Efficacy and cost-effectiveness of intracameral vancomycin in reducing postoperative endophthalmitis incidence in Australia

Acute postoperative endophthalmitis after phacoemulsification in a private ophthalmic surgical group

PURPOSE

To analyze the incidence, causes, risk factors and treatment of acute postoperative endophthalmitis (POE) after phacoemulsification in a private ophthalmological group.

DESIGN

Uncontrolled retrospective observational study of all cases of POE over 22 years.

MATERIAL AND METHODS

369,476 eyes were included after phacoemulsification in 41 surgical centers of the Clínica Baviera-AIER EYE Group from 2002 to 2023. POE cases were reviewed.

RESULTS

The general group was divided into two: group A (2002-2007), with vancomycin in the intracameral irrigation flow (27,705 eyes); Group B (2008-2023), with intracameral cefuroxime (341,771 eyes). 31 cases of POE were found (incidence, 0.0084%); 5 in group A (0.018%) and 26 in group B (0.0076%) (P = .314), with a mean age of 67.3 years (14 men and 17 women). Cultures were positive in 14 cases in Groups A and B. Treatment was based on intravitreal antibiotics and vitrectomy. The mean time to symptom onset was 6.76 days and the mean time to resolution was 120.7 days. 12 eyes achieved corrected distance visual acuity ≥ 20/40.

CONCLUSIONS

The incidence of POEwas 0.0084% (0.0181% in group A and 0.0076% in group B). The probability of having POE in group A was 2.37 times greater than in group B (OR: 2.37; 95% CI: 0.71-6.2; P = .079). The only significant risk factor for POE was posterior capsular rupture.

Economic evaluation of an adjunctive intraocular and peri-ocular steroid vitreoretinal surgery for open globe trauma: Cost-effectiveness of the ASCOT randomised controlled trial

BACKGROUND

In the United Kingdom, it is estimated that 5,000 patients sustain eye injuries or ocular trauma requiring hospital admission annually, of which 250 patients will be permanently blinded. This study explores the cost-effectiveness of Adjunctive Steroid Combination in Ocular Trauma (ASCOT) given during surgery versus standard treatment in vitreoretinal surgery in patients with open globe trauma.

METHODS

This economic evaluation was embedded alongside the ASCOT RCT (ClinicalTrials.gov Identifier: NCT02873026). We conducted a primary cost-effectiveness analysis from a National Health Service perspective using the proportion of patients who achieved a visual acuity of 10 or more letter improvement on the Early Treatment Diabetic Retinopathy Study (ETDRS) scale as the measure of effect, in developing incremental cost-effectiveness ratios (ICERs). Secondary cost-utility analysis using the EuroQol 5 Dimension 5 Level (EQ-5D-5L) to generate a cost per quality-adjusted life-year (QALY), and a cost-effectiveness analysis using vision-specific quality of life (QoL) was conducted. Sensitivity analyses were also applied to investigate parameter uncertainties.

RESULTS

The sample size of the ASCOT intervention arm and standard care arm of this study was 130 and 129, respectively. The intervention cost per patient was estimated at £132. The proportion of participants with an ETDRS of 10 or more letter improvement was 0.47 for the ASCOT group with a mean cost of £5,526 per patient, while the standard care group had an effect of 0.43 with a mean cost of £5,099 per patient. The ICER value of the primary outcome was £12,178 per 10 or more letter improvement on the ETDRS score. The secondary result in terms of cost per QALYs gained had a probability of 44% being cost-effective at a willingness-to-pay threshold of £30,000/QALY gained.

CONCLUSIONS

Though there is no formally accepted cost-effectiveness willingness-to-pay threshold for 10-letter or more improvement, the ASCOT intervention for open globe trauma is a low-cost intervention. The ASCOT intervention is not cost-effective when compared to the standard care in this group and setting. The proportion of patients in the ASCOT intervention arm with 10 or more letter improvement produced some positive results but this is outweighed by the costs.

