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van Rooij J, Nolte K, van de Vondervoort F, Lekkerkerk S, Bourgonje V, Wubbels R. Prophylactic Intracameral Antibiotics and Endophthalmitis After Cataract Surgery. JAMA Ophthalmol 2024; 142:699-706. [PMID: 38900438 PMCID: PMC11190831 DOI: 10.1001/jamaophthalmol.2024.1716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/07/2024] [Indexed: 06/21/2024]
Abstract
Importance Although the effectiveness of intracameral antibiotics to prevent postoperative endophthalmitis is described, selective use of antibiotics combined with 1% povidone iodine disinfection might be equally effective and could lead to cost reduction and avoidance of unnecessary use of antibiotics. Objective To compare the incidence of postoperative endophthalmitis when 1% povidone iodine disinfection is applied in combination with selective intracameral antibiotics with the incidence after routine use of intracameral antibiotics in combination with 5% povidone iodine. Design, Setting, and Participant This was a retrospective cohort study using incidence data from the ongoing endophthalmitis register of the Rotterdam Eye Hospital, a specialized hospital providing both secondary and tertiary ophthalmological care, when intracameral antibiotics were used only during cataract procedures with occurrence of a posterior capsular tear in comparison with results from cohorts described in the literature where routine antibiotics were used. All patients who had cataract (phacoemulsification) surgery at the Rotterdam Eye Hospital between 1993 and 2022 were included. No cataract surgical procedures combined with other intraocular procedures were included. Exposure Povidone iodine disinfection and intracameral antibiotics during cataract surgery either routinely or only in case of posterior capsular tears. Main Outcome and Measure Postoperative endophthalmitis incidence. Results Postoperative endophthalmitis incidence after 56 598 cataract (phacoemulsification) surgical procedures in the Rotterdam Eye Hospital between 2016 and 2022 was 0.000 (95% CI, 0.000-0.000). A PubMed literature search until September 2023 with respect to the incidence of postoperative endophthalmitis after routine antibiotic prophylaxis yielded 37 publications with an overall postoperative endophthalmitis incidence of 0.000 (95% CI, 0.000-0.000). Conclusions and Relevance No difference was observed between the postoperative endophthalmitis incidence during the last 7 years in the Rotterdam Eye Hospital and the overall postoperative endophthalmitis incidence after routine intracameral antibiotics prophylaxis as described in the literature. Disinfection with 1% povidone iodine in combination with selective antibiotic prophylaxis may be equally effective as routine antibiotic use and 5% povidone iodine.
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Affiliation(s)
| | - Karina Nolte
- Rotterdam Eye Hospital, Rotterdam, the Netherlands
| | | | - Sybren Lekkerkerk
- Department of Medical Microbiology, Maasstad General Hospital, Rotterdam, the Netherlands
| | | | - René Wubbels
- Rotterdam Ophthalmic Institute, Rotterdam, the Netherlands
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Sen S, Mishra C, Rameshkumar G, Babu Kannan N, Shekhar M, Lalitha P. Microbiological Profile of Post-cataract Surgery Endophthalmitis with Usage of Prophylactic Intracameral Moxifloxacin. Ocul Immunol Inflamm 2024; 32:796-802. [PMID: 36749937 DOI: 10.1080/09273948.2023.2170249] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/06/2022] [Accepted: 01/15/2023] [Indexed: 02/09/2023]
Abstract
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.
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Affiliation(s)
- Sagnik Sen
- Department of Retina and Vitreous, Aravind Eye Hospital, Madurai, India
| | - Chitaranjan Mishra
- Department of Retina and Vitreous, Aravind Eye Hospital, Madurai, India
- Trilochan Nethralaya, Sambalpur, Odisha
| | | | | | - Madhu Shekhar
- Department of IOL and Cataract Services, Aravind Eye Hospital, Madurai, India
| | - Prajna Lalitha
- Department of Microbiology, Aravind Eye Hospital, Madurai, India
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Kato A, Horita N, Namkoong H, Nomura E, Masuhara N, Kaneko T, Mizuki N, Takeuchi M. Prophylactic antibiotics for postcataract surgery endophthalmitis: a systematic review and network meta-analysis of 6.8 million eyes. Sci Rep 2022; 12:17416. [PMID: 36258003 PMCID: PMC9579149 DOI: 10.1038/s41598-022-21423-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/27/2022] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Ai Kato
- grid.268441.d0000 0001 1033 6139Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004 Japan ,Department of Ophthalmology, Chigasaki Municipal Hospital, Chigasaki, Kanagawa Japan
| | - Nobuyuki Horita
- grid.470126.60000 0004 1767 0473Chemotherapy Center, Yokohama City University Hospital, Yokohama, Kanagawa Japan
| | - Ho Namkoong
- grid.26091.3c0000 0004 1936 9959Department of Infectious Diseases, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Eiichi Nomura
- grid.268441.d0000 0001 1033 6139Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004 Japan
| | - Nami Masuhara
- Department of Ophthalmology, Chigasaki Municipal Hospital, Chigasaki, Kanagawa Japan
| | - Takeshi Kaneko
- grid.268441.d0000 0001 1033 6139Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa Japan
| | - Nobuhisa Mizuki
- grid.268441.d0000 0001 1033 6139Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004 Japan
| | - Masaki Takeuchi
- grid.268441.d0000 0001 1033 6139Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004 Japan
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Shi SL, Yu XN, Cui YL, Zheng SF, Shentu XC. Incidence of endophthalmitis after phacoemulsification cataract surgery: a Meta-analysis. Int J Ophthalmol 2022; 15:327-335. [PMID: 35186695 PMCID: PMC8818473 DOI: 10.18240/ijo.2022.02.20] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/11/2021] [Indexed: 11/23/2022] Open
Abstract
AIM To evaluate the overall endophthalmitis incidence and the effectiveness of potential prophylaxis measures following phacoemulsification cataract surgery (PCS). METHODS The PubMed and Web of Science databases were searched from inception to April 30th, 2021. We included studies that reported on the incidence of endophthalmitis following PCS. The quality of the included studies was critically evaluated with the Newcastle-Ottawa quality assessment scale. The random effect or the fixed-effects model was used to evaluated the pooled incidence based on the heterogeneity. The publication bias was assessed by Egger's linear regression and Begg's rank correlation tests. RESULTS A total of 39 studies containing 5 878 114 eyes were included and critically appraised in the Meta-analysis. For overall incidence of endophthalmitis after PCS, the Meta-analysis yielded a pooled estimate of 0.092% (95%CI: 0.083%-0.101%). The incidence appeared to decrease with time (before 2000: 0.097%, 95%CI: 0.060%-0.135%; 2000 to 2010: 0.089%, 95%CI: 0.076%-0.101%; after 2010: 0.063%, 95%CI: 0.050%-0.077%). Compared with typical povidone-iodine solution (0.178%, 95%CI: 0.071%-0.285%) and antibiotics subconjunctival injections (0.047%, 95%CI: 0.001%-0.095%), the use of intracameral antibiotics significantly reduced the incidence of endophthalmitis after PCS (0.045%, 95%CI: 0.034%-0.055%, RR: 7.942, 95%CI: 4.510-13.985). CONCLUSION Due to the advancement of phacoemulsification technology and the widespread use of intracameral antibiotics, the incidence of endophthalmitis following PCS shows a decreasing trend over time. The use of intracameral antibiotics administration will significantly reduce the risk of endophthalmitis.
