Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from 2 million consecutive cataract surgeries

Ocular Pharmacology

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

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

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

New Approaches to Overcoming Antimicrobial Resistance in Endophthalmitis

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

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Incidence and Predictive Risk Factors for Post-Cataract Surgery Endophthalmitis in Ministry of Health Hospitals from 2012 to 2020

PURPOSE

Postoperative endophthalmitis is a devastating complication, leading to poor visual prognosis. The purpose of this study is to determine the incidence, risk factors, and visual outcome of post-cataract surgery endophthalmitis in Malaysia over a 9-year period (2012-2020).

METHODS

Data from National Eye Database (NED), involving all patients who have undergone cataract surgery from January 2012 until December 2020 were analyzed.

RESULTS

Total number of patients who had undergone cataract surgery between the year 2012 till 2020 were 231,281 patients (267,781 eyes). Incidence of POE in this population was 0.08%. Patient aged 70 and above (p-value 0.047), Malay ethnicity (p-value: 0.009), presence of ischemic heart disease, renal failure, diabetic retinopathy, and poorer preoperative vision were shown to have a higher risk of POE. Cataract surgeries done in KK-KKM, duration more than 45 minutes, use of general anaesthesia, and no IOL or ACIOL implantation were significantly more in POE patients. Multivariate analysis revealed Malay ethnicity, presence of ocular comorbidity, poor preoperative vision, ACIOL, and presence of intra-operative complication were predictive factors for POE.

CONCLUSIONS

Incidence of POE is low in the Malaysian population. Surgeons have to be aware that Malay ethnicity, presence of ocular comorbidity, poor preoperative visual acuity, placement of IOL and complicated cataract operation have higher risk of POE.

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

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

ASCRS clinical advisory on intracameral moxifloxacin injection for infection prophylaxis

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

Antibiotic prophylaxis for cataract surgery - Practice patterns amongst Indian Ophthalmologists

Purpose

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

Methods

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

Results

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

Conclusion

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

Postoperative Complications of True Dropless Cataract Surgery versus Standard Topical Drops

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

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

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

Potential environmental effect of reducing the variation of disposable materials used for cataract surgery

PURPOSE

To analyze the cataract package variability in 1 country, Austria.

SETTING

Austrian Departments of Ophthalmology.

DESIGN

Cross-sectional study.

METHODS

The cataract package components of 3 different Austrian hospitals were weighed and life cycle assessment on each product performed. This data was then extrapolated to the sales figures of the main Austrian cataract package suppliers to estimate the carbon footprint of all cataract packages used in Austria in 2021.

RESULTS

There were 55 different cataract package compositions in use with an average weight of 0.7 kg. These compositions differ significantly in weight and composition considering that the smallest package was 57% lighter than the largest package. The size of the surgical drapes also showed considerable variation, with a difference of up to 71%. This is substantial, considering that drapes and covers account for about 53% of the package weight.

CONCLUSIONS

There was a considerable variation in package composition and product size, which could provide opportunities to save carbon dioxide emissions in cataract surgery. If all Austrian eye departments were to reduce the material quantities and drape sizes to the lower third of the cataract packages used in the Austria in 2021, cataract package associated CO 2 emissions could be reduced by 34%.

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.

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

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

Ochrobactrum anthropi: A Rare Cause of Culture-Proven Acute Post-Operative Cluster Endophthalmitis

AIM

To report the clinical presentation and management outcomes of an outbreak of culture-proven post-operative endophthalmitis (POE) secondary to Ochrobactrum anthropi.

METHODS

This study was conducted at a tertiary-care eye hospital in South India.

RESULTS

Fifty-five patients underwent cataract surgery by six surgeons on three consecutive days in the same surgical facility in September 2020. Four patients developed POE after a mean interval of 12.0 ± 4.8 days and underwent immediate vitreous tap and intravitreal antibiotic injections (Vancomycin and Ceftazidime). All patients required a core vitrectomy (culture positive, n = 4/4). Two patients underwent an additional intraocular lens explantation, 2 and 4 months after presentation. All the four patients showed good anatomical and functional recoveries (mean follow-up, 5.75 ± 1.5 months). Two other patients had an exaggerated post-operative inflammation, which was successfully treated with topical medications.

CONCLUSIONS

O. anthropi is a rare cause of acute POE. Although the isolated organism was multi-drug resistant, the outcome was good in all the patients.

