Endophthalmitis following cataract surgery: the role of prophylactic postoperative chloramphenicol eye drops

Effect of a topical antibiotic and povidone-iodine vs povidone-iodine alone on conjunctival flora:systematic review and meta-analysis

TOPIC

This systematic review and meta-analysis aimed to determine whether adding preoperative topical antibiotics to povidone-iodine (PVI) offers any additional benefit over PVI alone in reducing conjunctival bacterial flora, thereby potentially lowering the risk of postoperative endophthalmitis. The participants included 1423 eyes undergoing elective intraocular surgeries (eg, cataract, keratoplasty, and trabeculectomy) or receiving intravitreal injections. The interventions studied were PVI combined with third-generation quinolones (levofloxacin, moxifloxacin, or gatifloxacin) compared with PVI alone. The outcome measure was postintervention rate of positive conjunctival bacterial cultures before ophthalmic procedure.

CLINICAL RELEVANCE

Postoperative endophthalmitis is a rare but serious complication of intraocular surgery, potentially leading to significant vision loss. Although PVI is widely recognized as an essential prophylactic measure, the role of preoperative topical antibiotics remains debated. Defining the necessity of antibiotic use in routine cataract surgery is important, especially given the concerns about antibiotic resistance and the rising cost of health care. The current standard of care varies globally, with PVI commonly used alone in many regions, such as the United Kingdom.

METHODS

Studies were included based on the comparison of preoperative PVI with or without antibiotics in patients undergoing intraocular surgery. Searches were conducted in PubMed, Cochrane, and Embase databases, covering literature up to October 2024. Risk of bias was assessed using the Cochrane risk of bias tool.

RESULTS

7 studies were included, comprising 1423 eyes. A meta-analysis revealed no significant difference in the reduction of conjunctival bacterial flora between PVI + antibiotics and PVI alone (odds ratio [OR], 0.77; 95% CI, 0.42-1.42; P = .41). Subgroup analysis showed that levofloxacin combined with PVI significantly reduced positive culture rates (OR, 0.48; 95% CI, 0.29-0.81; P = .006), whereas moxifloxacin and gatifloxacin did not show similar benefits. Moderate heterogeneity was observed across studies ( I2 = 58%; P = .04).

CONCLUSIONS

This review found no conclusive benefit of using preoperative topical antibiotics alongside PVI in routine ophthalmic procedures. However, in patients at high-risk of endophthalmitis, levofloxacin may offer additional protection.

PROSPERO REGISTRATION NUMBER

CRD42024603822.

Topical Chloramphenicol in Ophthalmology: Old is Gold

PURPOSE

Topical chloramphenicol is one of the most ubiquitous antibiotics used in ophthalmology and oculoplastic surgery globally. It shows broad-spectrum activity against a variety of different pathogenic organisms, is well tolerated on the ocular surface and displays excellent topical pharmacokinetics. Chloramphenicol has been available for purchase over the counter in the United Kingdom since 2005. Despite this, the largest health economy in the world, The United States has had a de-facto moratorium on its use for the past 30 years. In this review, we aim to evaluate topical chloramphenicol in ophthalmology and oculoplastic surgery and to determine whether its reputation within the US is warranted and justified.

METHODS

We conducted a comprehensive literature review to evaluate the different facets of chloramphenicol, providing a detailed understanding of the drug, its historical context, the benefits and perceived risks, including safety concerns, and clinical perspectives of its use in clinical practice.

RESULTS

The mechanism of chloramphenicol, the context around which the drug's use in the US declined, and the drug's evidence base and safety data, including published case reports of serious adverse events, were analysed. The perceived benefits of the drug, particularly in light of antimicrobial resistance and its economic impact, were reviewed. Finally, perspectives on its use in clinical practice in ophthalmology and associated allied specialities were presented.

CONCLUSION

Chloramphenicol and its topical application have been misunderstood for many decades, particularly in the United States. Its demise across the Atlantic was due to an overzealous response to a dubious association with a weak evidence base. Numerous authors have since validated the safety profile of the and its safety has been borne out. The benefits of chloramphenicol, an effective broad-spectrum agent with a positive cost differential in the era of anti-microbial resistance and fiscal tightening, cannot be understated. Its likely effectiveness as a therapeutic topical agent in ophthalmic surgery makes it a valuable tool in the ophthalmic anti-microbial armoury. We would encourage the reinstatement of this valuable yet misunderstood drug as a first-line agent for simple ophthalmic infections.