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Affiliation(s)
- Si-Lu Shi
- Eye Center of the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, Zhejiang Province, China
| | - Xiao-Ning Yu
- Eye Center of the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, Zhejiang Province, China
| | - Yi-Lei Cui
- Eye Center of the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, Zhejiang Province, China
| | - Si-Fan Zheng
- GKT School of Medical Education, King's College London, London SE1 1UL, England, UK
| | - Xing-Chao Shentu
- Eye Center of the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, Zhejiang Province, China
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Rangel CM, Parra MM, Corrales MI, Garcia D, Sánchez-Ávila R, Varón CL, Villareal E, Villarreal D, Tello A, Galvis V. ENDOPHTHALMITIS IN OPHTHALMOLOGICAL REFERRAL CENTRE IN COLOMBIA: AETIOLOGY AND MICROBIAL RESISTANCE. CESKA A SLOVENSKA OFTALMOLOGIE : CASOPIS CESKE OFTALMOLOGICKE SPOLECNOSTI A SLOVENSKE OFTALMOLOGICKE SPOLECNOSTI 2022; 78:160-173. [PMID: 35922145 DOI: 10.31348/2022/19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
AIMS To describe the aetiology and microbial susceptibility profile of endophthalmitis cases treated at an ophthalmological referral centre in Colombia. MATERIAL AND METHODS A retrospective descriptive study was carried out with all endophthalmitis cases referred to the Fundación Oftalmológica de Santander FOSCAL (Floridablanca, Colombia) from 1 January 2012 to 31 December 2015. RESULTS 121 eyes of 121 patients were evaluated. 77.7% of them were male and the mean age was 42.9 years. Five of them (4.1%) corresponded to endogenous endophthalmitis, and 116 (95.9%) to exogenous endophthalmitis. Of the latter, 66.9% were associated with trauma (almost one-half of them associated with intraocular foreign body), and 29.5% with intraocular surgery. The most common isolated microorganisms in the exogenous endophthalmitis group corresponded to methicillin-resistant and methicillin-sensitive strains of Staphylococcus epidermidis and Staphylococcus aureus, which were mostly susceptible to imipenem, vancomycin and moxifloxacin and resistant to ceftazidime. CONCLUSION Endophthalmitis is a potentially sight-threatening condition, especially in cases of inadequate treatment. Therefore, antimicrobial therapy should be guided by vitreous humour culture to assure that the causative microorganism is susceptible to the selected agent. The results of our study lead us to propose vancomycin, moxifloxacin or imipenem as first-line antimicrobial options.
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Kamath A, Pai A, Reddy JK. Nocardia Endophthalmitis- Prophylactic Prevention with an Innovative Approach. Open Ophthalmol J 2021. [DOI: 10.2174/1874364102115010258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
Nocardia is a common cause of endophthalmitis in southern India. It is an aggressive disease with a poor prognosis.
Objective:
This study was conducted using an amikacin antibiotic in the drip irrigation of balanced saline solution (BSS) during the surgery to prophylactically study the occurrence of Nocardia endophthalmitis and any subsequent toxic effects of the antibiotics used.
Methods:
Prospective study period was of 6 months, starting from July to December-2018. Preoperative and postoperative specular counts and macular thickness using Ocular Coherence Tomography (OCT) were compared with any incidence of Nocardia endophthalmitis. A total of 500 patients operated for manual SICS were randomly assigned into 2 groups. The first group of 250 patients received antibiotic amikacin added to the Balanced Saline Solution (BSS) irrigating solution throughout the course of the surgery. The second control group received no antibiotics. Manual SICS was performed on all 500 patients by a single surgeon and was found to be uneventful. Pre- and postoperative corneal endothelial cell density and mean macular thickness using OCT were taken and recorded of all the patients, respectively, and data obtained were statistically compared.
Results:
No incidence of Nocardia endophthalmitis among the cataract surgeries operated was found. There was no drug-related toxicity to the cornea or macula. Furthermore, no incidence of Nocardia endophthalmitis has been reported since 2018 after using antibiotics.
Conclusion:
A simple routine of adding amikacin in the drip prophylactically during the course of surgery helped us prevent Nocardia endophthalmitis with no side effects. Also, it will be an innovative technique that is economically feasible and effective in regions where Nocardia endophthalmitis is prevalent.
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Toxic Anterior Segment Syndrome with Intracameral Moxifloxacin: Case Report and Review of the Literature. Case Rep Ophthalmol Med 2021; 2021:5526097. [PMID: 33747588 PMCID: PMC7943300 DOI: 10.1155/2021/5526097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Rossi T, Romano MR, Iannetta D, Romano V, Gualdi L, D'Agostino I, Ripandelli G. Cataract surgery practice patterns worldwide: a survey. BMJ Open Ophthalmol 2021; 6:e000464. [PMID: 33501377 PMCID: PMC7812090 DOI: 10.1136/bmjophth-2020-000464] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 11/15/2020] [Accepted: 12/03/2020] [Indexed: 11/24/2022] Open
Abstract
Objective To report the results of a global survey on cataract practice patterns related to preoperative, intraoperative and postoperative care, surgical setting and personnel allocation. Methods and analysis An online 28 questions survey was sent to 240 ophthalmologists asking to describe prevailing trends in their institutions across 38 countries and 5 continents. Questions inquired country, institution, surgical volume and setting, anaesthesia, preoperative and intraoperative examination and postsurgical care. Statistical analysis used crosstabs lambda statistics for non-parametric nominal variables. P value less than 0.05 was considered statistically significant. Results 209/240 (87%) ophthalmologists responded: 38% representing public hospitals, 36% private practices and 26% academic sites; overall surgical volume was between 241 700 and 410 500 cataracts per year. There was a significant correlation between type of institution and surgical volume. Complete results available in online (https://freeonlinesurveys.com/r/W6BcLLxy). Conclusion Cataract surgery related patterns of perioperative care showed significant difference among respondents, regardless to type of institution, surgical volume and country. Many evidence-based procedures are unevenly practiced around the world and some widespread and expensive habits lack solid scientific evidence while consuming enormous amount of resources both monetary and human. There is a need to reach consensus and share evidence-based practice patterns.
