A retrospective study of endophtalmitis rates comparing quinolone antibiotics

Tracing the barriers to decarbonising ophthalmology: A review

As climate change demands increasingly urgent mitigation of greenhouse gas emissions, the health sector needs to do its part to decarbonise. Ophthalmologists share concerns about climate change and seek opportunities to reduce their environmental impact. When measuring the footprint of ophthalmology, major contributions are from patient travel to clinics, and from the large amounts of single-use disposable materials that are consumed during surgeries and sterile procedures. Ophthalmic services in India have already demonstrated systems that consume far fewer of these products through efficient throughput of patients and the safe reuse of many items, while maintaining equivalent safety and quality outcomes. Choosing these low-cost low-emission options would seem obvious, but many ophthalmologists experience barriers that prevent them operating as Indian surgeons do. Understanding these barriers to change is a crucial step in the decarbonisation of ophthalmology and the health sector more broadly.

Reducing topical drug waste in ophthalmic surgery: multisociety position paper

This position article on reducing topical drug waste with ophthalmic surgery was written by the Ophthalmic Instrument Cleaning and Sterilization Task Force, comprising representatives of the ASCRS, American Academy of Ophthalmology, American Glaucoma Society, and Outpatient Ophthalmic Surgery Society. Drug waste significantly increases the costs and carbon footprint of ophthalmic surgery. Surgical facilities should be permitted to use topical drugs in multidose containers on multiple patients until the manufacturer's labeled date of expiration, if proper guidelines are followed. Surgical patients requiring a topical medication not used for other patients should be allowed to bring that partially used medication home for postoperative use. These recommendations are based on published evidence and clarification of policies from multiple regulatory and accrediting agencies with jurisdiction over surgical facilities. Surveys suggest that most ambulatory surgery centers and hospitals performing cataract surgery are wasting topical drugs unnecessarily.

Release of Moxifloxacin From Corneal Collagen Shields

OBJECTIVES

To investigate the diffusion of moxifloxacin through bandage contact lenses (BCLs) versus corneal collagen shields (CSs), the relative ability of BCLs and CSs to release moxifloxacin, and the potential of release of moxifloxacin from CSs in the clinical setting.

METHODS

Using an in vitro model, the diffusion of 5% moxifloxacin across BCLs and CSs was compared. Next, the amount of drug release from BCLs and CSs soaked in 0.5% moxifloxacin was measured. Finally, based on a clinical model, CSs were soaked in Vigamox (commercial moxifloxacin) and the total concentration released was detected. Collagen shields remained intact after 24 hr; therefore, enzymatic digestion and mechanical grinding of the CS were performed to determine whether further drug could be released. The concentration of moxifloxacin was measured using a spectrophotometer at set time points up to 24 hr.

RESULTS

In the diffusion assay, 35.7±10.5% diffused through the BCLs and 36.2±11.8% diffused through the CSs (P=0.77). The absorption assay demonstrated at 120 min, a total of 33.3±6.77 μg/mL was released from BCLs compared with 45.8±5.2 μg/mL from the CSs (P=0.0008). In vitro experiments to simulate clinical application of Vigamox-soaked CS found the concentration of moxifloxacin released of 127.7±7.25 μg/mL in 2 mL of phosphate-buffered saline over 24 hr.

CONCLUSIONS

Moxifloxacin diffuses through BCLs and CSs at similar rates; however, CSs have greater capacity to absorb and release moxifloxacin compared with BCLs. Vigamox-soaked CSs released 250 μg of moxifloxacin and may be a useful method to prevent endophthalmitis.

Post-cataract surgery endophthalmitis: Brief literature review

PURPOSE

To investigate recent evidence in prophylaxis and management of post-cataract surgery endophthalmitis.

METHODS

We conducted a literature search using Pubmed database for post cataract surgery endophthalmitis, and relevant articles were selected from original English papers published since 2015.

RESULTS

Forty-nine articles were published regarding post-cataract surgery endophthalmitis from January 2015 to February 2016. A low incidence of post-cataract surgery endophthalmitis has been reported. A growing number of articles are focusing on preventing endophthalmitis using intracameral antibiotics.