Comparison of preoperative prophylaxis with povidone-iodine (5%) and moxifloxacin (0.5%) versus povidone-iodine (5%) alone: a prospective study from India

PURPOSE

To compare the effect of povidone-iodine (PI) 5% and moxifloxacin 0.5% solutions versus PI 5% solution alone on the conjunctival bacterial flora.

METHODOLOGY

This is a comparative study in which the study population comprised adult patients scheduled for elective small incision cataract surgery. The eye to be operated (control eye) received topical moxifloxacin 0.5% drops 4 times, 1 day before surgery and 2 applications on the day of surgery. As placebo, the contralateral eye (study eye) received saline 0.90% drops as per the same schedule. Before surgery, on table, PI 5% was instilled in the conjunctival sac in both eyes. Conjunctival swabs were taken before initiation of therapy and 3 min after instillation of PI.

RESULTS

Of the 96 pairs of eyes included in the study, conjunctival cultures before prophylaxis were similar between the two groups (p = 0.31), with 54 samples (56%) of the study group and 49 (51%) of the control group showing growth. With positive cultures reducing to 7 (14%) in the study group and 8 (16%) in the control group, both the prophylaxis methods appeared equally efficacious (p = 0.79). Both the groups showed a significant reduction in positive cultures following prophylaxis (p < 0.0001).

CONCLUSIONS

PI 5% alone as preoperative prophylaxis was as effective as its combination therapy with moxifloxacin 0.5% in the reduction in conjunctival bacterial colonization.

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.

Cost-Effectiveness of Preoperative Topical Antibiotic Prophylaxis for Endophthalmitis Following Cataract Surgery

PURPOSE

To determine the cost-effectiveness of preoperative topical antibiotic prophylaxis for the prevention of endophthalmitis following cataract surgery.

DESIGN

Cost-effectiveness analysis using a decision-analytic microsimulation model.

METHODS

Preoperative topical antibiotic prophylaxis vs no-prophylaxis costs and effects were projected over a life-time horizon for a simulated cohort of 500 000 adult patients (≥18 years old) requiring cataract surgery in theoretical surgical centers in the United States. Efficacy and cost (2021 US dollars) values were obtained from the literature and discounted at 3% per year.

RESULTS

Based on inputted parameters, the mean incidence of endophthalmitis following cataract surgery for preoperative topical antibiotic prophylaxis vs no-prophylaxis was 0.034% (95% CI 0%-0.2%) and 0.042% (95% CI 0%-0.3%), respectively-an absolute risk reduction of 0.008%. The mean life-time costs for cataract surgery with prophylaxis and no-prophylaxis were $2486.67 (95% CI $2193.61-$2802.44) and $2409.03 (95% CI $2129.94-$2706.69), respectively. The quality-adjusted life-years (QALYs) associated with prophylaxis and no-prophylaxis were 10.33495 (95% CI 7.81629-12.38158) and 10.33498 (95% CI 7.81284-12.38316), respectively. Assuming a cost-effectiveness criterion of ≤$50 000 per QALY gained, the threshold analyses indicated that prophylaxis would be cost-effective if the incidence of endophthalmitis after cataract surgery was greater than 5.5% or if the price of the preoperative topical antibiotic prophylaxis was less than $0.75.

CONCLUSIONS

General use of preoperative topical antibiotic prophylaxis is not cost-effective compared with no-prophylaxis for the prevention of endophthalmitis following cataract surgery. Preoperative topical antibiotic prophylaxis, however, would be cost-effective at a higher incidence of endophthalmitis and/or a substantially lower price for prophylaxis.

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.

Ophthalmic Antimicrobial Prescribing in Australian Healthcare Facilities

The National Antimicrobial Prescribing Survey (NAPS) is a web-based, standardized tool, widely adopted in Australian healthcare facilities to assess the reasons for, the quantity of, and the quality of antimicrobial prescribing. It consists of multiple modules tailored towards the needs of a variety of healthcare facilities. Data regarding ophthalmological antimicrobial use from Hospital NAPS, Surgical NAPS, and Aged Care NAPS were analysed. In Hospital NAPS, the most common reasons for inappropriate prescribing were incorrect dose or frequency and incorrect duration. Prolonged duration was also common in Aged Care prescribing: about one quarter of all antimicrobials had been prescribed for greater than 6 months. All three modules found chloramphenicol to be the most prescribed antimicrobial with a high rate of inappropriate prescribing, usually for conjunctivitis.

