Antibiotic prophylaxis practice patterns for cataract surgery in India - Results from an online survey

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.

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.

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.

Intracameral Drug Delivery: A Review of Agents, Indications, and Outcomes

An intracameral (IC) injection directly delivers the drug into the anterior chamber of the eye. This targeted drug delivery technique overcomes the ocular barriers and offers a high therapeutic concentration of medication at the desired site and consequently better clinical outcomes. IC drug delivery is a safe and effective modality with many advantages over topical delivery. These include excellent bioavailability, reduced systemic risk, and minimal ocular toxicity. Agents delivered via IC injection have shown promising results against infection, inflammation, ocular hypertension, and neovascularization. Current literature shows that IC antibiotics, including cefuroxime, vancomycin, and moxifloxacin, are routinely used for prophylaxis of endophthalmitis. Other drugs available for IC use are steroids, anesthetics, mydriatics, miotics, antivascular endothelial growth factor, antiglaucoma, and alkylating agents. Introduction of sustained-release devices containing dexamethasone or Bimatoprost in anterior chamber via IC route has the potential in treating ocular inflammation and raised intraocular pressure. The complications such as hemorrhagic occlusive retinal vasculitis and toxic anterior segment syndrome have been documented with IC prophylaxis but are rare. In this review, we provide an overview of available IC drugs, their pharmacokinetics, the spectrum of activity, dosage and preparation, prophylactic and therapeutic usage, clinical efficacy, and safety profiles.

The management of cataract surgery in diabetic patients

A cataract in the eye is a major cause of vision loss in diabetic patients, which occurs earlier and develops faster than non-diabetic patients, and often requires surgery for treatment. However, diabetic patients undergoing cataract surgery have a higher risk of intraoperative and postoperative complications than non-diabetic patients. For diabetic patients undergoing any surgery, careful perioperative assessment and management are required to reduce postoperative complications and improve surgical outcomes. Better understanding of their needs may guide perioperative practitioners to manage their care appropriately. This article presents recent evidence and guidance associated with the preoperative, intraoperative and postoperative management of diabetic patients undergoing cataract surgery and to inform perioperative practitioners of the challenges and potential complications to provide the best care and improve sight.

Efficacy and safety of dropless cataract surgery

Purpose

To evaluate the clinical outcome following intraoperative transzonular intravitreal injection of triamcinolone acetonide and moxifloxacin in patients undergoing phacoemulsification cataract extraction with intraocular lens (IOL) implantation.

Methods

In this prospective, non-randomized, clinical, interventional study, a total of 200 eyes were enrolled. Patients who voluntarily gave their consent after being informed about dropless cataract surgery along with its pros and cons were included. Those who had glaucoma or were known steroid responders as well as those who were lost to follow-up were excluded. 0.1 ml each of moxifloxacin (500 mg) and triamcinolone acetonide (4 mg) were injected transzonularly following IOL implantation in phacoemulsification cataract surgery with the help of 27G curved cannula. Slit-lamp examination was done to detect cells, visual acuity was noted, and intraocular pressure was measured postoperatively on day 1, 7, 30, 60, and 90.

Results

Uncorrected visual acuity (UCVA) greater than 6/9 was achieved in 96% of patients at the end of 3 months. The mean IOP was found to be normal in all the cases at every visit. Twenty patients complained of floaters on postoperative day 1 (D1), which decreased to zero after 60 days (D60). None of the patients needed any eye drop during the entire postoperative period.

Conclusion

The study demonstrates that this procedure is advantageous and safe.

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.

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.