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.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Previous intravitreal injection as a risk factor of posterior capsule rupture in cataract surgery: a systematic review and meta-analysis

PURPOSE

Intravitreal injections and cataract surgery are two common procedures in the elderly. Posterior capsular rupture (PCR) is a rare but important complication of cataract surgery. We systematically reviewed the literature on previous intravitreal injections as a risk factor of PCR and performed meta-analyses to provide pooled summary risk estimates.

METHODS

We searched 13 literature databases on 1 June 2021 for studies evaluating the risk of PCR in eyes undergoing cataract surgery with data on previous intravitreal injections. Data extraction was made independently by two authors and discussed afterwards until reaching consensus. Random effects meta-analyses on the pooled odds ratio (OR) of PCR in eyes with previous intravitreal injections were made using MetaXL 5.3.

RESULTS

Six studies on 1 051 097 eyes undergoing cataract surgery were eligible for the qualitative and quantitative review. Previous history of intravitreal injections was present in 7034 eyes (majority was anti-VEGF). Our meta-analyses revealed that any previous intravitreal injection was a risk factor for PCR with an OR of 2.30 (95% CI 1.39-3.81). For each previous intravitreal injection, the risk of PCR was OR 1.04 (95% CI 1.01-1.08) (equivalent of relative risk ~1.04). In other words, risk of PCR increases by 4% for each previous intravitreal injection.

CONCLUSIONS

Previous intravitreal injection is a risk factor for PCR and should be taken into account when planning cataract surgery. However, to be regarded as a clinically significant risk of PCR, a substantial number of previous intravitreal injection (e.g. ≥10) should have been administered, considering that the a priori risk of PCR is very low (~1%).

Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery

PURPOSE

To determine whether four new operating room (OR) protocols instituted because of COVID-19 reduced the cataract surgical postoperative endophthalmitis rate (POE).

DESIGN

Retrospective, sequential, clinical registry study.

METHODS

85 552 sequential patients undergoing cataract surgery at the Aravind Eye Hospitals between 1 January 2020 and 25 March 2020 (56 551 in group 1) and 3 May 2020 and 31 August 2020 (29 011 in group 2). In group 1, patients were not gowned, surgical gloves were disinfected but not changed between cases, OR floors were not cleaned between every case, and multiple patients underwent preparation and surgery in the same OR. In group 2, each patient was gowned, surgical gloves were changed between each case, OR floors and counters were cleaned between patients, and only one patient at a time underwent preparation and surgery in the OR.

RESULTS

Group 1 was older, had slightly more females, and better preoperative vision. More eyes in group 2 underwent phacoemulsification (p=0.18). Three eyes (0.005%) in group 1 and 2 eyes (0.006%) in group 2 developed POE (p=0.77). Only one eye that underwent phacoemulsification developed POE; this was in group 1. There was no difference in posterior capsule rupture rate between the two groups.

CONCLUSIONS

Adopting a set of four temporary OR protocols that are often mandatory in the Western world did not reduce the POE rate. Along with previously published studies, these results challenge the necessity of these common practices which may be needlessly costly and wasteful, arguing for the reevaluation of empiric and potentially unnecessary guidelines that govern ophthalmic surgeries.

Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2021 ASCRS member survey

In an online survey of >1200 global cataract surgeons, 66% were using intracameral (IC) antibiotic prophylaxis. This compared with 50% and 30% in the 2014 and 2007 surveys, respectively. Irrigation bottle infusion and intravitreal injection was each used by only 5% of respondents. For IC antibiotics, vancomycin was used by 6% in the United States (52% in 2014), compared with 83% for moxifloxacin (31% in 2014). Equal numbers used compounded moxifloxacin or the Vigamox bottle as the source. There was a decrease in respondents using preoperative (73% from 85%) and postoperative (86% from 97%) topical antibiotic prophylaxis; the latter was not used by 24% of surgeons injecting IC antibiotics. Reasons cited by those not using IC antibiotics include mixing/compounding risk (66%) and being unconvinced of the need (48%). However, 80% believe having a commercially approved IC antibiotic is important; if reasonably priced, this would increase adoption of IC prophylaxis to 93%.

Acute postoperative endophthalmitis after resurgery following primary cataract surgery: 9 years experience from a tertiary eyecare center

PURPOSE

To report the incidence, risk factors, and visual outcomes of acute postoperative endophthalmitis in patients undergoing resurgery after cataract surgery.

SETTING

Tertiary eye hospital in southern India.

DESIGN

Retrospective, clinical registry.

METHODS

Medical records of patients were retrospectively reviewed from January 2010 to December 2018. Incidence, risk factors, causative organisms, management, and outcomes were studied. Patients who underwent resurgery within 6 weeks of primary cataract surgery and developed endophthalmitis within 6 weeks of resurgery were included.

