IC moxifloxacin. Purpose: The aim of this study was to evaluate the centralized preparation of IC moxifloxacin production for quality assurance and to quantify a potential reduction in costs. Methods: The APPC's compounding procedure of IC moxifloxacin was evaluated using United States Pharmacopeia (USP) Convention 797 standard and compared with practices described in evidence-based literature. Patients who received IC moxifloxacin intraoperatively from one of 3 ophthalmologists during cataract surgery performed between February 15, 2016, and August 15, 2016, were identified using electronic health records. Cost savings were calculated by reviewing costs associated with drug supplies used by the APPC. Results: The APPC process for the centralized preparation of IC moxifloxacin was deemed compliant with USP 797's sterile compounding standards. USP 797 validation criteria included proper sterile technique, equipment, room sterility and pressure, beyond use dating, and storage. Implementation of the centralized production of moxifloxacin reduced the direct product cost per surgery from $140 to $20 (a cost savings of $120 per surgery). There were 459 cataract surgeries analyzed during the study period, resulting in a savings of $55 080 over 6 months. Conclusion: The APPC's centralized compounding procedure was found to be compliant with pharmacy compounding standards and to yield significant cost savings.

Early anti-VEGF treatment for hemorrhagic occlusive retinal vasculitis as a complication of cataract surgery

Background

We report a case of hemorrhagic occlusive retinal vasculitis (HORV) after prophylactic intracameral vancomycin use during an uneventful cataract surgery treated with early anti-VEGF treatment.

Case presentation

A 51-year-old female underwent uneventful cataract surgery with prophylactic intracameral vancomycin during the procedure. On the seventh post-operative-day, she presented with sudden painful, visual loss. Fundus examination revealed peripheral hemorrhagic retinal vasculitis. She received anti-VEGF therapy to prevent further vision loss and retinal neovascularization due to extensive retinal ischemia. At the 6-month follow-up visit, visual acuity was 20/20 with no sign of neovascularization.

Conclusions

Postoperative HORV is a devastating condition that can occur after otherwise uncomplicated cataract surgery. The nature of this rare condition remains unknown. Early anti-VEGF administration seems to demonstrate favorable results.

Nanoparticles for drug delivery to the anterior segment of the eye

Commercially available ocular drug delivery systems are effective but less efficacious to manage diseases/disorders of the anterior segment of the eye. Recent advances in nanotechnology and molecular biology offer a great opportunity for efficacious ocular drug delivery for the treatments of anterior segment diseases/disorders. Nanoparticles have been designed for preparing eye drops or injectable solutions to surmount ocular obstacles faced after administration. Better drug pharmacokinetics, pharmacodynamics, non-specific toxicity, immunogenicity, and biorecognition can be achieved to improve drug efficacy when drugs are loaded in the nanoparticles. Despite the fact that a number of review articles have been published at various points in the past regarding nanoparticles for drug delivery, there is not a review yet focusing on the development of nanoparticles for ocular drug delivery to the anterior segment of the eye. This review fills in the gap and summarizes the development of nanoparticles as drug carriers for improving the penetration and bioavailability of drugs to the anterior segment of the eye.

Pharmaceutical microscale and nanoscale approaches for efficient treatment of ocular diseases

Efficient treatment of ocular diseases can be achieved thanks to the proper use of ophthalmic formulations based on emerging pharmaceutical approaches. Among them, microtechnology and nanotechnology strategies are of great interest in the development of novel drug delivery systems to be used for ocular therapy. The location of the target site in the eye as well as the ophthalmic disease will determine the route of administration (topical, intraocular, periocular, and suprachoroidal administration) and the most adequate device. In this review, we discuss the use of colloidal pharmaceutical systems (nanoparticles, liposomes, niosomes, dendrimers, and microemulsions), microparticles (microcapsules and microspheres), and hybrid systems (combination of different strategies) in the treatment of ophthalmic diseases. Emphasis has been placed in the therapeutic significance of each drug delivery system for clinical translation.

Toxicity of Intracameral Injection of Fourth-Generation Fluoroquinolones on the Corneal Endothelium

PURPOSE

The aim of this study was to compare the cellular susceptibility patterns and morphologic changes in the corneal endothelium associated with the use of fourth-generation fluoroquinolones.

METHOD

Endothelial susceptibility was assessed through intracameral injection of besifloxacin, gatifloxacin, and moxifloxacin. Human umbilical vein endothelial cells (HUVECs) were used as the standard cellular lineage to assess the quantitative toxicity of each antibiotic solution. Qualitative changes in the morphologic character of the corneal structure and the endothelial layer were generated using a combination of ex vivo and in vivo assays. Experimental assays were conducted in triplicate, and the results were statistically analyzed.