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Affiliation(s)
- Tommaso Rossi
- Ophthalmology, Ospedale Policlinico San Martino Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia, Genova, Italy
| | - Mario R Romano
- Department of Health Sciences, Humanitas University, Milan, Italy
| | - Danilo Iannetta
- Ophthalmology, Arcispedale Santa Maria Nuova di Reggio Emilia, Reggio Emilia, Italy
| | - Vito Romano
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | | | - Isabella D'Agostino
- Ophthalmology, Ospedale Policlinico San Martino Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia, Genova, Italy
| | - Guido Ripandelli
- IRCSS Fondazione G B Bietti per lo Studio e la Ricerca in Oftalmologia ONLUS, Roma, Italy
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Subudhi P, Patro S, Agarwal P, Khan Z, Subudhi BNR, Mekap C, Padhi A. Safety and Efficacy of a New Posterior Chamber Phakic Intraocular Lens in Cases of High Myopia: Early Results. Clin Ophthalmol 2020; 14:3681-3689. [PMID: 33162752 PMCID: PMC7642691 DOI: 10.2147/opth.s270690] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/02/2020] [Indexed: 12/20/2022] Open
Abstract
Purpose To demonstrate the visual outcomes of a foldable, hydroxy ethyl-methacrylate, single-piece, posterior chamber phakic intraocular lens (pIOL). Study Type Retrospective study. Materials and Methods Patients presenting with moderate to high myopia who underwent surgical correction with a posterior chamber phakic IOL (refractive intraocular lens, phakic intraocular lens, Appasamy Associates, Chennai, India) were retrospectively reviewed. Only patients with at least one-year follow-up were included. Manifest refraction, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), endothelial cell density (ECD), and pIOL vault were analyzed 1, 3, 6, and 12 months after surgery. Intraoperative and postoperative events were recorded in all cases. Results The study included 30 eyes from 15 patients. The mean patient age was 25.8 ± 3 years. The spherical equivalent of manifest refraction was −11.47 ± 4.38 D preoperatively and −0.44 ± 0.55 D postoperatively. The preoperative CDVA was 0.17 ± 0.12 logMAR. The postoperative UDVA was 0.053 ± 0.11 logMAR (min: −0.17 and max: 0.2) and 0.019 ± 0.091 logMAR (min: −0.17 and max: 0.2) at the end of 1 month and 6 months, respectively. At the end of the 12-month visit, the postoperative UDVA was 0.032 ± 0.094, and the safety index was 2.42. The mean ECD was 2639 cells/mm2 (min: 2389 and max: 2993 with SD: 139.53) at the preoperative visit and 2445 cells/mm2 (min: 2050 and max: 2701) at the 12-month visit (5.8% loss, p less than 0.001). ECD loss from 6 months to 12 months was not statistically significant. No significant cataract formation, significant endothelial cell loss, glaucoma, uveitis, or any other vision-threatening complication were observed. Conclusion Based on postoperative experience, we found that RIL phakic IOLs are safe and effective for treating high myopia at short-term follow-up.
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Affiliation(s)
- Praveen Subudhi
- Cornea and Refractive surgery services, Ruby Eye Hospital, Berhampur, Odisha, India.,Ophthalmology Department, Hitech Medical College, Bhubaneswar, Odisha, India
| | - Sweta Patro
- Cornea and Refractive surgery services, Ruby Eye Hospital, Berhampur, Odisha, India
| | | | - Zahiruddin Khan
- Ophthalmology Department, Hitech Medical College, Bhubaneswar, Odisha, India
| | | | - Chandan Mekap
- Cornea and Refractive surgery services, Ruby Eye Hospital, Berhampur, Odisha, India
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Rathi VM, Sharma S, Das T, Khanna RC. Endophthalmitis Prophylaxis Study, Report 2: Intracameral antibiotic prophylaxis with or without postoperative topical antibiotic in cataract surgery. Indian J Ophthalmol 2020; 68:2451-2455. [PMID: 33120637 PMCID: PMC7774195 DOI: 10.4103/ijo.ijo_1738_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose: Intracameral antibiotic in cataract surgery has shown level I evidence as prophylaxis for postoperative endophthalmitis. Not much is known if one should also use topical antibiotics after intracameral injection. The purpose of the study was to determine efficacy of intracameral antibiotic with and without postoperative topical antibiotic in reducing the incidence of acute endophthalmitis after cataract surgery in rural India. Methods: A prospective comparative, non-randomized interventional study was designed in 15 rural centres in India. The study recruited 40,006 patients (n = 42,466 eyes), who underwent cataract surgery (phacoemulsification/small incision cataract surgery), and received intracameral antibiotic (cefuroxime/moxifloxacin). Postoperative topical antibiotic prescription was left to the choice of the treating physician, but they were encouraged not to use it in uneventful surgeries. Primary outcome measure was occurrence of acute clinical endophthalmitis within 6 weeks of surgery. Statistical analysis was done using STATA software v13.1 (StataCorp, Texas); P value of <0.05 was considered statistically significant. Results: In the study, 17,932 (42%) eyes received intracameral cefuroxime (ICC) and 24,534 (58%) eyes received intracameral moxifloxacin (ICM). Topical antibiotic was not prescribed to 17,855 (42%) eyes - 5723 (32%) eyes in ICC group and 12,132 (68%) eyes in ICM group. Acute clinical endophthalmitis occurred in 15 (0.035%) eyes - 1 / 3515 (0.028%) eyes and 1 / 2231 (0.045%) eyes that received and did not receive topical antibiotic, respectively. The difference in occurrence of endophthalmitis with/without topical antibiotics in each group (ICC: 0.016% and 0.017%; P = 0.958; ICM: 0.040% and 0.058%; P = 0.538) was not significant (P = 0.376). Conclusion: Supplementing intracameral antibiotic with topical antibiotic postoperatively did not impact the occurrence of acute post cataract surgery endophthalmitis in rural India
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Affiliation(s)
- Varsha M Rathi
- Allen Foster Research Centre for Community Eye Health, Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye Care, L V Prasad Eye Institute (LVPEI), Banjara Hills, Hyderabad, India
| | - Savitri Sharma
- Jhaveri Microbiology Centre, Brien Holden Eye Research Centre, LVPEI, Hyderabad, India
| | - Taraprasad Das
- Kanuri Santhamma Center for Vitreoretinal Diseases, LVPEI, Hyderabad, India
| | - Rohit C Khanna
- Allen Foster Research Centre for Community Eye Health, Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye Care, L V Prasad Eye Institute (LVPEI), Banjara Hills, Hyderabad, India
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11
