ESCRS Endophthalmitis Study: Intracameral cefuroxime injections prevent endophthalmitis

Prophylactic intracameral cefuroxime injections prevent the development of endophthalmitis after cataract surgery, according to results of the European Society of Cataract and Refractive Surgeons Endophthalmitis Study. The finding remains controversial in the United States, where cefuroxime has not been approved by the FDA and the standard of care to prevent endophthalmitis after cataract surgery is the administration of preoperative, perioperative, and postoperative topical fluoroquinolone drops.

Key Points

Hong Kong-Prophylactic intracameral cefuroxime injections prevent development of endophthalmitis after cataract surgery, according to Peter Barry, FRCS, FRCOphth, who reported the results of the European Society of Cataract and Refractive Surgeons (ESCRS) Endophthalmitis Study here at the World Ophthalmology Congress.

The ESCRS study, he said, was designed to address the questions of whether perioperative antibiotics prevent the development of endophthalmitis and, if so, what is the most efficacious route of administration-intracameral injection, intensive topical application, or both.

The study included more than 16,000 patients who were randomly assigned to one of four treatment groups:

According to the published report of the investigation, "all patients received povidone-iodine 5% drops [Betadine] into the conjunctival sac and onto the cornea for a minimum of 3 minutes before surgery, and all patients were requested to use levofloxacin 0.5% eyedrops [Oftaquix] four times daily for 6 days starting the day after surgery."1

The results demonstrated that, in the group that received placebo drops and no injection of antibiotic, the rate of presumed endophthalmitis was about 33 per 10,000 (0.33%) and 23 per 10,000 (0.23%) for proven endophthalmitis by positive gram stain, positive polymerase chain reaction, and a positive culture of the anterior chamber or vitreous tap specimens.

"When compared with the groups that received intracameral cefuroxime, the rates were [approximately] six per 10,000 for presumed endophthalmitis and four per 10,000 for proven endophthalmitis, demonstrating that the use of the intracameral antibiotic reduced the rate of endophthalmitis by a rate exceeding a factor of five," Dr. Barry reported.

Causative organisms

When considering the principal bacterial organisms responsible for the endophthalmitis in this study, staphylococcal infections caused 11 cases, and streptococcal infections caused eight cases.

"The final visual acuity levels in the 11 patients with staphylococcal infections ranged from 20/20 to 20/80. No study patient was legally blind," Dr. Barry said. "In the cases with streptococcal infections, the final visual acuities ranged from 20/20 to no light perception. Five of these patients were legally blind as a result of a streptococcal infection, and none of these patients were treated with cefuroxime.

"The results suggest that not only does the use of intracameral cefuroxime dramatically reduce the incidence of postoperative endophthalmitis by a factor of five [when compared with controls], but also even if the patient is unfortunate enough to develop endophthalmitis postoperatively, the changes of the patient going blind are dramatically reduced," Dr. Barry emphasized.

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