RESULTS

At 1 hour of exposure, all HUVECs exposed to antibiotics showed viability above 85%, after 3 hours of exposure to besifloxacin, gatifloxacin, and moxifloxacin, the percentages of viable cells were 68.3 ± 4.0 (P < 0.001), 90.7 ± 4.2 (P < 0.05), and 93.3 ± 1.5 (P > 0.05), respectively. All fluoroquinolones tested showed toxicity to HUVECs, resulting in significant (P < 0.001) loss of cellular viability after 24 hours of drug exposure. Giant endothelial cells were observed in animals treated with the 3 fluoroquinolones in contrast to the absence of these abnormal cells in the untreated group. Early cellular detachment was seen in the endothelial layer after exposure to gatifloxacin and moxifloxacin.

CONCLUSIONS

We concluded that injection of fourth-generation fluoroquinolones in the aqueous humor did not adversely affect the corneal endothelium. However, these results suggested that prophylactic intracameral injection of besifloxacin, gatifloxacin, or moxifloxacin, if needed, should be administered as a last therapeutic resource in clinical practice, with careful and constant monitoring of corneal endothelium.

Hemorrhagic Occlusive Retinal Vasculitis After First Eye Cataract Surgery Without Subsequent Second Eye Involvement

A case of monocular postoperative hemorrhagic occlusive retinal vasculitis (HORV) after uncomplicated bilateral cataract surgery is described. HORV is a severe syndrome that leads to painless visual loss after uncomplicated cataract surgery. The same surgical procedure was adopted in both eyes except for the use of intracameral vancomycin, which was injected only in the eye that developed HORV. Diffuse retinal ischemia with vascular sheathing and intraretinal hemorrhages were detected during the fourth postoperative day. Despite treatment, the patient developed severe neovascular glaucoma. This case supports the causative role of vancomycin in the pathogenesis of HORV and suggests avoiding it for chemoprophylaxis. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:764-766.].

Endophthalmitis Prophylaxis for Cataract Surgery

Endophthalmitis after cataract surgery is a rare but potentially devastating complication. There is great variability in endophthalmitis prophylaxis practice patterns worldwide. Treatment varies globally and is based on the microbiological profile and availability of formulations. Periocular povidone-iodine antisepsis is universally adopted and considered the standard of care in most practices. Perioperative topical antibiotics are also very popular despite the lack of level 1 evidence confirming efficacy. Based on growing observational evidence, routine intracameral antibiotic prophylaxis is increasing, especially where approved commercial intraocular preparations are available. This review updates recent trends and evidence regarding endophthalmitis prophylaxis and the preferred choice of intracameral antibiotics.

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

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

Endophthalmitis Reduction with Intracameral Moxifloxacin Prophylaxis: Analysis of 600 000 Surgeries

PURPOSE

To compare the postoperative endophthalmitis rate before and after initiation of intracameral (IC) moxifloxacin prophylaxis for both phacoemulsification and sutureless, manual small-incision cataract surgery (M-SICS), as well as in patients with posterior capsular rupture (PCR).

DESIGN

Retrospective, clinical registry.

PARTICIPANTS

All cataract surgeries (617 453) performed during the 29-month period from January 2014 to May 2016 at the 10 regional Aravind eye hospitals were included.

METHODS

The electronic health record data for all study eyes were analyzed. Endophthalmitis rates before and after moxifloxaxin were statistically compared for all eyes and separately for both phacoemulsification and M-SICS, and for the eyes complicated by PCR.

MAIN OUTCOME MEASURES

The postoperative endophthalmitis rates before and after initiation of IC moxifloxacin prophylaxis.

RESULTS

Overall, 302 815 eyes did not receive IC moxifloxacin and 314 638 eyes did, and there was a significant decline in the endophthalmitis rate, from 0.07% (214/302 815) to 0.02% (64/314 638) (P < 0.001), with moxifloxacin. For the 194 252 phacoemulsification eyes, the endophthalmitis rate was 0.07% (75/104 894) without IC moxifloxacin prophylaxis, compared with 0.01% (11/89 358) with moxifloxacin (P < 0.001). For the 414 657 M-SICS eyes, the endophthalmitis rate was 0.07% (135/192 149) without IC moxifloxacin prophylaxis, compared with 0.02% (52/222 508) with moxifloxacin (P < 0.001). Approximately half of the 8479 eyes that had PCR received IC moxifloxacin, and half did not. Without IC moxifloxacin, PCR increased the endophthalmitis rate nearly 7-fold to 0.48% (20/4186); IC moxifloxacin reduced the endophthalmitis rate with PCR to 0.21% (9/4293) (P = 0.034). No adverse events were due to IC moxifloxacin.

