Intracameral antibiotic prophylaxis remains controversial

Results of the European Society of Cataract and Refractive Surgeons prospective randomized study of postcataract surgery endophthalmitis prophylaxis showed a significant benefit for using intracameral cefuroxime at the conclusion of the case. However, the jury is still out on the role of intracameral antibiotics for preventing infection, said Francis S. Mah, MD, assistant professor of ophthalmology, cornea, external disease, and refractive surgery service, and co-medical director, The Charles T. Campbell Eye Microbiology Laboratory, Department of Ophthalmology, University of Pittsburgh Medical Center.

"The undertaking of this study is commendable, but it is the subject of ongoing critique. More research is needed," Dr. Mah said. "Surgeons who currently are using an intracameral antibiotic with good safety and success may continue, but for those who have not adopted the technique, it seems reasonable to wait."

If intracameral antibiotics are to be used, further study is needed to identify the optimal drug and dose. In addition, optimal safety will depend on an agent that affords a simple method of use, he said.

"Ideally, surgeons should be able to take a commercially available formulation and put it directly into the eye," he said.

In the meantime, cataract surgeons can reduce the risk of postoperative endophthalmitis by treating periocular conditions, meticulously draping the lids and lashes, and using 5% povidone-iodine solution for preoperative antisepsis to the lids, lashes, and conjunctiva with a contact time of at least 3 minutes. Surrogate evidence supports the use of topical antibiotics, and fourth-generation fluoroquinolones are the agents of choice.

In patients at high risk, systemic fluoroquinolones or subconjunctival antibiotics can be considered, he said.

Importantly, topical antibiotics should not be tapered because that regimen increases the risk of organism resistance, he added.

"Continue the treatment four times a day for at least 1 week," Dr. Mah concluded.