Intracameral Bacteriophage Injection as Postoperative Prophylaxis for Enterococcus faecalis-Induced Endophthalmitis After Cataract Surgery in Rabbits

Purpose

Post–cataract surgery bacterial endophthalmitis is a serious postoperative complication, and Enterococcus spp.–induced endophthalmitis reportedly has a particularly poor visual prognosis. This study aimed to demonstrate the prophylactic effect of postoperative intracameral phage administration in Enterococcus faecalis–induced endophthalmitis after cataract surgery in rabbits.

Methods

Endophthalmitis was induced in rabbits by injecting E. faecalis into the anterior chamber just after lensectomy while simultaneously administering either phage phiEF24C-P2 or vehicle. Retinal function was evaluated using electroretinography. The number of viable bacteria and myeloperoxidase (MPO) activity in the eye and histopathologic examinations were analyzed 48 hours after infection.

Results

In the vehicle-treated group, retinal function at 24 hours after infection was impaired, and the number of viable bacteria and MPO activity in the eye increased 48 hours later. In the phage-administered group, retinal function was maintained; the number of viable bacteria and MPO activity were significantly suppressed. Histopathologic examinations showed disruption of the retinal layers and the presence of numerous E. faecalis in the lens capsule and vitreous cavity in vehicle-treated eyes. In contrast, retinal structures were intact, and no E. faecalis staining was observed in phage-treated eyes. No retinal dysfunction was observed in the group that received phage only without lensectomy; almost no phage was detected in the eyes after 14 days of treatment.

Conclusions

Phage administration in the anterior chamber did not cause retinal dysfunction and suppressed postoperative endophthalmitis in rabbits.

Translational Relevance

In vivo results of intracameral phage administration suggest that phages are a promising prophylactic candidate for postoperative endophthalmitis.

Comparative meta-omics for identifying pathogens associated with prosthetic joint infection

Prosthetic joint infections (PJI) are economically and personally costly, and their incidence has been increasing in the United States. Herein, we compared 16S rRNA amplicon sequencing (16S), shotgun metagenomics (MG) and metatranscriptomics (MT) in identifying pathogens causing PJI. Samples were collected from 30 patients, including 10 patients undergoing revision arthroplasty for infection, 10 patients receiving revision for aseptic failure, and 10 patients undergoing primary total joint arthroplasty. Synovial fluid and peripheral blood samples from the patients were obtained at time of surgery. Analysis revealed distinct microbial communities between primary, aseptic, and infected samples using MG, MT, (PERMANOVA p = 0.001), and 16S sequencing (PERMANOVA p < 0.01). MG and MT had higher concordance with culture (83%) compared to 0% concordance of 16S results. Supervised learning methods revealed MT datasets most clearly differentiated infected, primary, and aseptic sample groups. MT data also revealed more antibiotic resistance genes, with improved concordance results compared to MG. These data suggest that a differential and underlying microbial ecology exists within uninfected and infected joints. This study represents the first application of RNA-based sequencing (MT). Further work on larger cohorts will provide opportunities to employ deep learning approaches to improve accuracy, predictive power, and clinical utility.

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.

Cefuroxime (Aprokam®) in the Prophylaxis of Postoperative Endophthalmitis After Cataract Surgery Versus Absence of Antibiotic Prophylaxis: A Cost-Effectiveness Analysis in Poland

OBJECTIVE

The analysis aims to assess the cost-effectiveness of cefuroxime (Aprokam®) in the prophylaxis of postoperative endophthalmitis (POE) after cataract surgery compared with the absence of antibiotic prophylaxis from the National Health Fund perspective in Poland.

METHODS

We performed a cost-effectiveness and cost-utility analysis using the decision tree and Markov model, respectively, for patients after cataract surgery. The efficacy of Aprokam was 0.21 (95% confidence interval [CI], 0.08-0.55) and is based on the results of the European Society of Cataract and Refractive Surgery study. According to the epidemiological data from Poland, the risk of POE is 0.377%. The costs associated with the Aprokam administration and POE treatment costs were included. We determined the utilities of the health states in the model depending on visual loss due to POE. To determine the uncertainty of estimates parameters, a one-way deterministic and probabilistic sensitivity analysis were performed.