RESULTS

A total of 5705 patients (0.64%) underwent resurgery. Of 5705 resurgeries, 11 patients (0.19%) developed postoperative endophthalmitis. The incidence of endophthalmitis was higher in the eyes having a breach in the posterior capsule than the eyes with no breach in the posterior capsule (10/1277 [0.78%] vs 1/4428 [0.02%]). Among the 11 patients, secondary intraocular lens (IOL) implantation was the most common indication for resurgery (9/11 [82%]) after which endophthalmitis occurred. Three (27.3%) of the 11 patients were culture-positive. Nine (82%) of 11 patients were managed with a vitreous tap along with intravitreal antibiotics and steroid injections. After treatment, 80% of the patients achieved a visual acuity of 6/18 or greater (logMAR 0.5, P value < .05). None of the eyes developed phthisis bulbi.

CONCLUSIONS

Eyes having a breach in the posterior capsule requiring vitrectomy and taken for resurgery as secondary IOL implantation were having an increased risk for endophthalmitis. The posttreatment visual outcomes were favorable.

Macular and choroidal thickness after intracameral moxifloxacin for prevention of postcataract endophthalmitis

PURPOSE

To determine any changes in macular or choroidal thickness associated with the use of intracameral moxifloxacin as postcataract endophthalmitis prophylaxis.

SETTING

University of Campinas, Campinas, São Paulo, Brazil.

DESIGN

Prospective, randomized, partially masked, single-site clinical trial.

METHODS

Phacoemulsification surgery patients in the experimental group (Group A) received a 0.03 mL intracameral injection of undiluted moxifloxacin from a sealed bottle immediately after phacoemulsification surgery (150 μg in 0.03 mL-Vigamox solution), whereas the control group (Group B) did not. Investigators evaluated in masked fashion macular and choroidal thickness using spectral-domain optical coherence tomography preoperatively and postoperatively.

RESULTS

A total of 93 patients were included (48 in Group A and 45 in Group B). Baseline parameters were similar between the groups. Either of the 2 parameters assessed differed statistically between the groups or preoperatively vs postoperatively. On postoperative day 30, central macular thickness was 8.85 ± 14.78 μm in Group A and 10.26 ± 22.44 μm in Group B (P = .7232); choroidal thickness as measured by enhanced depth imaging (EDI) was 1.45 ± 16.13 μm in Group A and 3.74 ± 16.15 in Group B (P = .5017). On postoperative day 60, central macular thickness was 19.53 ± 39.28 μm in Group A and 17.14 ± 53.68 μm in Group B (P = .8363); EDI was 5.08 ± 21.96 μm in Group A and 5.24 ± 15.8 in Group B (P = .9752).

CONCLUSIONS

The application of intracameral injection of 0.03 mL of undiluted 0.5% moxifloxacin during phacoemulsification surgery as endophthalmitis prophylaxis induced no changes in macular or choroidal thickness.

Survey of cataract surgeons' and nurses' attitudes toward operating room waste

In an online survey of more than 1300 cataract surgeons and nurses, 93% believed that operating room waste is excessive and should be reduced; 78% believed that we should reuse more supplies; 90% were concerned about global warming; and 87% wanted medical societies to advocate for reducing the surgical carbon footprint. The most commonly cited reasons for excessive waste were regulatory and manufacturer restrictions on reuse or multiple use of devices, supplies, and pharmaceuticals. More than 90% believed that profit, liability reduction, and failure to consider carbon footprint drive manufacturers to produce more single-use products; more than 90% want more reusable products and more regulatory and manufacturer discretion over when and which products can be reused. Assuming comparable cost, 79% of surgeons preferred reusable over disposable instruments. In order of decreasing consensus, most were interested in reusing topical and intracameral medications, phacoemulsification tips, irrigating solutions/tubing, blades, cannulas, devices, and surgical gowns.

Postoperative Endophthalmitis in Immediate Sequential Bilateral Cataract Surgery: A Nationwide Registry Study

PURPOSE

To report the incidence of postoperative endophthalmitis (PE) after immediate sequential bilateral cataract surgery (ISBCS) in Sweden.

DESIGN

Retrospective cohort registry study.

PARTICIPANTS

Patient data from 1 457 172 cataract extractions, including 1 364 934 unilateral surgeries and 92 238 ISBCSs.

METHODS

Endophthalmitis cases reported to the Swedish National Cataract Register (NCR) during a 16-year period (2002-2017) were analyzed in comparison to all control cases with regard to patient characteristics, surgical technique, and capsule complication.