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The Anterior Chamber Injection of Moxifloxacin Injection to Prevent Endophthalmitis after Cataract Surgery: A Meta-analysis. J Ophthalmol 2020; 2020:7242969. [PMID: 32908685 PMCID: PMC7468651 DOI: 10.1155/2020/7242969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/17/2020] [Accepted: 06/19/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose A meta-analysis was performed to compare the efficacy of an anterior chamber injection of moxifloxacin in the prevention of endophthalmitis after cataract surgery. Methods A computer-based search of PubMed, Embase, the Cochrane Library, and the Clinical Trial database for articles related to anterior intraventricular injection of moxifloxacin for the prevention of endophthalmitis after cataract surgery was performed through April 2019. Study selection, data exclusion, and quality assessment were performed by two independent observers. Statistical analysis for the meta-analysis was performed by RevMan5.3 software. Results Eight studies were included, with a total of 123,819 eyes. The meta-analysis showed that an anterior chamber injection of moxifloxacin can prevent the incidence of endophthalmitis after cataract surgery (OR = 0.29, 95% CI (0.15, 0.56), P=0.0002), and the difference was statistically significant. There were no significant differences between the moxifloxacin injection and nonmoxifloxacin injection groups in regard to UCVA (log MAR) (SMD = −0.13, 95% CI (−0.62, 0.35), P=0.60), BCVA (log MAR) (SMD = −0.27, 95% CI (−1.28, 0.74), P=0.60), IOP (SMD = −0.04, 95% CI (−0.02, 0.01), P=0.22), corneal edema (OR = 1.03, 95% CI (0.23, 4.69), P=0.97), CCT (SMD = −0.01, 95% CI (−0.07, 0.05), P=0.77), or ECD (SMD = 0.00, 95% CI (−0.06, 0.07), P=0.94). Conclusion An anterior chamber injection of moxifloxacin can effectively prevent the incidence of endophthalmitis after cataract surgery, while the moxifloxacin injection and nonmoxifloxacin injection groups had similar results in regard to UCVA (log MAR), BCVA (log MAR), IOP, corneal edema, CCT, and ECD.
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12
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Microbiological Isolates and Antibiotic Susceptibilities in Cases of Posttraumatic Endophthalmitis: A 15-Year Review. J Ophthalmol 2020; 2020:5053923. [PMID: 32411430 PMCID: PMC7210529 DOI: 10.1155/2020/5053923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/15/2019] [Accepted: 12/07/2019] [Indexed: 11/29/2022] Open
Abstract
Purpose The objective of this study was to evaluate the microbiological spectrum and antibiotic susceptibilities of isolates in posttraumatic endophthalmitis over a 15-year period. Methods A retrospective study of 3,163 posttraumatic endophthalmitis cases was conducted between July 2004 and July 2019. The outcome measures included the microbiological spectrum and antibiotic susceptibilities. Chi-squared tests were conducted to detect trends in changes in antibiotic sensitivity over the 15-year period. P values of <0.05 were considered statistically significant. Results Of the 3,163 cases of posttraumatic endophthalmitis, 1,003 culture-positive isolates were identified. Among these, there were 848 (84.5%) Gram-positive isolates, 109 (10.9%) Gram-negative isolates, and 46 (4.6%) fungal isolates. The most common isolates were Staphylococcal species. There was a significant increase in the percentage of fungal isolates over the 15-year period (P=0.02). Gram-positive organisms showed the greatest level of susceptibility to vancomycin (99.6%). The susceptibilities of the 109 Gram-negative isolated organisms were as follows: levofloxacin (95.8%), meropenem (95.7%), ciprofloxacin (93.5%), tobramycin (90.8%), imipenem (88.9%), trimethoprim-sulfamethoxazole (TMP-SMX) (87.7%), ertapenem (80%), and ceftazidime (79.1%). The susceptibility of Gram-positive organisms to several antibiotics, including levofloxacin (P=0.004), ciprofloxacin (P < 0.001), and chloramphenicol (P=0.001) decreased over time, whereas the susceptibility to TMP-SMX increased over time (P < 0.001). The susceptibility of Gram-negative bacilli to ceftazidime decreased over time (P=0.03). Conclusions Over the 15-year study period, most isolates were Gram-positive cocci, especially coagulase-negative staphylococci (CNS). Vancomycin seemed to be the most effective antibiotic for Gram-positive bacteria. Gram-negative bacteria appeared to be most susceptible to fluoroquinolones. A number of antibiotics showed an increasing trend of microbial resistance.
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Commonly used intracameral antibiotics for endophthalmitis prophylaxis: A literature review. Surv Ophthalmol 2020; 66:98-108. [PMID: 32343980 DOI: 10.1016/j.survophthal.2020.04.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 04/12/2020] [Accepted: 04/13/2020] [Indexed: 01/25/2023]
Abstract
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.
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Chang VS, Schwartz SG, Davis JL, Flynn HW. Endophthalmitis following cataract surgery and intracameral antibiotic: Moxifloxacin resistant Staphylococcus epidermidis. Am J Ophthalmol Case Rep 2019; 13:127-130. [PMID: 30662972 PMCID: PMC6325070 DOI: 10.1016/j.ajoc.2018.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/22/2018] [Accepted: 12/03/2018] [Indexed: 12/17/2022] Open
Abstract
Purpose To describe an immunosuppressed patient who developed acute-onset postoperative endophthalmitis caused by a moxifloxacin-resistant strain of Staphylococcus epidermidis after cataract surgery despite the use of intracameral moxifloxacin. Observations A 76-year old woman with a history of birdshot chorioretinopathy controlled on systemic immunosuppression underwent uneventful cataract surgery in her right eye. Compounded intracameral moxifloxacin 0.2 cc of 1mg/0.1mL (Edge Pharmacy, Syracuse, NY) was injected intraoperatively as prophylaxis, and the patient was placed on a standard regimen of trimethoprim-polymyxin b (10000-0.1unit/mL) and prednisolone acetate 1% postoperatively. Four days later, the patient experienced a sudden decrease in vision in the right eye. Anterior chamber inflammation, vitritis, and vasculitis were seen in the operated eye. The patient underwent a vitreous tap and intravitreal injections of vancomycin (1mg/0.1mL), ceftazidime (2.25mg/0.1mL), and dexamethasone (0.4mg/0.1mL). Cultures grew Staphylococcus epidermidis, resistant to moxifloxacin (MIC ≥8mg/L). The inflammation resolved over two months. Eight months later, the patient underwent uncomplicated cataract surgery in the left eye. Intracameral antibiotics were not used, however her systemic immunosuppressive therapy was held for several weeks perioperatively. One year after the initial surgeries, the patient had an uncorrected visual acuity of 20/20 in each eye. Conclusions and Importance S. epidermidis, the most common cause of postoperative endophthalmitis, is increasingly resistant to fluoroquinolones. Adequate concentrations of intracameral antibiotics need to be achieved in order to exceed minimal inhibitory concentration values of the targeted pathogen. Although intracameral moxifloxacin has been reported to decrease the rate of endophthalmitis after cataract surgery, it does not eliminate the risk.