CONCLUSION

Based on the current evidence, intracameral antibiotics seems to be effective in preventing endophthalmitis after cataract surgery.

Customized Clinical Practice Guidelines for Management of Adult Cataract in Iran

Purpose:

To customize clinical practice guidelines (CPGs) for cataract management in the Iranian population.

Methods:

First, four CPGs (American Academy of Ophthalmology 2006 and 2011, Royal College of Ophthalmologists 2010, and Canadian Ophthalmological Society 2008) were selected from a number of available CPGs in the literature for cataract management. All recommendations of these guidelines, together with their references, were studied. Each recommendation was summarized in 4 tables. The first table showed the recommendation itself in clinical question components format along with its level of evidence. The second table contained structured abstracts of supporting articles related to the clinical question with their levels of evidence. The third table included the customized recommendation of the internal group respecting its clinical advantage, cost, and complications. In the fourth table, the internal group their recommendations from 1 to 9 based on the customizing capability of the recommendation (applicability, acceptability, external validity). Finally, customized recommendations were sent one month prior to a consensus session to faculty members of all universities across the country asking for their comments on recommendations.

Results:

The agreed recommendations were accepted as conclusive while those with no agreement were discussed at the consensus session. Finally, all customized recommendations were codified as 80 recommendations along with their sources and levels of evidence for the Iranian population.

Conclusion:

Customization of CPGs for management of adult cataract for the Iranian population seems to be useful for standardization of referral, diagnosis and treatment of patients.

Antibiotic prevention of postcataract endophthalmitis: a systematic review and meta-analysis

Endophthalmitis is one of the most feared complications after cataract surgery. The aim of this systematic review was to evaluate the effect of intracameral and topical antibiotics on the prevention of endophthalmitis after cataract surgery. A systematic literature review in the MEDLINE, CINAHL, Cochrane Library and EMBASE databases revealed one randomized trial and 17 observational studies concerning the prophylactic effect of intracameral antibiotic administration on the rate of endophthalmitis after cataract surgery. The effect of topical antibiotics on endophthalmitis rate was reported by one randomized trial and one observational study. The quality and design of the included studies were analysed using the Cochrane risk of bias tool. The quality of the evidence was evaluated using the GRADE approach. We found high-to-moderate quality evidence for a marked reduction in the risk of endophthalmitis with the use of intracameral antibiotic administration of cefazolin, cefuroxime and moxifloxacin, whereas no effect was found with the use of topical antibiotics or intracameral vancomycin. Endophthalmitis occurred on average in one of 2855 surgeries when intracameral antibiotics were used compared to one of 485 surgeries when intracameral antibiotics were not used. The relative risk (95% CI) of endophthalmitis was reduced to 0.12 (0.08; 0.18) when intracameral antibiotics were used. The difference was highly significant (p < 0.00001). Intracameral antibiotic therapy is the best choice for preventing endophthalmitis after cataract surgery. We did not find evidence to conclude that topical antibiotic therapy prevents endophthalmitis.

Endophthalmitis prophylaxis in cataract surgery: overview of current practice patterns in 9 European countries

Data on practice patterns for prophylaxis against infectious postoperative endophthalmitis (IPOE) during cataract surgery in 9 European countries were searched in national registers and reviews of published surveys. Summary reports assessed each nation's IPOE rates, nonantibiotic prophylactic routines, topical and intracameral antibiotic use, and coherence to the European Society of Cataract & Refractive Surgeons (ESCRS) 2007 guidelines. Although the reliability and completeness of available data vary between countries, the results show that IPOE rates differ significantly. Asepsis routines with povidone-iodine and postoperative topical antibiotics are generally adopted. Use of preoperative and perioperative topical antibiotics as well as intracameral cefuroxime varies widely between and within countries. Five years after publication of the ESCRS guidelines, there is no consensus on intracameral cefuroxime use. Major obstacles include legal barriers or persisting controversy about the scientific rationale for systematic intracameral cefuroxime use in some countries and, until recently, lack of a commercially available preparation.

[Efficacy of topical 0.3% ciprofloxacin application in reducing the conjunctival biota of patients undergoing cataract extraction]

OBJECTIVE

To determine the efficacy of topical 0.3% ciprofloxacin in reducing conjunctival biota in patients undergoing cataract surgery.