MAIN OUTCOME MEASURE

Incidence and determinants for PE in ISBCS compared with unilateral surgeries.

RESULTS

A total of 422 cases of PE were identified in 1 457 172 cataract extractions, yielding an overall incidence of 0.029% (95% confidence interval [CI], 0.0262-0.0317). For unilateral procedures, the rate was 0.0299% (95% CI, 0.0270-0.0328) or 408 cases in 1 364 934 operations, whereas that for ISBCS was 0.0152% (95% CI, 0.0072-0.0231) or 14 incidents in 92 238 operations (P = 0.01). In a logistic regression model including all cataract procedures, nonuse of intracameral (IC) antibiotics (ABs), capsule complication, age 85 years or more, male gender, and ocular comorbidity were found to be independent risk factors for PE. All these parameters were less frequent in ISBCS. Notwithstanding, in the same multivariate analysis, ISBCS in itself was associated with a significantly lower risk for PE. At follow-up, 5 of the 14 PE cases in the ISBCS cohort had a visual acuity (VA) of 20/200 or worse. Of these, one 93-year-old ISBCS patient developed bilateral infection.

CONCLUSIONS

After ISBCS in Sweden, PE occurred once in 6600 surgeries. The risk of sustaining a final VA of 20/200 or less was 1 incident in 18 000 operated eyes. When counseling potential ISBCS patients about the risk of PE, it seems reasonable to state that the reported risk in the literature is lower than that with unilateral surgery but not negligible. Precautions remain necessary.

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

PURPOSE

To estimate the association of cefuroxime and moxifloxacin in relation to the occurrence of endophthalmitis following phacoemulsification cataract surgery.

DESIGN

Retrospective clinical cohort study.

METHODS

We studied patients with noncomplex phacoemulsification cataract surgery in Kaiser Permanente Northern California during 2014-2019. Data were obtained for acute, postoperative endophthalmitis within 90 days of phacoemulsification, including culture and antibiogram results, intracameral and topical antibiotic agent, and dose. In a post hoc analysis, we also examined preoperative anterior chamber depth (ACD) and postoperative anterior chamber volume (ACV).

RESULTS

Of 216,141 surgeries, endophthalmitis occurred in 0.020% of moxifloxacin-injected eyes and 0.013% of cefuroxime eyes (relative risk 1.62 with 95% CI 0.82-3.20, P = .16). Of the 34 (0.016%) cases of endophthalmitis, cefuroxime 1 mg was injected into 13 eyes and moxifloxacin 0.1% into 21 eyes. Organisms with antibiograms were identified in 12 (35%) cases. Of these, bacteria recovered from cefuroxime-injected eyes were resistant to cefuroxime in all cases (4/4), with Enterococcus comprising half of these. In eyes injected with moxifloxacin 0.1%, 6 out of 7 organisms were sensitive to moxifloxacin injected with 0.1 mL and in 1 eye injected with 1 mL. Streptococcus was the most common organism recovered (6/9) in moxifloxacin-injected eyes. Preoperative ACD and postoperative calculated ACV were higher in eyes injected with moxifloxacin.

CONCLUSIONS

Endophthalmitis cases with positive cultures were generally related to organism resistance in cefuroxime eyes but to sensitive organisms in moxifloxacin eyes. Moxifloxacin doses may have been insufficient in eyes with larger ACV.

Postoperative endophthalmitis with and without intracameral moxifloxacin prophylaxis in a high volume surgery setting

Objective

This study was conducted to understand the effects of intracameral moxifloxacin in decreasing the incidence of postoperative endophthalmitis after cataract surgery in an eye hospital with a high volume surgical load.

Methods and analysis

In this single-centre, retrospective, clinical registry-based study, we compared the rates of postoperative endophthalmitis in 31 340 cataract surgery patients operated during 22 months after June 2018 who received intracameral moxifloxacin to 80 643 patients operated during 41 months before June 2018 who did not receive intracameral moxifloxacin. All patients received subconjunctival gentamycin and dexamethasone. Combined surgical procedures were excluded from the study.