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Affiliation(s)
- Victoria S Chang
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller, School of Medicine, Miami, FL, USA
| | - Stephen G Schwartz
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller, School of Medicine, Miami, FL, USA
| | - Janet L Davis
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller, School of Medicine, Miami, FL, USA
| | - Harry W Flynn
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller, School of Medicine, Miami, FL, USA
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Bowen RC, Zhou AX, Bondalapati S, Lawyer TW, Snow KB, Evans PR, Bardsley T, McFarland M, Kliethermes M, Shi D, Mamalis CA, Greene T, Rudnisky CJ, Ambati BK. Comparative analysis of the safety and efficacy of intracameral cefuroxime, moxifloxacin and vancomycin at the end of cataract surgery: a meta-analysis. Br J Ophthalmol 2018; 102:1268-1276. [PMID: 29326317 PMCID: PMC6041193 DOI: 10.1136/bjophthalmol-2017-311051] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 10/07/2017] [Accepted: 12/07/2017] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Randy C Bowen
- Department of Ophthalmology, University of Wisconsin, Madison, Wisconsin, USA
| | - Andrew Xingyu Zhou
- Department of Ophthalmology, University of Utah, Salt Lake City, Utah, USA
| | | | - Thomas W Lawyer
- Department of Ophthalmology, University of Utah, Salt Lake City, Utah, USA
| | - Karisa B Snow
- Department of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Patrick R Evans
- Department of Ophthalmology, University of Utah, Salt Lake City, Utah, USA
| | - Tyler Bardsley
- Department of Ophthalmology, University of Utah, Salt Lake City, Utah, USA
| | - Mary McFarland
- Department of Ophthalmology, University of Utah, Salt Lake City, Utah, USA
| | | | - Dallas Shi
- Department of Ophthalmology, University of Utah, Salt Lake City, Utah, USA
| | | | - Tom Greene
- Department of Ophthalmology, University of Utah, Salt Lake City, Utah, USA
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Galvis V, Tello A, Camacho PA, Rey JJ. Comment on: Antibiotic prophylaxis in cataract surgery - An evidence-based approach. Indian J Ophthalmol 2018; 66:603. [PMID: 29582837 PMCID: PMC5892079 DOI: 10.4103/ijo.ijo_1309_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Virgilio Galvis
- Department of Ophthalmology, Ophthalmological Foundation of Santander; Centro Oftalmológico Virgilio Galvis, Floridablanca; Department of Ophthalmology, Faculty of Health Sciences, Autonomous University of Bucaramanga UNAB, Bucaramanga, Santander, Colombia
| | - Alejandro Tello
- Department of Ophthalmology, Ophthalmological Foundation of Santander; Centro Oftalmológico Virgilio Galvis, Floridablanca; Department of Ophthalmology, Faculty of Health Sciences, Autonomous University of Bucaramanga UNAB, Bucaramanga, Santander, Colombia
| | - Paul A Camacho
- Department of Ophthalmology, Faculty of Health Sciences, Autonomous University of Bucaramanga UNAB, Bucaramanga, Santander; Department of Research, Ophthalmological Foundation of Santander, Floridablanca, Colombia
| | - Juan J Rey
- Department of Ophthalmology and Research, Faculty of Health Sciences, Autonomous University of Bucaramanga UNAB, Bucaramanga, Santander, Colombia
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Sahinoglu-Keskek N, Pelit A. Intracameral moxifloxacin for prophylaxis of postoperative endophthalmitis. SPEKTRUM DER AUGENHEILKUNDE 2017. [DOI: 10.1007/s00717-017-0350-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kessel L, Erngaard D, Flesner P, Andresen J, Hjortdal J. Do evidence-based guidelines change clinical practice patterns? Acta Ophthalmol 2017; 95:337-343. [PMID: 27966271 DOI: 10.1111/aos.13314] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 09/30/2016] [Indexed: 12/24/2022]
Abstract
In 2013, the Danish Health and Medicines Authorities published a National Clinical Guideline on the treatment of age-related cataracts. The guideline provided evidence-based recommendations on the indication for cataract surgery, cataract surgery in patients with age-related macular degeneration, on the use of toric intraocular lenses (IOLs) to correct preoperative corneal astigmatism, the use of intracameral and topical antibiotics to prevent endophthalmitis, choice of anti-inflammatory medication to control postoperative inflammation and prevent cystoid macular oedema, the use of immediate sequential bilateral cataract surgery and on the postoperative check-up of patients. A questionnaire was sent to all members of the Danish Ophthalmological Society before and after publication of the guideline. The responses showed that the guideline had changed practice patterns so that surgeons were more likely to prescribe non-steroidal anti-inflammatory eye drops and to not prescribe topical antibiotic eye drops after the guideline was published. Other parameters, most notably the use of toric IOLs and use of postoperative examinations were more guided by reimbursement standards than by evidence-based medicine. Thus, evidence-based guidelines do change practice patterns unless they are counteracted by the reimbursement system.