PATIENTS AND METHODS

Experimental, prospective, randomized, controlled and single-blind study. Forty-six eyes of 46 patients were randomized into 2 groups, the study group (n=23) received topical 0.3% ciprofloxacin one day before surgery for six times, and on the day of the surgery one drop every 15minutes starting one hour before surgery until 3 doses were completed. The control group (n=23) did not receive any antibiotics. For both groups for the surgical field 10% povidone-iodine was applied. Samples from the conjunctiva were taken at four different times and then cultured on solid media (chocolate agar, blood agar) and enrichment broth (thioglycolate). The aqueous humor samples were also cultured in thioglycolate. The presence of bacteria was identified quantitatively and qualitatively, and the frequency of contamination was measured by considering the presence of bacteria in liquid and solid culture media. The number of colony forming units (CFU) was counted in the solid culture medium.

RESULTS

Positive cultures were obtained in 82.6% and 78.2% of the patients in the study and control groups, respectively, before the administration of 0.3% ciprofloxacin. The administration of 0.3% ciprofloxacin significantly reduced the CFU compared to the control group (P<.05). Immediately after the use of povidone-iodine, the proportion of patients with a positive culture decreased to 21.7% in the study group, and 8.7% in the control group. At the end of the surgery, this percentage was 26% and 30.4%, respectively. The most common isolated pathogen was negative-coagulase Staphylococcus (66.7%).

CONCLUSION

The administration of 0.3% ciprofloxacin reduces conjunctival bacterial load in the preoperative period. However, it was unable to eradicate the bacteria completely. The administration of povidone-iodine reduced conjunctival biota in 50%-70% of patients undergoing cataract surgery.

Intracameral cefuroxime injection at the end of cataract surgery to reduce the incidence of endophthalmitis: French study

PURPOSE

To determine whether an intracameral injection of cefuroxime at the end of cataract surgery decreases the incidence of postoperative endophthalmitis.

SETTING

Dupuytren Hospital, Ophthalmology Department, Limoges, France.

DESIGN

Clinical trials.

METHODS

Patients having cataract surgery between April 2003 and June 2008 were included in a survey of operative-site infection. Intracameral cefuroxime injections started in June 2006. Preoperative data (beta-lactam allergy, a history of endophthalmitis, age, sex), intraoperative data (use of trypan blue, use of capsular ring or iris retractors, surgical time, senior or junior surgeon, corticosteroid injection, iris retractors), and the incidence of postoperative infections at 8 days and 1 month were prospectively collected.

RESULTS

During the inclusion period, 5115 patients had cataract surgery; 2289 received cefuroxime and 2826 did not. The incidence of endophthalmitis was 35 (1.238%) of 2826 patients without intracameral cefuroxime and 1 (0.044%) of 2289 patients with intracameral cefuroxime; the difference was statistically significant (P<.0001). No intraoperative factor was significantly associated with postoperative infection. No allergic reaction was reported.

CONCLUSION

Intracameral cefuroxime injection at the end of cataract surgery was safe and significantly decreased the incidence of endophthalmitis.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Toxicity comparison of intraocular azithromycin with and without a bioadhesive delivery system in rabbit eyes

PURPOSE

To determine whether the addition of a bioadhesive drug-delivery system to topical azithromycin induces intraocular inflammation and damage when introduced intraocularly by different approaches and in varying doses.

SETTING

John A. Moran Eye Center, Salt Lake City, Utah, USA.

DESIGN

Experimental study.

METHODS

Commercial topical azithromycin 1.0% was duplicated, including the benzalkonium chloride, but without inclusion of the Durasite bioadhesive drug-delivery system. Injections of 50 μL, 25 μL, and 10 μL of the antibiotic solutions were administered in a masked fashion to 2 rabbits; 1 eye (study eye) in each rabbit was randomized to receive azithromycin with the delivery system and the fellow eye (control eye) to receive azithromycin without the delivery system. Two rabbits had topical drops of each solution placed after a 2.8 mm incision was created. Masked slitlamp examinations, pachymetry, and intraocular pressure (IOP) were determined 1 day and 2 days postoperatively. The animals were humanely killed, and the endothelial density and histopathology were examined.