Results

There was a significant reduction (p<0.001) of postoperative endophthalmitis rates in cataract surgeries from 0.144% (116/80 643) to 0.025% (8/31 340) after initiation of intracameral moxifloxacin. Endophthalmitis rates decreased from 0.120% (12/9942) to 0.009% (1/10 787) in phacoemulsification group and from 0.147% (104/70 701) to 0.034% (7/20 553) in manual small-incision cataract surgeries. Gram-positive organisms including Coagulase-negative staphylococci (37.9%, n=11) and Staphylococcus aureus (S. aureus 34.5%, n=10) were the most common organisms isolated out of 29 culture-positive cases. 24.1% (28/116) endophthalmitis cases in group without moxifloxacin were culture positive compared with 14.3% (1/7) of cases in moxifloxacin group. 72% (n=8) of the Coagulase-negative staphylococci and 80% of S. aureus isolates (n=8) showed in vitro sensitivity to moxifloxacin.

Conclusion

Prophylactic use of intracameral moxifloxacin injection in addition to subconjunctival gentamycin in cataract surgery is associated with a significant decrease in rates of postoperative endophthalmitis when compared with the use of subconjunctival gentamycin alone in high volume settings.

Impact of prophylactic intracameral moxifloxacin on post-cataract surgery endophthalmitis: data from a tertiary eye care facility in rural India

PURPOSE

To study the impact of prophylactic intracameral (IC) moxifloxacin on the incidence, clinical profile and outcomes in eyes developing post-cataract surgery endophthalmitis (PCE).

METHODS

This was a single-centre, retrospective, comparative, observational study in which all eyes with PCE between June 2013 and May 2014 without IC moxifloxacin prophylaxis (group A) and June 2015-May 2016 with IC moxifloxacin prophylaxis (group B) were analysed.

RESULTS

A total of 101,815 cataract surgeries were performed in group A and 112,967 in group B. PCE was diagnosed in 179 eyes (0.18%) in group A and 92 eyes (0.08%) in group B (p < 0.001). Greater reduction in risk of PCE was seen in subsidised patients compared to private. The presenting and final visual acuity was significantly better in group B (p < 0.05).

CONCLUSIONS

Prophylactic IC moxifloxacin reduced the incidence of PCE with maximum benefit being observed for the subsidised patients and also helped achieve a significantly better visual acuity following the resolution of endophthalmitis.

PHACOVITRECTOMY FOR PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT REPAIR: A Retrospective Review

PURPOSE

To analyze the single surgery success rate and anterior segment complications related to phacoemulsification and intraocular lens implantation in a series of patients undergoing phacovitrectomy for all types of primary rhegmatogenous retinal detachment.

METHODS

We performed a retrospective interventional case series on 302 eyes undergoing phacovitrectomy for primary rhegmatogenous retinal detachment repair between November 1, 2016, and February 2, 2019, in Edmonton, Canada. Primary outcomes included single surgery retinal reattachment rate and anterior segment complications. Secondary outcomes included the effects of proliferative vitreoretinopathy and macula and/or peripheral internal limiting membrane peeling on the rate of surgical success.

RESULTS

The single surgery success rate of phacovitrectomy for all types of primary rhegmatogenous retinal detachment was 85.1%. The presence of proliferative vitreoretinopathy was associated with lower surgical success (odds ratio, 0.33; P = 0.01). Macular internal limiting membrane peeling was associated with higher surgical success (odds ratio, 2.4; P = 0.05). Anterior segment complications included posterior capsular opacification (28.8%), posterior synechiae (10.9%), and posterior capsular rupture (2.3%).

CONCLUSION

Phacovitrectomy is a safe and effective treatment option for the primary repair of rhegmatogenous retinal detachments. This study provides evidence to support the safe incorporation of phacoemulsification and intraocular lens implantation with retinal surgery.

Twenty years of endophthalmitis: Incidence, aetiology and clinical outcome

PURPOSE

To review the incidence, aetiology and outcomes of endophthalmitis during a 20-year period in a Norwegian university hospital.

METHODS

Single-centre retrospective review. Medical records of all patients admitted to Stavanger University Hospital with suspected endophthalmitis between January 1999 and December 2018 were reviewed.

RESULTS

We identified 84 eyes of 81 patients. Postoperative endophthalmitis (PE) was seen in 64 eyes (76%), endogenous endophthalmitis in thirteen eyes (15%), trauma in four eyes (5%) and three eyes (4%) had keratitis-associated endophthalmitis. Administration of intravitreal injections (IVI) was the most common cause (30%), followed by cataract surgery (CS) (21%). Of 40238 IVI, 23 PE cases were identified (incidence, 0.057%; 95% confidence interval [CI] 0.036-0.086%). Of 39697 CS, 12 PE cases were identified (incidence, 0.030%; 95%CI 0.016-0.053%). After introduction of intracameral cefuroxime PE incidence after CS decreased from 0.10% in 1999-2003 to 0.015% in 2004-2018 (p = 0.003). Eighty-four per cent of organisms were Gram-positive. Coagulase-negative staphylococci accounted for 54% of culture-proven cases, and 89% of post-IVI culture-proven cases. Thirty eyes (36%) either regained their previous vision or lost ≤1 Early Treatment Diabetic Retinopathy Study line. One third of endophthalmitis cases had a favourable visual outcome of logMAR 0.2 or better.