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Affiliation(s)
- Line Kessel
- Department of Ophthalmology; Centre of Head and Orthopedics; Rigshospitalet-Glostrup; Glostrup Denmark
- Institute of Clinical Medicine; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - Ditte Erngaard
- Department of Ophthalmology; Zealand University Hospital; Naestved Denmark
| | | | | | - Jesper Hjortdal
- Department of Ophthalmology; Aarhus University Hospital NBG; Aarhus Denmark
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Gower EW, Lindsley K, Tulenko SE, Nanji AA, Leyngold I, McDonnell PJ. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database Syst Rev 2017; 2:CD006364. [PMID: 28192644 PMCID: PMC5375161 DOI: 10.1002/14651858.cd006364.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Endophthalmitis is a severe inflammation of the anterior or posterior (or both) chambers of the eye that may be sterile or associated with infection. It is a potentially vision-threatening complication of cataract surgery. Prophylactic measures for endophthalmitis are targeted against various sources of infection. OBJECTIVES To evaluate the effects of perioperative antibiotic prophylaxis for endophthalmitis following cataract surgery compared with no prophylaxis or other form of prophylaxis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), Ovid MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to December 2016), Embase (January 1980 to December 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to December 2016),the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We used no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 6 December 2016. We also searched for additional studies that cited any included trials using the Science Citation Index. SELECTION CRITERIA We included randomized controlled trials that enrolled adults undergoing cataract surgery (any method and incision type) for lens opacities due to any origin. We included trials that evaluated preoperative antibiotics, intraoperative (intracameral, subconjunctival or systemic), or postoperative antibiotic prophylaxis for acute endophthalmitis. We excluded studies that evaluated antiseptic preoperative preparations using agents such as povidone iodine or antibiotics for treating acute endophthalmitis after cataract surgery. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts and full-text articles for eligibility, assessed the risk of bias for each included study, and abstracted data. MAIN RESULTS Five studies met the inclusion criteria for this review, including 101,005 adults and 132 endophthalmitis cases. While the sample size was very large, the heterogeneity of the study designs and modes of antibiotic delivery made it impossible to conduct a formal meta-analysis. Interventions investigated included the utility of adding vancomycin and gentamycin to the irrigating solution compared with standard balanced saline solution irrigation alone, use of intracameral cefuroxime with or without topical levofloxacin perioperatively, periocular penicillin injections and topical chloramphenicol-sulfadimidine drops compared with topical antibiotics alone, and mode of antibiotic delivery (subconjunctival versus retrobulbar injections; fixed versus separate instillation of gatifloxacin and prednisolone). The risk of bias among studies was low to unclear due to information not being reported. We identified one ongoing study.Two studies compared any antibiotic with no antibiotic. One study, which compared irrigation with antibiotics in balanced salt solution (BSS) versus BSS alone, was not sufficiently powered to detect differences in endophthalmitis between groups (very low-certainty evidence). One study found reduced risk of endophthalmitis when combining intracameral cefuroxime and topical levofloxacin (risk ratio (RR) 0.14, 95% confidence interval (CI) 0.03 to 0.63; 8106 participants; high-certainty evidence) or using intracameral cefuroxime alone (RR 0.21, CI 0.06 to 0.74; 8110 participants; high-certainty evidence) compared with placebo, and an uncertain effect when using topical levofloxacin alone compared with placebo (RR 0.72, CI 0.32 to 1.61; 8103 participants; moderate-certainty evidence).Two studies found reduced risk of endophthalmitis when combining antibiotic injections during surgery and topical antibiotics compared with topical antibiotics alone (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.12 to 0.92 (periocular penicillin and topical chloramphenicol-sulfadimidine; 6618 participants; moderate-certainty evidence); and RR 0.20, 95% CI 0.04 to 0.91 (intracameral cefuroxime and topical levofloxacin; 8101 participants; high-certainty evidence)).One study, which compared fixed versus separate instillation of gatifloxacin and prednisolone, was not sufficiently powered to detect differences in endophthalmitis between groups (very low-certainty evidence). Another study found no evidence of a difference in endophthalmitis when comparing subconjunctival versus retrobulbar antibiotic injections (RR 0.85, 95% CI 0.55 to 1.32; 77,015 participants; moderate-certainty evidence).Two studies reported any visual acuity outcome; one study, which compared fixed versus separate instillation of gatifloxacin and prednisolone, reported only that mean visual acuity was the same for both groups at 20 days postoperation. In the other study, the difference in the proportion of eyes with final visual acuity greater than 20/40 following endophthalmitis between groups receiving intracameral cefuroxime with or without topical levofloxacin compared with no intracameral cefuroxime was uncertain (RR 0.69, 95% CI 0.22 to 2.11; 29 participants; moderate-certainty evidence).Only one study reported adverse events (1 of 129 eyes had pupillary membrane in front of the intraocular lens and 8 eyes showed posterior capsule opacity). No study reported outcomes related to quality of life or economic outcomes. AUTHORS' CONCLUSIONS Multiple measures for preventing endophthalmitis following cataract surgery have been studied. High-certainty evidence shows that injection with cefuroxime with or without topical levofloxacin lowers the chance of endophthalmitis after surgery, and there is moderate-certainty evidence to suggest that using antibiotic eye drops in addition to antibiotic injection probably lowers the chance of endophthalmitis compared with using injections or eye drops alone. Clinical trials with rare outcomes require very large sample sizes and are quite costly to conduct; thus, it is unlikely that many additional clinical trials will be conducted to evaluate currently available prophylaxis. Practitioners should rely on current evidence to make informed decisions regarding prophylaxis choices.