RESULTS

The IOP (P<.001), pachymetry (P<.001), and signs of inflammation (P=.38 to .003) were consistently higher in the study eye, especially at the 50 μL dose, than in the control eye. This was confirmed by histopathology.

CONCLUSION

If the drug-delivery system gains access to the anterior chamber, it may cause substantial corneal edema and inflammation, even at low doses and after topical administration.

Prophylactic efficacy of ophthalmic quinolones in experimental endophthalmitis in rabbits

PURPOSE

The aim of this study was to determine the efficacy of 0.3% gatifloxacin ophthalmic solution in preventing bacterial endophthalmitis in rabbits.

METHODS

Eighty-four (84) albino phakic rabbits were injected unilaterally with 2 x 10(4) colony forming units of Enterococcus faecalis into the anterior chamber. The eyes received 0.3% ofloxacin ophthalmic ointment or 0.3% gatifloxacin ophthalmic solution with different regimens in three separate experiments: (1) 1 or 3 drops of gatifloxacin every 2 h or a single application of ofloxacin for 1 day; (2) 3 drops/day of gatifloxacin application started at 0, 6, and 24 h postinoculation, or 1 drop at 0 h, and 3 times daily gatifloxacin for the following 3 days; and (3) 1 or 3 drops of gatifloxacin application started at 0 h and no further application for the following 3 days. The control eyes received no treatment in the three experiments. The effectiveness of these different regimens was assessed by slit-lamp biomicroscopy and bacterial colony counts. The ocular penetration of the drugs was determined in a separate experiment, using 36 normal albino rabbits.

RESULTS

The concentration-time curves for gatifloxacin and ofloxacin appeared parallel, with mean peak concentrations of 1161 and 219 ng/mL, respectively, at 1 h postinstillation. In Experiment 1, gatifloxacin significantly reduced the inflammation and the number of living bacteria in the aqueous humor, compared with controls, whereas ofloxacin ointment did not. A single application of ofloxacin ointment was not better than 1 drop of gatifloxacin. The results of Experiment 2 showed that the effectiveness of gatifloxacin decreased as the interval between the inoculation and the onset of treatment increased. In Experiment 3, only 3 drops of gatifloxacin on day 1 kept the inflammation significantly lower than that in the control for 4 days.

CONCLUSIONS

Immediate postoperative prophylaxis would likely be effective in reducing the risk of enterococcal endophthalmitis by topical gatifloxacin.

Prevention of endophthalmitis by collagen shields presoaked in fourth-generation fluoroquinolones versus by topical prophylaxis

PURPOSE

To compare the prophylaxis of collagen shields presoaked in antibiotics versus antibiotic drops after bacterial anterior chamber challenge.

SETTING

John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.

METHODS

Forty rabbits received bilateral 0.03 mL intracameral injections of Staphylococcus epidermidis (5 x 10(8) colony-forming units). Four groups of 10 rabbits had their eyes randomized to receive (1) 3 mg/mL gatifloxacin (Zymar) drops or shield in Zymar, (2) Zymar drops or shield in 10 mg/mL gatifloxacin (Tequin), (3) 5 mg/mL moxifloxacin (Vigamox) drops or shield in Vigamox, or (4) balanced salt solution (BSS) drops or shield in BSS. Each eye received Zymar, Vigamox, or BSS 4 times 1 hour before injection. The antibiotic-BSS was administered every 2 hours (5 doses total). One day later, signs of endophthalmitis were scored under the slitlamp.

RESULTS

Groups 1 and 2 had significantly lower endophthalmitis incidences (total score > or = 8) than the BSS controls. Shield scores were not significantly different from those of the counterpart drops. The comparison between drops was not significant (P = .0513); the difference between shields (P = .0232) and the post-comparison Zymar versus BSS shields (P = .0021) were significant.

CONCLUSIONS

Topical therapy with gatifloxacin before and after intraocular bacteria challenge led to lower incidences of endophthalmitis in rabbits. Prophylaxis with presoaked collagen shields was not statistically different than that with topical drops.

