Anterior Uveitis Due to Intracameral Moxifloxacin: A Case Report

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.

The possible effect of topically applied azithromycin and moxifloxacin on the alleviation of uveitis

PURPOSE

To investigate the inhibitory effect of topically administered azithromycin (AZM), and moxifloxacin (MXF) against tumor necrosis factor-α (TNF-α) production in a rat model of endotoxin-induced uveitis (EIU).

METHODS

Thirty-six Wistar albino rats were divided into 6 equal groups. Groups 1, 2 and 3 were determined as sham, control group for topical AZM application and control group for topical MXF application, respectively. Sterile saline, topical AZM 1.5%, and topical MXF 0.5% were instilled 5 times daily for totally 6 days on both eyes of the rats in Group 4, Group 5, and Group 6, before and after inducing EIU by intravitreal injections of lipopolysaccharide, respectively. At 24 h after intravitreal injections, aqueous humor was collected from both eyes of each rat for the assessment of TNF-α concentration. Also, density of nuclear factor kappa B (NF-κB) in ciliary body, and the number of cells infiltrating the posterior segment of EIU rat eyes was assessed in one eye of each rat.

RESULTS

There was a significant reduction in mean aqueous humor concentration of TNF-α in EIU rats pretreated with topical AZM in comparison with those pretreated with sterile saline (139 ± 38.6 in Group 4 vs. 72 ± 12.6 in Group 5, p = 0.006). There was also a marked decrease in mean aqueous humor concentration of TNF-α in EIU rats pretreated with topical MXF (139 ± 38.6 in Group 4 vs.86.1 ± 35.5 in Group 6, p = 0.025). Also, evident suppressions were determined in mean density of NF-κB, and in mean number of cells in EIU rats pretreated either with topical AZM, or topical MXF.

CONCLUSIONS

Topically applied AZM or MXF may be beneficial in the suppression of TNF-α production in aqueous humor.

Unilateral Acute Iris Transillumination Syndrome following Uneventful Phacoemulsification Surgery with Intracameral Moxifloxacin

PURPOSE

We report a case of unilateral acute iris transillumination (AIT) and iris sphincter paralysis in a 63-year-old male undergone uneventful phacoemulsification surgery with intracameral moxifloxacin (ICM).

CASE PRESENTATION

This is a case of AIT with no history of viral disease or use of systemic fluoroquinolone but an association with ICM after uneventful phacoemulsification. The clinical features of the affected eye are perfectly similar to what has been described in BAIT and hence we consider that unilateral AIT and BAIT share the same etiopathogenesis. At the end of the phacoemulsification, the patient received 0.15 ml of 5mg/ml moxifloxacin, which is notably higher than the dose that is commonly used for ICM. This may have caused the patient to develop BAIT-like syndrome after the ICM.

CONCLUSION

0.1 ml of 5mg/ml moxifloxacin or less should be used to reduce the risk of occurrences of this toxic effect caused by ICM.

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.

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

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

Pharmacologically induced uveitis

Treatments of numerous systemic and local diseases of different etiologies may be accompanied by an unwanted side effect in the form of uveitis. We inform readers about medications that have the potential to cause uveitis and analyze the strength of association of these medications with uveitis. Subsequently, cessation of medication or appropriate treatment can be individualized for each patient for the purpose of preventing further damage to tissue structure and function. Being aware of these associations, physicians may readily identify medications that may cause uveitis and avoid expensive and unnecessary clinical and laboratory testing.