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Affiliation(s)
- Emily W Gower
- Gillings School of Global Public HealthUniversity of North Carolina135 Dauer Drive2102A McGavran Greenberg, CB#7435Chapel HillNorth CarolinaUSA27599
| | - Kristina Lindsley
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 North Wolfe Street, Mail Room E6132BaltimoreMarylandUSA21205
| | - Samantha E Tulenko
- Gillings School of Global Public HealthUniversity of North Carolina135 Dauer Drive2102A McGavran Greenberg, CB#7435Chapel HillNorth CarolinaUSA27599
| | - Afshan A Nanji
- Oregon Health & Science UniversityCasey Eye InstitutePortlandOregonUSA97239
| | - Ilya Leyngold
- Duke University Hospital Department of OphthalmologyDivision of Oculofacial Plastic and Reconstructive SurgeryDurhamNorth CarolinaUSA27710
| | - Peter J McDonnell
- Johns Hopkins University School of MedicineWilmer Eye Institute600 N. Wolfe StreetMaumenee 727BaltimoreMarylandUSA21287
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Huang J, Wang X, Chen X, Song Q, Liu W, Lu L. Perioperative Antibiotics to Prevent Acute Endophthalmitis after Ophthalmic Surgery: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0166141. [PMID: 27824933 PMCID: PMC5100907 DOI: 10.1371/journal.pone.0166141] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 10/24/2016] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Post-operative endophthalmitis is a rare and dreaded complication in ophthalmic operations because it often induces irreparable vision loss. Although many ophthalmological studies aimed at reducing the rate of endophthalmitis have been performed around the world, controversy continues to surround some issues, including the choice of antimicrobials and their route of administration, duration and timing. The aim of this study is to investigate some of these unresolved issues. METHODS A systematic review and meta-analysis of randomized controlled trials and observational studies was performed. The PubMed, EMBASE, Cochrane Library and Clinical Trials databases were searched to identify studies published until Feb. 2016. The relative risk (RR) for each clinical outcome data is presented with 95% confidence intervals (CIs). Pooled estimates of effects were calculated using random-effect models. RESULTS Thirty-four studies from twenty-four reports involving 1264797 eyes were included in this analysis. Endophthalmitis occurred, on average, in one out of 6177 eyes when intracameral vancomycin/moxifloxacin were used and in one out of 1517 eyes when intracameral vancomycin/moxifloxacin were not used. The relative risk (95% CI) of endophthalmitis was reduced to 0.20 (0.10, 0.42) when intracameral antibiotics were used (p<0.0001). The subconjunctival injection of antibiotics was not superior to other administration routes included in this study (RR = 1.67, 95% CI (0.55, 5.05), p = 0.36). A statistically significant difference was found in the rate of endophthalmitis between the use and lack of use of topical antibiotics (RR = 0.65, 95% CI (0.43, 0.99), p = 0.04). However, no statistically significant difference was found in microbial isolation rates between these groups (RR = 0.77, 95% CI (0.34, 1.75), p = 0.53). When long-term and short-term use of topical antibiotics before surgery were compared, a statistically significant difference was found in microbial isolation rates (RR = 0.57, 95% CI (0.44, 0.74), p<0.0001). CONCLUSIONS This meta-analysis concluded intracameral antibiotics are effective at preventing endophthalmitis in ocular surgery. A randomized controlled trial confirms the efficacy of cefuroxime but recent large cohort studies support the efficacy of vancomycin/moxifloxacin intracamerally. Intracameral antibitoics are superior to subconjunctival injections but that irrigation antibitoic data are not of enough quality to make a comparison. Different results were found in two clinical outcomes between the use or lack of use of topical antibiotic therapy, we did not find sufficient evidence to conclude that its use prevents endophthalmitis.
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Affiliation(s)
- Jinzhu Huang
- Department of Pharmacy, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Xiaofang Wang
- Department of Laboratory Medicine, Key Laboratory of Diagnostic Medicine (Ministry of Education), Chongqing Medical University, Chongqing, China
| | - Xiaohong Chen
- Department of Pharmacy, Chongqing Health Center for Women and Children, Chongqing, China
| | - Qiuyue Song
- Department of Health Statistics, Third Military Medical University, Chongqing, China
| | - Wen Liu
- Department of Pharmacy, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Laichun Lu
- College of Pharmacy, Third Military Medical University, Chongqing, China
- * E-mail:
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López Y, Samudio M, Fariña N, Castillo V, Abente S, Nentwich MM, González-Britez N, Laspina F, Carron A, Cibils D, de Kaspar HM. Effect of antibiotic prophylaxis on Coagulase-negative Staphylococcus virulence factor profiles in patients undergoing cataract surgery. Int Ophthalmol 2016; 37:929-937. [PMID: 27655297 DOI: 10.1007/s10792-016-0355-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/16/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE In this prospective study, multiplex polymerase chain reaction (PCR) was used to identify genes encoding virulence factors (ica, atlE and mecA) in Coagulase-negative Staphylococcus (CNS) isolates from the ocular microbiota of patients undergoing cataract surgery and to investigate possible changes in the CNS profile due to antibiotic prophylaxis. METHODS Between 09/2011 and 08/2013, patients undergoing cataract surgery were recruited at the Department of Ophthalmology, National University of Asuncion, Paraguay. In the eye to be operated on, patients received moxifloxacin 0.5 % eye drops four times at the day before surgery and a last drop 1 hour before surgery (T1). The other eye remained as control (T0). Conjunctival swabs were taken from both eyes 1 hour after the last drop. The presence of genes encoding biofilm formation (ica and atlE) and methicillin resistance (mecA) was detected by a multiplex PCR. RESULTS Of the 162 patients (162 study eyes, 162 fellow eye as control group), 87 (53.7 %) eyes were positive for CNS at T0 yielding 96 CNS isolates; 70 eyes (43.2 %) were positive at T1 yielding 77 CNS isolates. For this study, 43 CNS isolates (44.8 %) from T0 and 45 (64.3 %) from T1 were used. Of the total isolates, 81.8 % (72/88) had at least one virulence factor gene (37/43 from T0 and 35/45 from T1) (p = 0.314). Simultaneous detection of ica and atlE genes was higher in T0 (58.0 %) than T1 (46.7 %), but the difference was not significant (p = 0.28). CONCLUSION A high frequency of genes encoding virulence factors was observed in the coagulase-negative Staphylococcus isolates. The use of moxifloxacin did not significantly modify the CNS virulence factor profiles.
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Affiliation(s)
- Yolanda López
- Instituto de Investigaciones en Ciencias de la Salud (IICS), National University of Asunción, San Lorenzo, Paraguay
| | - Margarita Samudio
- Instituto de Investigaciones en Ciencias de la Salud (IICS), National University of Asunción, San Lorenzo, Paraguay.