CONCLUSION

PE after IVI occurred in 1 in 1750 procedures, and was the most common cause of PE. The incidence of PE after CS has decreased >sixfold since 2003, to 1 in 6700 surgeries. A high proportion of low-virulence bacterial species may have contributed to the favourable visual outcome.

Incremental effect of topical and oral moxifloxacin administration with surgical intracameral prophylaxis

OBJECTIVE

To determine how supplemental perioperative topical or oral moxifloxacin administration impacts anterior chamber (AC) antibiotic concentrations beyond those achieved by intracameral (IC) administration alone for postoperative endophthalmitis (POE) prophylaxis.

DESIGN

Mathematical modeling.

METHODS

The mathematical model developed by Arshinoff, Modabber, and Felfeli was adapted to calculate all reported data. A literature review of pharmacokinetic data for topical and oral moxifloxacin was used to inform the expansion of the model.

RESULTS

Our previously constructed IC model yields a dose of moxifloxacin in the AC sufficient to confer bactericidal coverage against the most common POE pathogen, methicillin-sensitive Staphylococcus aureus (MSSA), for ∼40 hours postoperatively. Topical 0.5% moxifloxacin eye drops alone, administered every 4 or 6 hours, achieve an AC concentration just above or at the mutant prevention concentration (MPC) for MSSA, respectively, whereas 8-hour dosing produces levels generally below the MPC. Combining topical moxifloxacin with IC increases the AC concentration above IC alone only after 20 or more hours and maintains the AC concentration at, or just below, the MPC for MSSA for as long as the drops are continued. Combined perioperative oral moxifloxacin with IC increases AC levels over IC alone only after 16 hours and maintains the AC concentration above the MPC for MSSA for an additional 5 hours, owing to the systemic reservoir.

CONCLUSIONS

The addition of topical or oral moxifloxacin supplemental to IC can extend the duration of bactericidal coverage for the most common, but not the most resistant POE-causing pathogens.

Efficacy of intracameral antibiotics following manual small incision cataract surgery in reducing the rates of endophthalmitis: A meta-analysis

BACKGROUND

Manual small incision cataract surgery (MSICS) is a widely used technique for cataract surgery in the developing world. Higher rates of postoperative endophthalmitis have been reported with this technique compared with phaco-emulsification. The purpose of this study was to evaluate the efficacy of prophylactic intracameral (IC) antibiotics in reducing the rates of postoperative endophthalmitis following MSICS.

METHODS

Systematic review and meta-analysis of patients undergoing MSICS. A literature search in PubMed and EMBASE databases was performed to identify studies published from October 1992 to April 2020 evaluating MSICS with a minimum of 500 eyes reported. Two authors independently assessed eligibility, extracted data and assessed the risk of bias. Heterogeneity was assessed using the I² test.

RESULTS

Twelve studies enrolling 1 494 307 eyes were included. IC antibiotics were used in 725 324 (48.5%) eyes. The risk ratio of developing endophthalmitis was 2.94 (95% CI, 1.07-8.12; P = .037) in eyes that did not receive IC antibiotics.

CONCLUSIONS

Routine use of IC antibiotics may help to reduce the rates of endophthalmitis following MSICS and significantly improve the safety of this effective form of cataract surgery.

What Is the Cost of a Posterior Capsule Rupture Complication?

BACKGROUND AND OBJECTIVE

To examine the cost of a posterior capsule rupture (PCR) in patients who underwent planned phacoemulsification.

PATIENTS AND METHODS

Retrospective review of 8,113 cataract surgeries performed between January 2014 and December 2017 at one academic institution. The rate of PCR was 0.55%, and 34 patients with PCR who met inclusion criteria were identified. Investigators evaluated the added operating room time required to manage PCR, subsequent surgeon visits beyond the typical average, referrals to other specialties, further imaging, and additional required surgeries.

RESULTS

Patients with PCR had an additional 2.76 (standard deviation [SD] ± 3.27) postoperative encounters and 3.06 (SD ± 3.78) visits to another subspecialty. Operating room time was found to average 61.43 minutes (range: 21 to 191 minutes) at an additional cost of $455.48 (SD ± $407.37). Additional visits, imaging, and procedures added $655.59 (SD ± $767.21). The total additional average cost was $1,111.07 (SD ± $1,021.20) per PCR.

