Use of intracameral antibiotics for endophthalmitis prophylaxis is also growing in the United States, albeit slowly, and Dr. Osher was hopeful that sooner or later, there would be a commercially available product approved for this indication.
“It is 8 years since Steve Lane, Sam Masket, and I wrote the first article reporting on the safe use of intracameral antibiotics in cataract surgery in the United States. There is still no FDA-approved product, but the tide is rising,” said Dr. Osher.
“The efficacy and safety of intracameral antibiotics is being supported by a growing body of research and published reports, and I think its time has come.”
Although there is no FDA-approved intracameral antibiotic, Dropless Cataract Surgery products (Imprimis Pharmaceuticals) combining antibiotics and anti-inflammatory products for transzonular administration is generating a lot of interest, Dr. Osher noted.
Dr. Packer observed that in October, 2016, Imprimis issued a press release announcing results of a fairly large retrospective study evaluating the efficacy of Dropless Cataract Surgery. The study included data from more than 1500 eyes injected with triamcinolone acetonide 3.0 mg/moxifloxacin 0.2 mg/vancomycin 2.0 mg. The results showed that for 92% of cases, no supplemental medication was needed in 92%. In addition, there was a low incidence of IOP elevation (0.9%), a 9.2% rate of breakthrough inflammation at days 14 to 21 after surgery, and visually significant cystoid macular edema developed in 2% of eyes. There were no cases of endophthalmitis.
“I think the incidence of CME in this series is concerningly high considering that a few years ago, we published a paper reporting a CME rate of only 0.1% among 2862 eyes that received topical anti-inflammatory medications for CME prophylaxis,” said Dr. Packer.
“Although a much larger series is needed to show definitively that Dropless Cataract Surgery reduces the risk of postoperative endophthalmitis, I would expect it is effective. Therefore, I think that this approach might at least have the potential to reduce the postoperative medication burden by eliminating the antibiotic drop from the regimen.”
Dr. Donnenfeld agreed that American cataract surgeons are turning increasingly to intracameral antibiotics for endophthalmitis prophylaxis. Accompanying this trend, however, hemorrhagic occlusive retinal vasculitis (HORV) was identified as a new syndrome associated with the use of intracameral vancomycin.
The first clinical series reporting on HORV were published in 2014 and 2015, and in July 2016, the American Society of Cataract and Refractive Surgery and the American Society of Retina Specialists issued a clinical alert about the complication, recognizing its potential impact on patient safety.
“Although HORV has been a rare event, it is potentially devastating as it has led to cases of bilateral blindness,” Dr. Donnenfeld said.