Fluoroquinolones kill bacteria much faster than cefuroxime, Dr. Jumper said. But they are losing their coverage as gram positive organisms develop resistance. He cited one study showing that half as many bacterial isolates are susceptible than were susceptible in the 1990s.
Cefuroxime shows more promise. A large randomized clinical trial of intracameral cefuroxime prophylaxis, conducted by the European Society of Cornea and Refractive Surgeons, showed a 5-fold reduction in endophthalmitis. “The study had to be stopped because of this big difference between the patients receiving the antibiotics and control,” Dr. Jumper said.
He noted that the rate of endophthalmitis was 1/300 in the control group. “That’s extremely high,” Dr. Jumper said. “If that was happening at the surgery center around you, that would cause a lot of concern.”
Some retrospective studies have also supported the use of the intracameral antibiotics. One study conducted at Kaiser Permanente in Northern California compared 2007 (when most patients were receiving topical antibiotics) to 2011 (when the system had switched to intracameral antibiotics). “In that period of time, there was a 22-fold reduction in endophthalmitis in that system,” he said.
By contrast, Dr. Jumper quoted a report from the Bascom Palmer Eye Institute at the University of Miami that rates of endophthalmitis were 10-fold lower without the use of intracameral antibiotics.
Use of antibiotics as prophylaxis has doubled among U.S. cataract and refractive surgeons since the European study, Dr. Jumper reported. Most U.S. doctors are using moxifloxacin or vancomycin off label because, in contrast to Europe, there is no approved drug for this purpose.
“That’s holding us back,” he said. “There would be even more intracameral use if there was an approved drug like there is in Europe.”
Because the only antibiotics for this purpose are available off label, patients in the United States run the risk of compounding errors. Dr. Jumper cited the example of a patient who received 60 mg of intracameral cefuroxime instead of the normal dose of 1 mg.
“That led to severe corneal, retinal, and optic nerve damage,” he said.