RESULTS

Using Aprokam allows avoiding 0.003 POEs per patient. The benefit from the intervention is 0.0007 quality-adjusted life years per patient in the lifetime horizon. The total costs of prophylaxis are higher at about €1.70. The cost of avoiding one POE (incremental cost-effectiveness ratio) is about €569.85. The estimated incremental cost-effectiveness utility ratio is equal to €2427.72/quality-adjusted life-years, and it is significantly lower than the cost-effectiveness threshold in Poland in 2019 (about 7.5% of the threshold). In all scenarios of performed one-way sensitivity analyses, Aprokam is cost-effective.

CONCLUSIONS

In Poland, the use of Aprokam is cost-effective, with the estimated incremental cost-utility ratio significantly lower than the cost-effectiveness threshold.

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.

Telephone follow-up of the elderly after cataract surgery

Study’s purpose:

To analyze the effectiveness of telephone intervention for the nursing diagnosis of delayed surgical recovery in older persons who have undergone cataract surgery.

Design:

Blinded, randomized, and controlled trial. A total of 95 patients of both sexes who were over 60 years old and had undergone cataract surgery were divided into an intervention group (48 patients) and a control group (47 patients), allocated using BioEstat 5.3 Software.

Results:

The intervention included postoperative follow-up recovery of cataracts and prevention of complications performed on the 1st, 4th, 10th, and 20th postoperative days. After the intervention, the intervention group had a decrease in the length of surgical recovery ( p = .000). The occurrence in the intervention group was 6.3%, while in the control group, it was 36.2% (odds ratio (OR) = 0.118; confidence interval (CI) = 1.02, 10.23). The number of nursing interventions nevertheless decreased during the telephone follow-up.

Conclusion:

For older persons, the telephone guidelines increase adherence to treatment, promote clinical improvement, promote surgical recovery over time, and improve independence and autonomy.

Identification of Dietzia Species in a Patient with Endophthalmitis following Penetrating Injury with Retained Intraocular Metallic Foreign Body

To the best of our knowledge, we report the first case of Dietzia species in a patient with endophthalmitis. A 47-year-old man presented to the ophthalmology department with decreased vision, redness, and minimal pain in his right eye after a foreign body struck his eye following working using a hammer and chisel. Broad-spectrum polymerase chain reaction (PCR) and deoxyribonucleic acid (DNA) sequencing targeting 16S ribosomal ribonucleic acid-(rRNA-) encoding gene on an undiluted vitreous sample revealed 100% identity with GenBank sequences of Dietzia species including D. natronolimnaea, D. dagingensis, and D. cercidiphylli. The culture of the vitreous samples demonstrated the growth of Gram-positive cocci and polymorphic rods. The isolate from the culture was identified as D. natronolimnaea using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS). The combination of surgical and medical treatment (pars plana vitrectomy and systemic and topical antibiotics) eradicated the infection successfully.

Post-cataract eye drops can be avoided by depot steroid injections

There are over 400 000 cataract operations now being performed annually in the UK. With the majority of those patients being older people, comorbidities such as dementia or arthritis can prevent patients putting in their own post-operative eye drops. Where there is a lack of family or other support, district nursing services are often called upon to administer these eye drops, which are typically prescribed four times a day for 4 weeks, thus potentially totalling 112 visits for drop instillation per patient. To reduce the burden of these post-operative eye drops on district nursing services, administration of an intra-operative sub-Tenon's depot steroid injection is possible for cataract patients who then do not require any post-operative drop instillation. As a trial of this practice, 16 such patients were injected in one year, thus providing a reduction of 1792 in the number of visits requested. Taking an estimated cost of each district nurse visit of £38, this shift in practice potentially saved more than £68 000; the additional cost of the injection over the cost of eye drops was just £8.80 for the year. This practice presents an opportunity to protect valuable community nursing resources, but advocacy for change in practice would be needed with secondary care, or via commissioners.

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.