CONCLUSION

Posterior capsular ruptures impose a substantial cost burden on the health care system. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:444-447.].

Posterior Capsule Rupture during Cataract Surgery in Eyes Receiving Intravitreal anti-VEGF Injections

PURPOSE

To examine the risk of posterior capsule rupture (PCR) during phacoemulsification cataract surgery in patients who received intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections prior to surgery.

METHODS

A retrospective study was conducted of cataract surgeries at the Sue Anschutz-Rodgers UCHealth Eye Center from January 1, 2014, through December 31, 2018. The primary outcome was the occurrence of PCR during surgery. Other variables of interest included age, race, sex, ocular comorbidities, diabetes, mature cataract, primary surgeon, injection frequency and type, and date of most recent injection. Predictors of PCR were assessed using logistic regression with generalized estimating equations to account for correlation between patient eyes. Additional sub-analysis was performed on eyes with PCR with and without anti-VEGF injection history to compare intraoperative characteristics, post-operative complications, and visual outcomes.

RESULTS

In total 10,327 cataract surgeries were included in the analysis, and 308 of these eyes received anti-VEGF injections prior to surgery. Of the 308 eyes that received anti-VEGF injections, eight (2.6%) had a PCR during surgery compared to 45 of 10,019 eyes (0.5%) that did not receive injections (unadjusted OR = 5.9, 95% CI: 2.8-12.7, p < .0001). Males and diabetics were more likely to have received injections and had higher rates of PCR, so these variables were adjusted for in the multivariate analysis of the association between injections and PCR (adjusted OR = 4.7, 95% CI: 2.1-10.4, p-value = 0.0001). Eyes with mature cataracts and those that underwent surgery with a resident as the primary surgeon were also at higher risk of PCR, but these variables were not associated with the anti-VEGF injection. Injection frequency, time between most recent injection and surgery, and type of anti-VEGF agent were not significantly associated with PCR.

CONCLUSIONS

History of intravitreal anti-VEGF injections was associated with higher odds of PCR during cataract surgery.

Peri-Operative Intracameral Antibiotics: The Perfect Storm?

In our University journal club we discussed a large, retrospective study of cataract surgery endophthalmitis rates before and after instituting the use of an intracameral fluoroquinolone antibiotic. We identified several factors involved in the use of off-label, compounded moxifloxacin in intraocular surgery. The introduction of phacoemulsification for cataract surgery led to the potential for smaller incisions. Intraocular lens technology improved to allow for foldable lenses, obviating the requirement to enlarge the incision. This allowed for clear corneal incisions, which unfortunately allow bidirectional passage of liquid. Preservatives were introduced into multi-dose ophthalmic products in the mid 20th century to retard microbial growth. However, more recently, chronic use of benzalkonium chloride has led to concerns about concerns about conjunctival toxicity, especially in patients with ocular surface disease. In the formulation of ocular moxifloxacin, developers were able to develop a "self-preserved", multi-dose product. Other concerns with eyedrops include varying levels of adherence and performance, and the expansion of compounding pharmacies from a named-patient basis to widespread national delivery, with concerns for lower quality. Integrating these factors, use of intracameral moxifloxacin as a prophylactic during cataract and other anterior segment surgery has become a standard of care in much of the U.S. We are concerned that the current position is on a narrow ledge-the standard of care for millions of surgeries each year based upon off-label, compounting use of a single product. We discuss possible ramifications and solutions to this public health issue.

Visual and Refractive Outcomes of Cataract Surgeries Performed in One Year in a Private Practice Setting: Review of 2714 Procedures

Methods

Our center's database was used to identify all isolated cataract procedures performed during 2017. The electronic records were reviewed to collect the preoperative information, presence of intra- or postsurgical complications, and visual and refractive outcomes one month after surgery.

Results

In 2017, 2714 eyes of 1543 patients underwent cataract surgery in our center. Mean patient age was 70.42 years. 775 eyes (28.55%) had prior ophthalmic pathologies, and 113 eyes (4.16%) had undergone previous surgical procedures. Surgical complications developed in 35 eyes (1.29%), including 9 posterior capsule tears (0.33%) and 3 cases of dropped lens fragments (0.11%). A toric or multifocal intraocular lens was implanted in 45.6% of eyes. As regards postoperative complications, 59 eyes (2.17%) required a return to the operating theater, including 29 eyes (1.07%) requiring reinterventions due to an unexpected refractive result. There were no cases of endophthalmitis. Mean LogMAR-corrected distance visual acuity (CDVA) improved from 0.25 (SD 0.34) preoperatively to 0.04 (SD 0.17) postoperatively; 86.5% of eyes achieved a CDVA ≤0.0, with 97.5% achieving ≤0.3. In 86.4% of eyes, the difference between target and residual spherical equivalent difference was of 0.50 D or lower; 88% of eyes had a spherical equivalent ±0.50 D.