The Preventive Effect of Gentamicin in the Irrigating Solution on Endophthalmitis Caused by Methicillin-Resistant Staphylococcus epidermidis After Phacoemulsification with Intraocular Lens Implantation in Rabbits

OBJECTIVE

To analyze the effect of gentamicin in the irrigating solution on endophthalmitis caused by methicillin-resistant Staphylococcus epidermidis after phacoemulsification with intraocular lens implantation.

METHODS

Fifteen rabbits were randomly assigned into three groups. During surgery, group A was irrigated with gentamicin-free solution and injected with 100 μL of normal saline postoperatively, group B was irrigated with 80 μg/mL gentamicin and injected with 100 μl of MRSE suspension, group C was irrigated with gentamicin-free solution and injected with 100 μl of MRSE suspension. At different times, corneal endothelial cell count (CEC), inflammation grading，B-scan ultrasonography and histological examination were analyzed.

RESULTS

No endophthalmitis occurred in groups A and B. Group C developed severe endophthalmitis, with massive inflammatory exudation in the vitreous cavity.

CONCLUSION

Irrigating solution containing gentamicin is favorable to reduce the incidence of MRSE endophthalmitis after phacoemulsification with IOL in rabbits.

Optimization of femtosecond laser-constructed clear corneal wound sealability for cataract surgery

PURPOSE

To compare the sealability of femtosecond laser (FSL)-assisted corneal incisions (CIs) with that of triplanar manual (M)-CIs and to determine FSL wound parameters minimizing leakage.

SETTING

Private practice.

DESIGN

Phase IV, single-surgeon, retrospective cohort study.

METHODS

One eye per patient was included. Two groups defined by the main wound (FSL-CI or M-CI) were compared for leakage, inferred by placement of a suture at the end of surgery. Leakage in FSL-CIs was analyzed as a function of customizable wound parameters: anterior plane depth (APD), posterior plane depth (PPD), anterior side-cut angle (ASCA), and posterior side-cut angle (PSCA). The risk of leakage of FSL-CIs with optimal and nonoptimal parameters was further compared with that of M-CIs.

RESULTS

A total of 1100 eyes (757 [68.8%] FSL-CI; 343 [31.2%] M-CI) were included. Wound leakage occurred in 133 FSL-CI (17.6%) and 30 M-CI eyes (8.7%) (P < .001). FSL wound parameters associated with the lowest risk of leakage were 60% APD, 70% PPD, 120 degrees ASCA, and 70 degrees PSCA. FSL-CIs constructed with at least 3 optimal parameters (60% APD, 70% PPD, and 120 degrees ASCA) had a similar risk of leakage to M-CIs (odds ratio [OR], 1.1; 95% CI, 0.5-2.3). FSL-CIs with suboptimal parameters had twice the risk of leakage of M-CIs (OR, 2.0; 95% CI, 1.1-3.8).

CONCLUSIONS

Overall, FSL-CIs leaked more than M-CIs. However, FSL-CIs with optimized wound profiles had an equivalent risk of leakage to M-CIs. Wound parameter customization is an asset of FSL technology that allows optimization of FSL-CI sealability.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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.

Utility of wound cultures in the management of open globe injuries: a 5-year retrospective review

Background

Endophthalmitis after open globe injury can be devastating to vision recovery. As treatment of endophthalmitis is often empiric, some surgeons may obtain cultures at presentation of trauma in anticipation of later infection. This study examines the usefulness of wound cultures obtained during globe repair.

Results

Institutional Review Board approval was obtained. Medical records were retrospectively reviewed, with 168 open globes included. Cultures of the wound site had been taken in all cases included in this study. Wound cultures were positive in 63% of cases but were not used for clinical decision-making for any patient in this study. Two patients had evidence of endophthalmitis at presentation, with results of vitreous culture matching those from the wound. No patient later developed endophthalmitis after open globe repair.