CONCLUSIONS

Routine IC moxifloxacin prophylaxis reduced the overall endophthalmitis rate by 3.5-fold (3-fold for M-SICS and nearly 6-fold for phacoemulsification). There was also a statistical benefit for eyes complicated by PCR, and IC antibiotic prophylaxis should be strongly considered for this high-risk population. These conclusions are strengthened by the high volume of cases analyzed at a single hospital network over a comparatively short time frame. Considering the association of hemorrhagic occlusive retinal vasculitis with vancomycin and the commercial unavailability of IC cefuroxime in many countries, moxifloxacin appears to be an effective option for surgeons electing IC antibiotic prophylaxis.

Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery

BACKGROUND

Endophthalmitis is a severe inflammation of the anterior or posterior (or both) chambers of the eye that may be sterile or associated with infection. It is a potentially vision-threatening complication of cataract surgery. Prophylactic measures for endophthalmitis are targeted against various sources of infection.

OBJECTIVES

To evaluate the effects of perioperative antibiotic prophylaxis for endophthalmitis following cataract surgery compared with no prophylaxis or other form of prophylaxis.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), Ovid MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to December 2016), Embase (January 1980 to December 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to December 2016),the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We used no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 6 December 2016. We also searched for additional studies that cited any included trials using the Science Citation Index.

SELECTION CRITERIA

We included randomized controlled trials that enrolled adults undergoing cataract surgery (any method and incision type) for lens opacities due to any origin. We included trials that evaluated preoperative antibiotics, intraoperative (intracameral, subconjunctival or systemic), or postoperative antibiotic prophylaxis for acute endophthalmitis. We excluded studies that evaluated antiseptic preoperative preparations using agents such as povidone iodine or antibiotics for treating acute endophthalmitis after cataract surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full-text articles for eligibility, assessed the risk of bias for each included study, and abstracted data.

MAIN RESULTS

Five studies met the inclusion criteria for this review, including 101,005 adults and 132 endophthalmitis cases. While the sample size was very large, the heterogeneity of the study designs and modes of antibiotic delivery made it impossible to conduct a formal meta-analysis. Interventions investigated included the utility of adding vancomycin and gentamycin to the irrigating solution compared with standard balanced saline solution irrigation alone, use of intracameral cefuroxime with or without topical levofloxacin perioperatively, periocular penicillin injections and topical chloramphenicol-sulfadimidine drops compared with topical antibiotics alone, and mode of antibiotic delivery (subconjunctival versus retrobulbar injections; fixed versus separate instillation of gatifloxacin and prednisolone). The risk of bias among studies was low to unclear due to information not being reported. We identified one ongoing study.Two studies compared any antibiotic with no antibiotic. One study, which compared irrigation with antibiotics in balanced salt solution (BSS) versus BSS alone, was not sufficiently powered to detect differences in endophthalmitis between groups (very low-certainty evidence). One study found reduced risk of endophthalmitis when combining intracameral cefuroxime and topical levofloxacin (risk ratio (RR) 0.14, 95% confidence interval (CI) 0.03 to 0.63; 8106 participants; high-certainty evidence) or using intracameral cefuroxime alone (RR 0.21, CI 0.06 to 0.74; 8110 participants; high-certainty evidence) compared with placebo, and an uncertain effect when using topical levofloxacin alone compared with placebo (RR 0.72, CI 0.32 to 1.61; 8103 participants; moderate-certainty evidence).Two studies found reduced risk of endophthalmitis when combining antibiotic injections during surgery and topical antibiotics compared with topical antibiotics alone (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.12 to 0.92 (periocular penicillin and topical chloramphenicol-sulfadimidine; 6618 participants; moderate-certainty evidence); and RR 0.20, 95% CI 0.04 to 0.91 (intracameral cefuroxime and topical levofloxacin; 8101 participants; high-certainty evidence)).One study, which compared fixed versus separate instillation of gatifloxacin and prednisolone, was not sufficiently powered to detect differences in endophthalmitis between groups (very low-certainty evidence). Another study found no evidence of a difference in endophthalmitis when comparing subconjunctival versus retrobulbar antibiotic injections (RR 0.85, 95% CI 0.55 to 1.32; 77,015 participants; moderate-certainty evidence).Two studies reported any visual acuity outcome; one study, which compared fixed versus separate instillation of gatifloxacin and prednisolone, reported only that mean visual acuity was the same for both groups at 20 days postoperation. In the other study, the difference in the proportion of eyes with final visual acuity greater than 20/40 following endophthalmitis between groups receiving intracameral cefuroxime with or without topical levofloxacin compared with no intracameral cefuroxime was uncertain (RR 0.69, 95% CI 0.22 to 2.11; 29 participants; moderate-certainty evidence).Only one study reported adverse events (1 of 129 eyes had pupillary membrane in front of the intraocular lens and 8 eyes showed posterior capsule opacity). No study reported outcomes related to quality of life or economic outcomes.

