Intracameral vancomycin safe, effective over long term

May 15, 2007

Howard V. Gimbel, MD, MPH, has used intracameral injection of vancomycin to prevent endophthalmitis after cataract surgery since 1990. In an analysis of more than 35,000 eyes operated on over 15 years, the incidence of presumed endopthalmitis was only 0.01% and there was no evidence of complications associated with the antibiotic injection.

Key Points

Las Vegas-Based on 15 years of use, intracameral injection of vancomycin at the end of the procedure appears to be a safe and effective method for minimizing the risk of endophthalmitis following cataract surgery, according to data presented by Howard V. Gimbel, MD, MPH, at the annual meeting of the American Academy of Ophthalmology.

Dr. Gimbel reported on his personal experience with intracameral vancomycin during the Spotlight Session on Toxic Anterior Segment Syndrome (TASS) and Endophthalmitis. Using it since 1990 in a total of 35,237 eyes, he encountered only four cases of presumed endophthalmitis for an incidence rate of 0.01%. All of the eyes were culture-negative, three appeared clinically to have TASS, and the fourth had clinical features of a low-grade endophthalmitis. Postmanagement, all achieved final best-corrected visual acuity (BCVA) of 20/25 or better.

Dr. Gimbel noted that this experience contrasts favorably with rates of endophthalmitis in the Calgary Health Region (0.06%), the European Society of Cataract and Refractive Surgeons endophthalmitis prophylaxis study (0.05%), and a published report from Spanish ophthalmologists (0.06%). In addition, he has not found the use of intracameral vancomycin to be associated with any complications, including evidence of causing endothelial cell damage.

He also contrasted the results he achieved using an intracameral bolus of vancomycin with his previous experience of adding antibiotics to the irrigating solution. With the use of gentamicin in balanced salt solution (BSS), the incidence of endophthalmitis increased from 0.02% in 1985 to 0.15% in 1987. Vancomycin was then substituted. The incidence of endophthalmitis for cases performed with vancomycin in the irrigating solution was 0.05% in 1988 and 0.16% in 1989.

"Those rates were still relatively low, but too high for our comfort level, so we switched to the bolus technique," said Dr. Gimbel, who is also professor and chair, Department of Ophthalmology, Loma Linda University, Loma Linda, CA.

The technique for the intracameral bolus delivery of vancomycin involves placement of the cannula under the IOL for in-the-bag injection of a dose of 1 mg/0.1 ml diluted in BSS. Then, pressure in the eye is re-established with BSS introduced through the paracentesis incision.

Four endophthalmitis cases

Dr. Gimbel also provided brief summaries of the four cases of presumed endophthalmitis and highlighted his approach to management with posterior continuous curvilinear capsulorhexis (PCCC), anterior vitrectomy, and intravitreal antibiotic injection used in three of them.

The first case occurred in 1994 and was in an eye with a 5.5-mm scleral tunnel incision. The next two cases were in eyes having 3.2-mm temporal clear corneal incisions and occurred in 1995. All three of those cases presented on the first day postop with hypopyon and fibrin, but no pain. They were managed with posterior capsule opening for anterior vitrectomy and injection of intravi-treal vancomycin. Final BCVA of 20/20 was achieved between 6 days and 7 weeks postop.

When performing PCCC for anterior vitrectomy, the irrigation-aspiration (I/A) handpiece is introduced through the cataract incision to clear the fibrin. Then, viscoelastic is injected to displace the IOL and allow posterior capsule capsulorhexis. After vitrectomy, vancomycin is injected into the vitreous cavity.

"This technique allows access to the vitreous without necessitating pars plana incisions, and it allowed us to initiate management immediately without delays associated with referral and hospital admission," Dr. Gimbel said. "We feel there may be potential benefit of early PCCC and vitrectomy in endophthalmitis as well as in TASS. The technique allows reduction in the load of toxins, bacteria, inflammatory cells, and fibrin, along with early vitreous culture and antibiotic injection, and appears useful for enabling earlier visual recovery."