Conclusions

The visual and refractive outcomes of cataract surgery in a private practice setting were excellent, well over the benchmarks set by the ESCRS. The safety profile was also within expected standards. This study provides information for ophthalmologists in private practice on expected outcomes.

Commonly used intracameral antibiotics for endophthalmitis prophylaxis: A literature review

Endophthalmitis is a serious complication of cataract surgery that occurs in thousands of patients each year. To decrease the incidence of postoperative endophthalmitis, many surgeons inject intracameral antibiotics (cefuroxime, moxifloxacin, and vancomycin) routinely at the end of surgery. A large number of recently published retrospective studies and large database analyses have reported decreased endophthalmitis rates with routine antibiotic use, and the only prospective, multicenter, randomized trial performed by the European Society of Cataract and Refractive Surgery demonstrated that intracameral cefuroxime decreases the incidence of postoperative endophthalmitis. Routine cefuroxime use has become common in many European countries, whereas moxifloxacin is the most commonly used drug in India, and vancomycin use predominates in Australia. The decision regarding whether or not to use intracameral prophylaxis and the drug that is selected varies considerably throughout the world because of antibiotic availability and cost, and the spectrum of causative organisms. Adverse events due to intracameral antibiotics are infrequent, but complications such as hemorrhagic occlusive retinal vasculitis have been reported. Because additional prospective, comparative trials have not been performed, a consensus regarding best practices to prevent postoperative endophthalmitis has not been reached. Additionally, many surgeons do not routinely use intracameral antibiotics because they believe them unnecessary with modern aseptic techniques, small incision surgery, and shorter operating times. We discuss the most commonly used intracameral antibiotics, present the risks and potential benefits of this approach, and highlight challenges with drug compounding and safety.

Incidence of cystoid macular oedema with intracameral cephalosporin or vancomycin in cataract surgery

Purpose: To compare the incidence of pseudophakic cystoid macular oedema (CME) in patients who receive intracameral cephalosporin versus intracameral vancomycin during cataract surgery.Methods: A retrospective chart review was conducted on subjects with the diagnosis of CME between January 1 2010 and July 31 2017. Inclusion criterion was the documentation of CME after cataract extraction. Exclusion criteria were intraoperative complication, prior history of macular oedema, epiretinal membrane, uveitis, other pre-existing retinal pathology, or other post-operative pathology including other ocular surgery in the post-operative period.Results: The final analysis included 89 eyes with optical coherence tomography (OCT) proven CME. The incidence of pseudophakic CME in our population of 10,165 cataract surgeries after applying the above-stated exclusion criteria was 0.88%. The incidence of pseudophakic CME in subjects who received intracameral cephalosporin was 0.87% (mean age in years 69 ± 11; 31 male [39%], 48 female [61%]). The incidence of pseudophakic CME in subjects who received intracameral vancomycin was 0.96% (mean age in years 66 ± 13; 4 male [40%], 6 female [60%]). Pearson's chi-square test demonstrated no significant difference between these groups (p = 0.7705).Conclusions: There was no statistical difference in the incidence of pseudophakic CME in subjects who received intracameral cephalosporin versus intracameral vancomycin during cataract surgery.

Drop-free approaches for cataract surgery

PURPOSE OF REVIEW

Routine prophylaxis for adverse events following cataract surgery is evolving. Prior reliance on topical eyedrop instillation by patients is giving way to surgeon directed injections at the time of cataract surgery. The benefit of this new approach is assured delivery of drugs in standardized doses which should optimize the healing process and reduce the incidence of untoward events with higher confidence.

RECENT FINDINGS

Adoption rates of intracameral antibiotic injection amongst European and American cataract surgeons is increasing. Techniques to inject periocular corticosteroid for routine inflammation prophylaxis are also in development. In combination with intraoperative pharmacologic dilation, a drop-free modality can be achieved.

SUMMARY

Intraoperative injections offer the patient and surgeon assured drug delivery and hold promise to avoid the pitfalls of patient adherence, incorrect topical instillation, and topical drop-associated corneal issues.