AUTHORS' CONCLUSIONS

Multiple measures for preventing endophthalmitis following cataract surgery have been studied. High-certainty evidence shows that injection with cefuroxime with or without topical levofloxacin lowers the chance of endophthalmitis after surgery, and there is moderate-certainty evidence to suggest that using antibiotic eye drops in addition to antibiotic injection probably lowers the chance of endophthalmitis compared with using injections or eye drops alone. Clinical trials with rare outcomes require very large sample sizes and are quite costly to conduct; thus, it is unlikely that many additional clinical trials will be conducted to evaluate currently available prophylaxis. Practitioners should rely on current evidence to make informed decisions regarding prophylaxis choices.

POSTOPERATIVE HEMORRHAGIC OCCLUSIVE RETINAL VASCULITIS: A FORME FRUSTE VARIANT?

PURPOSE

To present a forme fruste variant of hemorrhagic occlusive retinal vasculitis (HORV) after uncomplicated cataract surgery performed with vancomycin in the irrigating solution.

METHODS

A report of a single patient who developed HORV; the clinical features and course are described and compared with previously reported cases.

RESULTS

Ultra-widefield fluorescein angiography demonstrated an occlusive vasculitis in both eyes 1 week after uncomplicated cataract surgery in which vancomycin was added to the irrigating solution. An extensive systemic evaluation including a hypercoagulable workup, serum electrophoresis, complete blood count, and carotid and cardiac ultrasound was negative. Visual acuity was unaffected, and the patient remained 20/20 in each eye one year after surgery without treatment. This is a markedly different outcome than seen in previously reported cases of HORV.

CONCLUSION

Ultra-widefield angiography was helpful to confirming the diagnosis of HORV in this milder case example in a patient who maintained excellent vision. This forme fruste variant of HORV after exposure to vancomycin suggests that the incidence of HORV after cataract surgery may be more common than previously reported. Vigilance, close observation, and broad reporting can help further clarify the incidence and potential adverse effects of routinely using intracameral vancomycin during cataract surgery.

Transzonular vitreous injection vs a single drop compounded topical pharmaceutical regimen after cataract surgery

Purpose

To compare the relative effectiveness of a Tri-Moxi-Vanc intraocular solution injected transzonularly into the vitreous with the topical formulation of Pred-Moxi-Ketor (given for the first week postoperatively) followed by Pred-Ketor (given for weeks 2–4 after surgery).

Patients and methods

This was a single-site, single-surgeon, prospective, randomized, subject-masked contralateral eye study with an active comparator and was approved by an appropriate ethics committee. Twenty-five subjects with uncomplicated cataract who were scheduled for cataract surgery were enrolled. If surgery was uneventful, subjects received either an injection in that eye or followed a minimum drop postoperative pharmaceutical regimen. The second eye surgery was performed with the opposite treatment. Subjects were followed for 1 month. Measures of interest were the changes in intraocular pressure (IOP) from baseline and the changes in corneal and macular thickness. Subjects were also asked to evaluate pain perception, visual quality, and overall satisfaction with surgery. They were also asked which regimen they preferred.

Results

IOP was not statistically significantly different between the groups (P=0.81); there was also no statistically significant difference in IOP over time (P=0.74). There was no statistically significant difference in central macular thickness at 1 week and 1 month between the groups (P=0.18). The central corneal thickness was significantly greater 1 day postoperatively relative to baseline, but there was no statistically significant difference between the groups at any time point (P=0.92). The difference in reported pain was also not statistically significantly different between the groups (P=0.67). Satisfaction with surgery was similar for both groups, but significantly more subjects preferred the injection for overall experience (P<0.01).

Conclusion

Cataract surgery completed with the two pharmaceutical regimens was similar in outcome. Significantly more subjects preferred the injection, presumably as a function of the greater convenience with no apparent difference in the therapeutic effect.

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.

Antibiotic prophylaxis: different practice patterns within and outside the United States

Endophthalmitis remains a rare but important cause of visual loss. Prophylaxis strategies are important to reduce rates of endophthalmitis after cataract surgery, intravitreal injection, and other procedures. There is substantial variability between the US and the rest of the world. During cataract surgery, intracameral antibiotics are commonly used in many nations, especially in Europe, but are less commonly used in the US. A randomized clinical trial from the European Society of Cataract and Refractive Surgeons reported an approximately fivefold reduction in endophthalmitis rates associated with intracameral cefuroxime but these results are controversial. There are no randomized clinical trials regarding endophthalmitis associated with intravitreal injection. Topical antibiotics are commonly used in many nations, but are less commonly used in the US. At this time, there is no global consensus and it appears unlikely that additional major clinical trials will conclusively define the optimal endophthalmitis prophylaxis techniques.