Conclusions

Despite a high rate of wound contamination, few cases of endophthalmitis (1.2%) were seen in this series. In no case did the results of wound culture impact choice of antibiotic prophylaxis or treatment. Cultures obtained at the time of open globe repair were not cost effective in the subsequent management of the injury.

The Routine Use of Intracameral Antibiotics to Prevent Endophthalmitis After Cataract Surgery: How Good is the Evidence?

Post-operative endophthalmitis (POE) following cataract surgery is an uncommon, vision-threatening complication that has been reported to occur at rates of between approximately 0.03% and 0.2%. Prompt diagnosis and treatment of endophthalmitis is critical for minimizing vision loss, but most recent efforts have focused on the prophylactic administration of antibiotics to prevent the development of endophthalmitis. Surgeons from around the world have different topical and intracameral antibiotic usage patterns to prevent endophthalmitis, and to date no general consensus regarding best practice has emerged. Several studies have reported on the routine use of intracameral cefuroxime, moxifloxacin, and vancomycin, including a single randomized clinical trial by the European Society of Cataract and Refractive Surgery (ESCRS) in 2007. These studies have notable shortcomings, but many authors suggest that intracameral cefuroxime together with topical antibiotics probably decreases the risk of endophthalmitis. However, the deleterious effects of routine prophylactic antibiotics, which include toxicity, cost, and increasing antimicrobial resistance, among others, are noteworthy. In contrast, aseptic technique with pre-operative instillation of povidone-iodine remains the only technique supported by level I evidence to reduce the incidence of endophthalmitis. Although the routine use of intracameral antibiotics continues to increase throughout the world, data from multicenter, randomized, prospective trials is needed to provide better guidance regarding the prophylactic use of antibiotics.

Comparative analysis of the safety and efficacy of intracameral cefuroxime, moxifloxacin and vancomycin at the end of cataract surgery: a meta-analysis

BACKGROUND

Current practice methods are unclear as to the most safe and effective prophylactic pharmacotherapy and method of delivery to reduce postoperative endophthalmitis occurrence.

METHODS

A systematic review and meta-analysis using Meta-analysis of Observational Studies in Epidemiology guidelines was performed to compare the efficacy of intracameral cefuroxime, moxifloxacin and vancomycin in preventing postphacoemulsification cataract surgery endophthalmitis. A safety analysis of intracameral antibiotics was concurrently performed.

DATA SOURCES

BIOSIS Previews, CINAHL, ClinicalTrials.gov, Cochrane Library, Dissertations & Theses, EMBASE, PubMed, ScienceDirect and Scopus were searched from inception to January 2017. Data were pooled using a random effects model. All articles were individually reviewed and data were extracted by two independent reviewers. Funnel plot, risk of bias and quality of evidence analyses were performed.

RESULTS

Seventeen studies with over 900 000 eyes were included, which favoured the use of intracameral antibiotics at the end of cataract surgery (OR 0.20; 95% CI 0.13 to 0.32; P<0.00001). The average weighted postoperative endophthalmitis incidence rates with intracameral cefuroxime, moxifloxacin and vancomycin were 0.0332%, 0.0153% and 0.0106%, respectively. Secondary analyses showed no difference in efficacy between intracameral plus topical antibiotics versus intracameral alone (P>0.3). Most studies had low to moderate risk of bias. The safety analysis showed minimal toxicity for moxifloxacin. Dosing errors led to the majority of toxicities with cefuroxime. Although rare, vancomycin was associated with toxic retinal events.

CONCLUSION

Intracameral cefuroxime and moxifloxacin reduced endophthalmitis rates compared with controls with minimal or no toxicity events at standard doses. Additionally, intracameral antibiotics alone may be as effective as intracameral plus topical antibiotics.