Control of inflammation and prophylaxis of endophthalmitis after cataract surgery: a multicenter study

PURPOSE

To compare two different postcataract surgery antibiotic/steroid therapeutic combinations, for clinical results as well as patient satisfaction.

METHODS

Prospective randomized clinical trial of patients with bilateral operative cataract. Postoperatively, for 15 days one eye was randomly assigned to therapy with the combination chloramphenicol 0.25%-betamethasone 0.13% gel three times a day (Group 1) and the other to the combination tobramycin 0.3%-dexamethasone 0.1% eyedrops four times a day (Group 2).

RESULTS

A total of 142 patients (284 eyes) completed the study. The authors could not detect any significant difference between Group 1 and Group 2 concerning preoperative evaluation, surgical procedure, and complications. Pertaining to the two therapeutic regimens, efficacy, side effects, and clinical findings such as uncorrected visual acuity, intraocular pressure, edema or hyperemia of eyelids and/or conjunctiva, conjunctival and/or ciliary vessels congestion, decreased corneal transparency, corneal edema, Descemet folds, anterior chamber Tyndall and depth, and posterior synechiae were also comparable. Postoperative subjective pain and dry eye sensation were comparable between the two groups, while the gel preparation elicited a significantly more pleasant sensation in the patients (p=0.04).

CONCLUSIONS

The motivation for use of a gel is to prolong the permanence of associated drugs on the ocular surface, increasing potency and decreasing concentration of the drug and rate of administration. This in order to improve compliance and decrease potential side effects. Chloramphenicol 0.25%-betamethasone 0.13% gel combination proved to have comparable efficacy, tolerance, and better acceptance by the patients than an aqueous tobramycin 0.3%-dexamethasone 0.1% preparation.

Patterns of perioperative prophylaxis for cataract surgery in Canada

BACKGROUND

The objective of this study was to document prophylactic methods used for cataract surgery in Canada.

METHODS

The Web-based link to a password-protected, anonymous, online survey was e-mailed or mailed, between November 2004 and January 2005, to 800 ophthalmologists practicing in Canada.

RESULTS

Of the 239 respondents (30% response rate), 216 performed cataract surgery. Phacoemulsification was preferred by 99%. Topical antibiotics, of which moxifloxacin was the most common (32%), were used preoperatively by 78%. Intraoperatively, 98% used providone-iodine antisepsis of skin, 15% used intracameral antibiotics and 11% subconjunctival antibiotics. Postoperative topical antibiotics, of which moxifloxacin was the most common (30%), were used by 97%, and 1% routinely used postoperative systemic antibiotics. Prophylactic regimen was changed after vitreous loss by 39%, of whom 68% added systemic antibiotics. Reported mean rate of postoperative endophthalmitis occurring within the previous year was 0.088%. Community practicing ophthalmologists were more likely to use preoperative topical antibiotics (p = 0.0016, chi2). As case volume increased, surgeons were more likely to use intracameral antibiotics (p = 0.0185, exact Mantel-Haenszel chi2 test) and postoperative topical antibiotics (p = 0.0044, exact Mantel-Haenszel chi2 test), and less likely to use subconjunctival antibiotics (p = 0.0011, exact Mantel-Haenszel chi2). As time in practice decreased, surgeons were more likely to use postoperative topical antibiotics (p = 0.0319, exact Mantel-Haenszel chi2 test). Provincial region was associated with preoperative topical antibiotic use (p = 0.0076, Fisher's exact test), intracameral antibiotic use (p = 0.0314, Fisher's exact test), and subconjunctival antibiotic use (p = 0.0373, Fisher's exact test). There was no association between reported rate of postoperative endophthalmitis and any form of perioperative antibiotic use.

INTERPRETATION

Prophylactic methods commonly used for cataract surgery in Canada include providone-iodine antisepsis and perioperative topical antibiotics. Intracameral and subconjunctival antibiotics are currently not common prophylactic methods. Systemic antibiotics are used prophylactically by a subset of ophthalmologists for cases complicated by vitreous loss.