Pathogens and antibiotic sensitivities in endophthalmitis

BACKGROUND

Antibiotic prophylaxis in cataract surgery is intended to minimize endophthalmitis. We describe pathogenic organisms, antibiotic sensitivities and antibiotic prophylaxis in culture-proven endophthalmitis cases.

DESIGN

Retrospective consecutive case series and community-based setting were used.

PARTICIPANTS

Two hundred fifteen cases of endophthalmitis after cataract surgery performed during 2007-2012 in Kaiser Permanente, California.

METHODS AND MAIN OUTCOME MEASURES

Descriptive analysis of isolated organisms and antibiotic sensitivities in relation to antibiotic prophylaxis in culture-proven endophthalmitis cases.

RESULTS

The majority of culture-confirmed organisms (n = 83) were Gram positive (96%), most notably coagulase-negative Staphylococci (n = 34, 52%), of which all that underwent testing were sensitive to vancomycin (n = 32). Among 19 cases that had received only topical antibiotic prophylaxis, seven (37%) were resistant to the antibiotic given: 50% of cases (5 of 10 isolates) that had received ofloxacin were resistant to this antibiotic, 40% (2 of 5 isolates) that had received gatifloxacin were resistant. In contrast, 100% of cases (n = 4) that had received aminoglycosides were susceptible. Few culture-confirmed cases occurred in patients who received intracameral antibiotic (n = 4).

CONCLUSIONS

In cases where fluoroquinolones were administered as antibiotic prophylaxis, isolates demonstrated a degree of bacterial resistance. The majority of endophthalmitis cases isolated occured following topical antibiotic prophylaxis only and were attributed to Gram-positive organisms, while few occurred in association with intracameral antibiotic.

The Incidence of Postoperative Endophthalmitis Before and After a Revised Preoperative Surgical Site Preparation Protocol

PURPOSE

To compare the incidence of postoperative endophthalmitis before and after the implementation of a preoperative surgical site preparation protocol for cataract surgery.

DESIGN

Retrospective cohort study.

METHODS

Records of patients with postoperative endophthalmitis between January 2006 and August 2013 were reviewed. A revised protocol implemented after January 2009 included the addition of preoperative 0.3% topical tobramycin, 10% povidone-iodine for cleansing, and using a disposable sterile drape. The incidence, microbiological profile, and outcomes of these cases were analyzed.

RESULTS

The incidence of preprotocol endophthalmitis was significantly higher than in the postprotocol period (P = 0.018). More patients in the preprotocol group grew Pseudomonas aeruginosa and Streptococcus pneumoniae as compared with those in the postprotocol group (P = 0.014). A smaller number of patients attained a poor visual outcome after the implementation of the revised protocol (P = 0.035).

CONCLUSIONS

In our study, the addition of antibiotic eye drops before cataract surgery and perioperative cleansing with 10% povidone-iodine were effective means to reduce the incidence of postoperative endophthalmitis.

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.

Perioperative prophylaxis for endophthalmitis after cataract surgery in iran

Purpose:

To describe prophylactic patterns employed against endophthalmitis after cataract surgery in Iran.

Methods:

This cross-sectional study included 486 ophthalmologists filling in a self-administered questionnaire during the 20^th Annual Congress of the Iranian Society of Ophthalmology in December 2010, Tehran, working in both private and academic medical centers. Prophylactic measures used preoperatively, intraoperatively and postoperatively and self-reported rates of endophthalmitis were assessed as the main outcome measurements.

Results:

In the preoperative phase, 75.5% of surgeons used povidone-iodine in the conjunctival sac and 71.4% of them did not use antibiotics. The rate of intraoperative prophylaxis was 61.9% either in the form of intracameral antibiotics or subconjunctival injection (mostly cephazolin or gentamicin). Only 7.8% of participants used intracameral cephalosporins. Postoperative antibiotics [mostly chloramphenicol (57%) and ciprofloxacin (28%)] were used by 94.2% of surgeons. On average, ten years of practice were required to observe one case of endophthalmitis.

Conclusion:

The surgeons in present setting used various prophylactic regimens against endophthalmitis after cataract surgery. Setting a local and evidence-based clinical practice guideline seems necessary.

