Intracameral antibiotics a must to avoid infection post-cataract surgery

Walnut Creek, CA-The creation of a sufficiently long-internal incision as well as stromal hydration and a moderate final IOP are effective steps to reduce fluid ingress-and lower risk of infection-into the eye following cataract surgery, according to Neal Shorstein, MD.

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Opportunities for infections to develop during cataract surgery occur at two time points:

·      Intraoperatively, when organisms on eyelids and lashes can enter the eye or through contaminated instrumentation.

·      Postoperatively through an incompetent wound.

To combat this, antiseptic agents are applied preoperatively with antibiotic drops and povidone-iodine, intraoperatively with antibiotics delivered by various routes, and postoperatively using antibiotic drops, said Dr. Shorstein, ophthalmologist and associate chief of quality, Diablo Service Area, Kaiser Permanente, Walnut Creek, CA.

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To prevent postoperative infections caused by organisms that enter the eye intraoperatively, various topical, subconjunctival, and intracameral antibiotics are applied before, during, and after surgery.

Since the 1990s, a number of studies have been conducted that demonstrated the benefits of intracameral antibiotic injections for reducing the risk of endophthalmitis more than other forms of surgical site prophylaxis. Therefore, the decision is not whether to inject intracameral drugs, but rather which drug to use, Dr. Shorstein explained.

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The most predominant infectious organisms have been Gram-positive bacteria-a high percentage of which are covered effectively by cefuroxime and vancomycin. However, the use of cefuroxime has been reported to be questionable in patients with a penicillin allergy because of fear of cross-reactivity, and also due to the two-step process required to compound the drug, he noted.

Watch as intracameral antibiotic (0.1 mL) is injected into the anterior chamber. (Video courtesy of Neal Shorstein, MD)

“Compounding concerns, including contamination and dilution errors, are not trivial,” Dr. Shorstein said.

Moxifloxacin has less strong Gram-positive coverage, but better Gram-negative coverage, he explained.

Vancomycin, while it has the best Gram-positive coverage, also requires complex compounding, and with routine prophylactic use, its efficacy may diminish, he noted.

The Centers for Disease Control has discouraged its routine use, according to Dr. Shorstein.

For Dr. Shorstein, injecting intracameral antibiotics is the best route for reducing infections.

“Based on the evidence, intracameral antibiotics should be injected in every patient, especially those with capsular rupture,” Dr. Shorstein said. “The type of antibiotic used should be judged based on the ability to acquire the drug and the spectrum of organisms recovered from cases at your center.

“Meticulous wound construction and management should reduce or eliminate the ingress of organisms postoperatively and might even bring into question whether postoperative eye drops are even necessary following optimal, uncomplicated surgery,” he continued.

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