Topical ophthalmic fourth-generation fluoroquinolones: Appropriate use and cost considerations

PURPOSE

The utilization and refill rates of topical ophthalmic fourth-generation fluoroquinolones among physicians, as well as the associated costs, were studied.

METHODS

A large data set of retrospective pharmacy prescription claims was obtained from multiple plans, including commercial managed care organizations, Medicaid, and Medicare. The data included the number and cost of all new and refill prescriptions for six months for gatifloxacin 0.3% and moxifloxacin 0.5% by physician specialty. New prescription and refill data were also analyzed from a state Medicaid plan to determine if similar trends existed.

RESULTS

Primary care physicians wrote approximately 7,000 (7.7%) gatifloxacin and 84,000 (92.3%) moxifloxacin prescriptions, with pediatricians accounting for 4,000 (5.1%) gatifloxacin and 75,000 (94.9%) moxifloxacin prescriptions. Eye care physicians accounted for a similar amount of prescriptions for each antibiotic during the same period. The total cost of prescriptions for all primary care practitioners was approximately $170,000 for gatifloxacin and $2.5 million for moxifloxacin; prescriptions written by pediatricians accounted for $110,000 for gatifloxacin and $2.2 million for moxifloxacin.

CONCLUSION

Prescription drug claims from payers using pharmacy benefit management companies during a six-month period indicated that the numbers of prescriptions written for gatifloxacin and moxifloxacin were similar among eye care physicians, but primary care physicians wrote a greater number of prescriptions for moxifloxacin. Analysis of claims to a Medicaid database revealed an increase in the prescriptions written by primary care physicians for moxifloxacin after its addition to the drug formulary.

Endophthalmitis: a reappraisal of incidence and treatment

PURPOSE OF REVIEW

The current publications that address either the incidence or treatment of endophthalmitis are reviewed.

RECENT FINDINGS

A large body of published research has recently addressed the issue of potential increases in the incidence of endophthalmitis, especially postcataract endophthalmitis. Additional studies have evaluated relatively new antibiotics and their potential effect on the prevention and treatment of endophthalmitis.

SUMMARY

Although there appears to be a renewed effort to report the incidence and theorized risk factors for postcataract endophthalmitis, there are wide discrepancies in the rate and potential causes of postoperative endophthalmitis. In regards to endophthalmitis treatment, helpful findings regarding the potency of newer antibiotics and the appropriateness of subconjunctival antibiotics are reviewed.

Endophthalmitis after Uncomplicated Cataract Surgery with the Use of Fourth-Generation Fluoroquinolones

OBJECTIVE

To estimate the rate of acute postoperative endophthalmitis after uncomplicated cataract surgery in patients treated before and after surgery with 1 of 2 different fourth-generation fluoroquinolone ophthalmic drops for surgical prophylaxis.

DESIGN

Retrospective, multicenter, observational case series.

PARTICIPANTS

Included in this study were 20,013 patients from 9 cataract surgery centers in 7 states in the United States.

METHODS

Patients who had undergone uncomplicated phacoemulsification who received preoperative and postoperative topical fourth-generation fluoroquinolones for surgical prophylaxis between March 2003 and July 2005 were included in the study. The files of patients in whom acute endophthalmitis developed were reviewed and analyzed.

MAIN OUTCOME MEASURES

Number and rate of endophthalmitis cases after uncomplicated cataract surgery.

RESULTS

During the study period, the participating surgeons performed 20,013 uncomplicated surgeries. Of these, 16,209 patients (81%) received topical gatifloxacin and 3804 patients (19%) were treated with topical moxifloxacin as antiinfective prophylaxis. A total of 14 patients experienced endophthalmitis. The overall rate of endophthalmitis was 0.07%. There were 9 endophthalmitis patients in the gatifloxacin group and 5 endophthalmitis patients in the moxifloxacin group. The rate of endophthalmitis in the gatifloxacin group was 0.06% and the rate in the moxifloxacin group was 0.1%. The difference in the rate of endophthalmitis between the 2 groups was not statistically significant. In 10 of the patients, vitreous culture results were positive. Coagulase-negative staphylococci, followed by streptococci, species were the most commonly isolated organisms in the culture-positive patients.