| | - Norma Fariña
- Instituto de Investigaciones en Ciencias de la Salud (IICS), National University of Asunción, San Lorenzo, Paraguay
| | - Verónica Castillo
- Department of Ophthalmology, National University of Asunción, San Lorenzo, Paraguay
| | - Sonia Abente
- Instituto de Investigaciones en Ciencias de la Salud (IICS), National University of Asunción, San Lorenzo, Paraguay
| | - Martin M Nentwich
- Department of Ophthalmology, Julius-Maximilians-University, Würzburg, Germany
| | - Nilsa González-Britez
- Instituto de Investigaciones en Ciencias de la Salud (IICS), National University of Asunción, San Lorenzo, Paraguay
| | - Florentina Laspina
- Instituto de Investigaciones en Ciencias de la Salud (IICS), National University of Asunción, San Lorenzo, Paraguay
| | - Agustín Carron
- Department of Ophthalmology, National University of Asunción, San Lorenzo, Paraguay
| | - Diógenes Cibils
- Department of Ophthalmology, National University of Asunción, San Lorenzo, Paraguay
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Office-Based Cataract Surgery: Population Health Outcomes Study of More than 21 000 Cases in the United States. Ophthalmology 2016; 123:723-8. [PMID: 26804760 DOI: 10.1016/j.ophtha.2015.12.020] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To identify safety and effectiveness outcomes of office-based cataract surgery. Each year, approximately 3.7 million cataract surgeries in the United States are performed in Ambulatory Surgery Center (ASC) and Hospital Outpatient Department (HOPD) locations. Medicare in July 2015 published a solicitation for expert opinion on reimbursing office-based cataract surgery. DESIGN Large-scale, retrospective, consecutive case series of cataract surgeries performed in Minor Procedure Rooms (MPRs) of a large US integrated healthcare center. PARTICIPANTS More than 13 500 patients undergoing elective office-based cataract surgery. METHODS Phacoemulsification cataract surgery performed in MPRs of Kaiser Permanente Colorado from 2011 to 2014. MAIN OUTCOME MEASURES Postoperative visual acuity and intraoperative and postoperative adverse events (AEs). RESULTS Office-based cataract surgery was completed in 21 501 eyes (13 507 patients, age 72.6±9.6 years). Phacoemulsification was performed in 99.9% of cases, and manual extracapsular extraction was performed in 0.1% of cases. Systemic comorbidities included hypertension (53.5%), diabetes (22.3%), and chronic obstructive pulmonary disease (9.4%). Postoperative mean best-corrected visual acuity measured 0.14±0.26 logarithm of the minimum angle of resolution units. Intraoperative ocular AEs included 119 (0.55%) cases of capsular tear and 73 (0.34%) cases of vitreous loss. Postoperative AEs included iritis (n = 330, 1.53%), corneal edema (n = 110, 0.53%), and retinal tear or detachment (n = 30, 0.14%). No endophthalmitis was reported. Second surgeries were performed in 0.70% of treated eyes within 6 months. There were no life- or vision-threatening intraoperative or perioperative AEs. CONCLUSIONS This is the largest US study to investigate the safety and effectiveness of office-based cataract surgery performed in MPRs. Office-based efficacy outcomes were consistently excellent, with a safety profile expected of minimally invasive cataract procedures performed in ASCs and HOPDs.
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Zhou AX, Messenger WB, Sargent S, Ambati BK. Safety of undiluted intracameral moxifloxacin without postoperative topical antibiotics in cataract surgery. Int Ophthalmol 2015; 36:493-8. [PMID: 26577588 DOI: 10.1007/s10792-015-0151-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 10/28/2015] [Indexed: 10/22/2022]
Abstract
The objective of this study is to evaluate the safety of undiluted 0.5 % intracameral moxifloxacin for postoperative endophthalmitis prophylaxis in cataract surgery patients without the use of additional postoperative topical antibiotics. All phacoemulsification cataract surgeries performed by a single surgeon (B.A.) at the John A. Moran Eye Center from June 2012 to May 2015 were reviewed retrospectively. From June 2012 to April 2014, patients were given topical 0.5 % moxifloxacin postoperatively. From May 2014 to May 2015, all patients were given moxifloxacin intracamerally with no antibiotics postoperatively. The follow-up period was 1 month after surgery. Preoperative visual acuity and postoperative visual acuity, corneal edema, and anterior chamber reaction were recorded and compared between the two groups. 384 cataract surgeries were performed during the study period. None of the 384 eyes in the study developed endophthalmitis. Of those 384 eyes, 222 were included in the study for analysis based on the inclusion and exclusion criteria. 131 were part of the topical antibiotic group and 91 were part of the intracameral group. The differences in uncorrected visual acuity at 1 day postoperatively (p = 0.595) and best corrected visual acuity at 1 month postoperatively (p = 0.099) were not statistically significant. Differences in corneal edema (p = 0.370) and anterior chamber reaction (p = 0.069) at 1 day postoperatively and corneal edema (p = 0.512) and anterior chamber reaction (p = 0.512) at 1 month postoperatively were also not statistically significant. Undiluted 0.5 % moxifloxacin can be safely injected intracamerally following cataract surgery without additional postoperative antibiotic prophylaxis to prevent endophthalmitis without adverse effects on patient outcomes.
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Affiliation(s)
- Andrew Xingyu Zhou
- John A. Moran Eye Center, University of Utah School of Medicine, 65 Mario Capecchi Drive, S5668, Salt Lake City, UT, 84132, USA
| | - Wyatt Boyer Messenger
- John A. Moran Eye Center, University of Utah School of Medicine, 65 Mario Capecchi Drive, S5668, Salt Lake City, UT, 84132, USA
| | - Steven Sargent
- John A. Moran Eye Center, University of Utah School of Medicine, 65 Mario Capecchi Drive, S5668, Salt Lake City, UT, 84132, USA
| | - Balamurali Krishna Ambati
- John A. Moran Eye Center, University of Utah School of Medicine, 65 Mario Capecchi Drive, S5668, Salt Lake City, UT, 84132, USA.
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Kessel L, Flesner P, Andresen J, Erngaard D, Tendal B, Hjortdal J. Antibiotic prevention of postcataract endophthalmitis: a systematic review and meta-analysis. Acta Ophthalmol 2015; 93:303-17. [PMID: 25779209 PMCID: PMC6680152 DOI: 10.1111/aos.12684] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 01/12/2015] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Line Kessel
- Department of OphthalmologyCopenhagen University Hospital GlostrupGlostrupDenmark
- Danish Health and Medicines AuthoritiesCopenhagenDenmark
| | | | | | - Ditte Erngaard
- Department of OphthalmologyNæstved HospitalNæstvedDenmark
| | - Britta Tendal
- Danish Health and Medicines AuthoritiesCopenhagenDenmark
| | - Jesper Hjortdal
- Department of OphthalmologyAarhus University Hospital NBGAarhusDenmark
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Kim JH, Kong SJ, Kim JW, Lim TH, Choi KY, Cho BJ. Efficacy and Safety of Immediate Sequential Bilateral Cataract Surgery. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2015. [DOI: 10.3341/jkos.2015.56.12.1854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Endophthalmitis remains a rare but serious cause of visual loss. Over time, changes have been noted in endophthalmitis in terms of predominant causes, infecting organisms, and antibiotic susceptibilities. There is controversy regarding the use of intracameral prophylactic antimicrobials during cataract surgery. Alternatively, there appears to be increasing evidence against using routine topical antibiotics for intravitreal injections. There are also increasing reports of multidrug-resistant organisms causing endophthalmitis, but the combination of vancomycin and ceftazidime appears effective for the vast majority of cases. Future trends may involve increasing utilization of polymerase chain reaction for diagnosis, and possibly office-based pars plana vitrectomy for treatment of endophthalmitis.
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Affiliation(s)
- Stephen G Schwartz
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 311 9 Street North, #100, Naples, FL 34102. (239) 659-3937. FAX (239) 659-3982.
| | - Harry W Flynn
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 Northwest 17 Street, Miami, FL 33136. (305) 326-6118. FAX (305) 326-6471.
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