Endophthalmitis: state of the art

Endophthalmitis is an uncommon diagnosis but can have devastating visual outcomes. Endophthalmitis may be endogenous or exogenous. Exogenous endophthalmitis is caused by introduction of pathogens through mechanisms such as ocular surgery, open-globe trauma, and intravitreal injections. Endogenous endophthalmitis occurs as a result of hematogenous spread of bacteria or fungi into the eye. These categories of endophthalmitis have different risk factors and causative pathogens, and thus require different diagnostic, prevention, and treatment strategies. Novel diagnostic techniques such as real-time polymerase chain reaction (RT-PCR) have been reported to provide improved diagnostic results over traditional culture techniques and may have a more expanded role in the future. While the role of povidone-iodine in prophylaxis of postoperative endophthalmitis is established, there remains controversy with regard to the effectiveness of other measures, including prophylactic antibiotics. The Endophthalmitis Vitrectomy Study (EVS) has provided us with valuable treatment guidelines. However, these guidelines cannot be directly applied to all categories of endophthalmitis, highlighting the need for continued research into attaining improved treatment outcomes.

Perioperative pharmacological management in patients with glaucoma

REVIEẂS AIM: When a phacoemulsification, a filtration surgery or a combined surgery are necessary, questions about the convenience of continuing certain antiglaucomatous drugs could appear. The aim of this review article is to unify criteria that will guide daily clinical practice and including the developing algorithms of action in the preoperative and postoperative periods of filtration surgery and/or cataract surgery.

PROPOSED PROTOCOLS

In the preoperative period of cataract surgery, the use of non-steroidal anti-inflammatory drugs is at the discretion of the surgeon, with the monodose presentation being recommended. The suspension of prostaglandines a fewdays before the surgery should be considered. Preservative-free drugs ensure a better recovery of the ocular surface (OS) after cataract surgery. Once all modifying factors of the intraocular pressure (IOP) have been removed, baseline IOP should be evaluated again, choosing preservative-free antiglaucomatous drugs when needed. The use of preservative-free ocular antihypertensive drugs and steroids in the preoperative period of glaucoma surgery reduces the risk of surgical failure. The interruption of prostaglandines is recommended. In the postoperative period of glaucoma surgery, steroids are the anti-inflammatory treatment of choice, the preservative-free ones being preferred. When reintroducing antiglaucomatous treatment, preservatives should be avoided to prevent scarring. The appropriate perioperative management of patients with glaucoma is essential to obtain a correct control of IOP, improve the situation of the OS, prevent complications and improve the result of the filtration surgery and cataract surgery.

CONCLUSIONS

this protocol aims to unify the different lines of action in order to decrease the incidence of adverse events and maximize the surgical outcome.

Comparison of peroperative subconjunctival injection of methylprednisolone and standard postoperative steroid drops after uneventful cataract surgery

PURPOSE

To compare the safety and efficacy of a single subconjunctival injection of methylprednisolone and a standard postoperative steroid regimen in terms of intraocular inflammation and intraocular pressure (IOP) after uncomplicated phacoemulsification surgery.

METHODS

Two groups of 25 patients each were included in this prospective randomized controlled trial. Patients in the injection group were given a subconjunctival injection of 20 mg methylprednisolone and the topical group received the conventional postoperative care with steroid eye drops (dexamethasone 1 mg/ml). The patients were examined 1 week and 1 month after surgery. Slit-lamp evaluation of anterior chamber inflammation and IOP were performed. Changes in IOP of ≥2.4 mmHg were considered clinically relevant.

RESULTS

In the injection group, mean IOP decreased from 15.4 ± 2.2 mmHg (baseline) to 14.1 ± 3.2 mmHg at 1 week (p = 0.03). The topical group had a stable IOP at 1 week (16.3 ± 2.6 mmHg) compared to baseline (16.1 ± 2.7 mmHg; p = 0.74). At 1 month, mean IOP was 14.3 ± 2.6 mmHg (p = 0.03) in the injection group and 15.6 ± 2.3 mmHg (p = 0.2) in the topical group. The intragroup changes were neither statistically significant nor clinically relevant at any postoperative visit. Both groups had the highest values of intraocular inflammation at the 1-week postoperative visit, followed by a decline to barely traceable levels at 1 month. The difference was not clinically relevant at any postoperative visit.

CONCLUSIONS

The subconjunctival injection of methylprednisolone appears to be as safe and effective as the conventional treatment, and it might therefore be considered for treatment of individuals with compliance issues.