CONCLUSIONS

The overall rate of endophthalmitis after uncomplicated cataract surgery in patients treated with topical fourth-generation fluoroquinolones as antiinfective prophylaxis was 0.07%. This rate was within the range of previously reported rates of endophthalmitis in the literature. The difference in the observed rate of postoperative endophthalmitis in patients treated with moxifloxacin versus gatifloxacin was not statistically significant.

Penetration of topically applied levofloxacin 0.5% and ofloxacin 0.3% into the vitreous of the non-inflamed human eye

BACKGROUND

The aim of the study was to evaluate the vitreous penetration of two commercially available ophthalmic fluoroquinolones: ofloxacin and levofloxacin.

METHODS

This prospective, double-blind, randomized clinical trial comprised 16 patients scheduled for vitrectomy surgery of one eye for macular hole or macular pucker. The patients were randomly assigned to receive topical ofloxacin 0.3% (n=9) or levofloxacin 0.5% (n=7) the day before, one drop at noon, 4 p.m., 8 p.m. and midnight. The next morning, patients were given their assigned masked antibiotic every 5 min for four doses starting 1 h before surgery. The vitreous humour samples, at least 0.3 ml each, were collected 1 h after the administration of the last dose, at the beginning of the pars plana vitrectomy with infusion disconnected. Samples were assayed for ofloxacin and levofloxacin concentrations by a method using high-performance liquid chromatography (HPLC) coupled with single mass spectrometry with electrospray ionization

RESULTS

Equal topical administration of levofloxacin yielded 2.5 times higher vitreal concentration than ofloxacin. The mean vitreous concentrations of ofloxacin and levofloxacin were 5.30+/-3.04 (SD) ng/ml and 13.09+/-5.24 ng/ml, respectively (P=0.002).

CONCLUSIONS

Equal dosing with topical administration of levofloxacin 0.5% and ofloxacin 0.3% allows better penetration into the vitreous for levofloxacin, but the levels of mean concentrations of each drug did not exceed the MIC(90) or MIC(50) for most ocular pathogenic bacteria in terms of conventional endophthalmitis therapy.

Endophthalmitis and incision construction

PURPOSE OF REVIEW

The relationship between endophthalmitis after cataract extraction and type of incision has been under debate lately. In particular, clear corneal incisions have been connected with an increased incidence of postoperative endophthalmitis. This review discusses recent reports within this area.

RECENT FINDINGS

Experimental studies have demonstrated the poor integrity of a clear corneal incision under certain circumstances. A relationship between wound leakage the day after surgery and endophthalmitis has also been reported. Some large studies have shown an increase of endophthalmitis that in time coincide with the increasing use of clear corneal incision. One earlier randomized controlled study showed a higher incidence of endophthalmitis after clear corneal incision compared with superior incision. Other case series have shown an equal distribution of endophthalmitis between surgeries using different types of incision. Some studies point to the multifactorial nature of endophthalmitis and the importance of every step from antiseptic surgical field to postoperative treatment.

SUMMARY

There is no conclusive evidence of the relationship between clear corneal incision and endophthalmitis. It seems, however, that in certain situations clear corneal incision may play a role in the occurrence of endophthalmitis.

ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery

PURPOSE

To present the development and design of the European Society of Cataract & Refractive Surgeons multicenter study of the prevention of postsurgical infective endophthalmitis after phacoemulsification and to describe the process for its successful implementation and conduct.

SETTING

Twenty-four ophthalmology units and eye clinics in Austria, Belgium, Germany, Italy, Poland, Portugal, Spain, Turkey, and the United Kingdom, with an administrative office in Ireland, coordinating center in England, and data management and statistical unit in Scotland.

METHODS

This partially masked randomized placebo-controlled multinational clinical study was designed to evaluate prospectively the prophylactic effect of intracameral cefuroxime and/or perioperative topical levofloxacin on postoperative endophthalmitis after cataract surgery. Random allocation was based on a 2 x 2 factorial design that included participating centers as a class variable. Real-time electronic data collection monitored study progress and provided weekly outcome tables, monthly recruitment summaries, and quarterly analytical reports for the study's Data Monitoring Committee, which evaluated the safety and efficacy by Internet-based conferences.