Change in Nationwide Incidence of Post-Cataract Surgery Endophthalmitis: Korean Cohort Study from 2002 to 2013

Purpose: To investigate the change in nationwide incidence of endophthalmitis following cataract surgery in Korea from 2002 to 2013. Methods: From a national sample cohort (n = 1 025 340), cases of postoperative endophthalmitis between 2002 and 2013 were identified. Results: From 70,719 cases of cataract surgery, 49 incidents of endophthalmitis were reported, yielding an incidence of 0.069% (95% confidence interval [CI], 0.051-0.092%). Overall, the endophthalmitis incidence decreased from 0.103% in 2002-2005 to 0.045% in 2010-2013, corresponding to an annually decreasing time-trend (0.902, 95% CI, 0.827-0.984). In diabetic patients, however, the incidence was 0.128% and did not change (time trend, 1.015; 95% CI, 0.828-1.245). Conclusions: This study revealed the incidence of endophthalmitis decreased during a 12-year period, but remained constant in diabetic patients.

Antibiotic prophylaxis in cataract surgery - An evidence-based approach

Various protocols are being followed for endophthalmitis prophylaxis in cataract surgery, and this subject continues to be a matter of debate. We summarize the most recent evidence-based studies on this topic with additional stress on intracameral (IC) antibiotic prophylaxis. Here, we discuss several large, international clinical studies which discuss the efficacy, adoption, safety, cost, and newer trends in antibiotic prophylaxis. Majority of these studies report a significant reduction in endophthalmitis rates with IC antibiotic prophylaxis. Efficacy data have been reported for IC cefuroxime, vancomycin, and moxifloxacin. Surgeons are now looking for alternatives to vancomycin for IC prophylaxis because of its association with the rare but sight-threatening complication of hemorrhagic occlusive retinal vasculitis. A recent large clinical study shows convincing efficacy with IC moxifloxacin prophylaxis. Two large studies have also reported significant endophthalmitis reduction following use of IC antibiotic prophylaxis, in eyes with posterior capsule tear which are at highest risk for infection. Except for one randomized controlled trial, there is a lack of prospective data on this subject; however, considering the complexity of performing such studies, surgeons have to rely on the mounting evidence from other recent big data studies. Availability of approved intraocular antibiotic formulations will see a much higher adoption in the future.

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

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

An updated estimate of costs of endophthalmitis following cataract surgery among Medicare patients: 2010-2014

BACKGROUND

Endophthalmitis, which can occur after ophthalmic surgery, is an inflammation of the intraocular cavity and causes temporary or permanent vision impairment. However, little is known about the cost of treatment. The objective of this analysis was to update and expand upon the results of a previously published report that estimated the direct medical cost of treatment for endophthalmitis.

METHODS

Retrospective data analysis using 2010 through 2014 United States Medicare Limited Data Sets. Procedure codes were used to identify beneficiaries who underwent cataract surgery; demographic and clinical characteristics at the time of diagnosis were determined. Patients were stratified into cases (those who developed endophthalmitis) and controls (those who did not develop endophthalmitis) in the 3 months following surgery. Claims (ie, charges) and reimbursements (ie, costs) for cases and controls in the 6 months following cataract surgery were identified and compared. Results are presented in 2015 US dollars.

RESULTS

Of a total of 153,860 cataract surgery patients, 181 were diagnosed with endophthalmitis following cataract surgery, at a rate of 1.2 per 1,000. Cases were more likely to be male and less likely to be white than controls; age was similar. Total medical claims and reimbursements as well as ophthalmic claims and reimbursements were significantly higher for cases compared with controls. Total reimbursements, adjusted for age, sex, and region, were $4,893 higher (83% greater) and adjusted ophthalmic reimbursements were $3,002 higher (156% greater) for cases than for controls. Claims and reimbursements were significantly higher across all types of Medicare cost components.

CONCLUSION

Postcataract surgery endophthalmitis is associated with a substantial cost. Successful prophylaxis with antibiotic agents would reduce the significant costs associated with treating endophthalmitis.