RESULTS

A 2-year lead time was required to meet harmonized standards of clinical research in the European Union, obtain ministerial authorization in 3 countries, gain institutional approvals at 24 hospitals, and procure indemnity insurance for surgical centers. Informed consent instruments, designed to comply with national health policies, were translated into 8 languages. The use of information technology to collect study data enabled the organizers to evaluate individual eligibility at enrollment, adherence with study medications during and after surgery, and postoperative status during follow-up.

CONCLUSION

This international cooperative study provided the opportunity to estimate the current incidence of endophthalmitis after cataract surgery in Europe and determine whether 1 or both of 2 antimicrobial regimens reduces the risk for postsurgical intraocular infection.

Reflective consideration of postoperative endophthalmitis as a quality marker

PURPOSE

To study the incidence of acute postoperative presumed infectious endophthalmitis (PIE) in a UK district general hospital over a 10-year period. Consideration of such departmental healthcare-associated infection frequency rates as part of reflective and comparative quality practice in the light of local concerns.

METHODS

Hospital-based retrospective case series: 12 831 cataract extraction operations from 01/01/1995 to 31/12/2004 were studied. All cases of PIE within 6 weeks of cataract surgery were ascertained and investigated in a standardised format. PIE incidence rate per 1000 cataract surgical procedures was contrasted with the existing literature.

RESULTS

Seven isolated PIE cases occurred following phacoemulsification. None followed extra-capsular extractions. The PIE rate was 0.55 [95% CI; 0.22 to 1.12] cases per 1000 cataract extractions, or one PIE case within 6 weeks of surgery in every 1833 [95% CI; 893 to 4545] cataract operations undertaken. Five cases were culture positive. Details of PIE cases are presented.

CONCLUSION

PIE incidence rates in our department are slightly lower than reported case series in similar settings. Whether this is due to a variety of preventive measures deployed locally and/or methods of case ascertainment in published studies is problematic and is discussed. Departmental benchmarking data is important in relation to rare, but critical, patient safety incidents. Collection and monitoring of endophthalmitis outcomes is of merit and may inform patient choice. Surgical site infection surveillance systems of relevance are discussed. Implications for making healthcare safer, including reflective practice are, discussed in relation to cataract care.

Cohort study of 27 cases of endophthalmitis at a single institution

PURPOSE

To identify potential risk factors associated with post-cataract surgery bacterial endophthalmitis.

SETTING

The John A. Moran Eye Center, Salt Lake City, Utah, USA.

METHODS

This retrospective cohort study consisted of patients who had surgery for cataract(s) at this eye hospital. A 10% sampling of all patients operated on for cataract surgery from January 1, 1996, to December 31, 2002, were compared with all cases of postcataract surgery bacterial endophthalmitis during this same time period at this institution. The main outcome measure(s) included surgical complication, first postoperative day wound leak, incision placement and location, intraocular lens material, whether a suture was placed, antibiotic used, collagen shield use, and whether the eye was patched.

RESULTS

A total of 1525 patients were in the control cohort, and there were 27 cases of endophthalmitis. In a multivariate regression analysis, the factors found to be statistically associated with endophthalmitis were (1) wound leak on the first postoperative day (odds ratio [OR] 44 +/- 42; confidence interval [CI] 6.85 to 287; P<.001); (2) capsular or zonular surgical complication (OR 17.2 +/- 14.2; CI 3.44 to 86.4; P=.001); (3) topical antibiotic started the day after surgery rather than the day of surgery (OR 13.7 +/- 12.9; CI 2.17 to 90.9; P=.005); (4) use of ciprofloxacin rather than ofloxacin topically after surgery (OR 5.3 +/- 3.6; CI 1.41 to 20.0; P=.014); (5) not patching after surgery (OR 7.1 +/- 5.6; CI 1.47 to 36.4; P=.015); and (6) not placing a collagen shield soaked in antibiotic (OR 2.7 +/- 1.3; CI 1.06 to 7.14 P=.037).

CONCLUSION

In sutureless cataract surgery, surgical complications and wound leak on the first postoperative day were most strongly associated with endophthalmitis.