Cataract Surgery Report

How intracameral antibiotics can reduce post-op drug costs

Vancomycin-ceftazidime may be the protocol of choice, but other options have proven efficacious and safe.

By James P. Gills, MD

About the Author: James P. Gills, MD, is founder and director of St. Luke’s Cataract & Laser Institute in Tarpon Springs, Fla., consulting professor at Duke University Medical Center, Durham, N.C., and affiliate professor at University of South Florida in Tampa. Disclosure: Dr. Gills has no relevant relationships to disclose.

Due to the potentially devastating complications of postoperative endophthalmitis, prophylactic antibiotics have been the subject of ongoing clinical research and debate. The rarity of this disease precludes practical clinical trials, so each clinician needs to exercise judgment as to what is best for his or her patients.

More than 40 years ago, I began using prophylactic antibiotics in the anterior chamber via infusion fluid during cataract surgery. For the past 35 years, I have used the protocol involving an anterior chamber injection of vancomycin, ceftazidime and dexamethasone (1/10th of the therapeutic dose) as both Robert Machemer, MD, and Gholam Peyman, MD, have suggested in personal communications.

ANTIBIOTICS OF CHOICE

Role of vancomycin

In 1988, Manus Kraff, MD, of Chicago, and I were running the Boston Marathon and we were discussing the technique of using vancomycin and gentamicin diluted in the phaco bottle. Dr. Kraff told me he adopted this technique, and in the 25 years since he has reported zero incidents of post-cataract surgery endophthalmitis in approximately 25,000 cases.

Vancomycin injected intracamerally at the end of surgery is the preferred drug of many surgeons, and their studies have also shown a significant decline in the rate of endophthalmitis. Richard Mackool, MD, of Mackool Eye Institute in Astoria, N.Y., and his group of 40 ophthalmologists reported in personal communication they have performed 75,000 consecutive cataract implant procedures over 14 years with no cases of endophthalmitis. Steve Arshinoff, MD, FRCSC, of North York, Ontario, started using vancomycin more than 30 years ago, and has also had a marked decrease of endophthalmitis.¹ Howard Gimbel, MD, FACS, of Calgary, Alberta, began using an injection of vancomycin in the capsular bag and anterior chamber at the end of cataract surgery in 1990 with similar results.²

Many centers throughout the United States have used vancomycin or other antibiotics in the anterior chamber, but have not reported on it in the literature. A personal survey has suggested that about half of the large practices in the United States are using prophylactic intracameral antibiotics.

Moxifloxacin and cefuroxime

Intracameral moxifloxacin has also been successful in preventing endophthalmitis. Ophthalmologists such as Steve Arshinoff MD, Samuel Masket, MD, (Los Angeles), Stephen Lane, MD. (Stillwater, Minn.) and Robert Osher, MD, (Cincinnati), have used this approach.^3-5 Samar Basak, MD, (Kolkata, India) has seen excellent results with intracameral moxifloxacin as well.

Dr. Basak’s five-year study of more than 12,000 consecutive routine cataract cases resulted in zero incidents of postoperative endophthalmitis, zero cases of TASS (toxic anterior segment syndrome) and no other major adverse reactions. Contrary to this, in the three years before his study, Dr. Basak performed 8,046 cataract surgeries without intracameral antibiotics and had nine cases of postoperative endophthalmitis, at a rate of 0.11%.⁶

Several European studies showed treating with intracameral cefuroxime injections at the end of surgery was safe and effective, and significantly decreased the incidence of endophthalmitis. Although these studies were open to criticism for their choice of antibiotic, they did show about a six-fold reduction in endophthalmitis.^7-9

In 2007, a survey was conducted in which one half of the surgeons administered intraocular antibiotics bolus directly into the anterior chamber while the other half used an infusion bottle. Although both methods appeared to be effective, injecting the antibiotics intracamerally at the end of the procedure is likely a more accurate way of administering the drugs.¹⁰ The incidence of endophthalmitis is relatively rare with vancomycin alone, and this approach is certainly preferred to using no intracameral antibiotics.

Vancomycin-ceftazidime mixture

Endophthalmitis has rarely been reported with the vancomycin and ceftazidime combination. This combination of gram-negative suppressive antibiotic and gram-positive suppressive antibiotic appears to be empirically as well as theoretically correct. This antibiotic combination also appears to be superior to the others, but the complexity of mixing vancomycin, ceftazidime and other solutions requires a competent staff and more time to prepare.

Jeffrey A. Wipfli, MD, (St. Luke’s Cataract & Laser Institute, Tarpon Springs, Fla.) joined our practice in 2009 and told me: “Prior to joining St. Luke’s, I had an endophthalmitis rate of approximately 1/1,000 to 1,500 cases (over 9.5 years). Since joining St. Luke’s, I have had zero cases of endophthalmitis using your [intracameral antibiotic] regimen in approximately 5,000 cases. I am a firm believer and feel there is no question that intracameral injections of antibiotics are efficacious.”

COURTESY: INGRID U. SCOTT, MD, MPH

While rare after cataract surgery, endopthalmitis can be a devastating complication for both the physician and patient.

In a recent article, a panel of five ophthalmologists discussed their use of intraocular antibiotics. Among them Eric Donnenfeld, MD, described his intracameral antibiotic protocol using an analogy of the famous bank robber, Willie Sutton, who replied when asked why he robbed banks, “because that’s where the money is.”

Likewise, Dr. Donnenfeld stated he uses intracameral vancomycin because that’s where the organisms responsible for endophthalmitis are. In the same article, William Trattler, MD, pointed out that although intracameral antibiotics have been shown to reduce the risk of endophthalmitis, an FDA-approved intracameral antibiotic currently does not exist.¹¹

At a national ophthalmological meeting, the entire group of physicians was asked the question: If an FDA-approved implant that contained an antibiotic to treat endophthalmitis were available, would you use it? A large percentage of the crowd raised their hands in the affirmative.

PREPARING THE SOLUTION

Ease of administration is important

Although the common thread here is the use of intracameral antibiotics at the time of cataract surgery, each clinician has her or his own method of preparing their solution. Toxicity and efficacy are key issues when determining the make-up of the solution. Ease of administration also plays a role.

Dr. Arshinoff’s protocol is a diluted solution of 3 ml of Vigamox (moxifloxacin, Alcon, Fort Worth, Texas) combined with 7 ml of BSS in a 12 cc syringe (millipore filter not needed). He injects 0.2 cc (equal to 1 mg/ ml) of solution into the AC at the end of the procedure.¹² Dr. Masket, on the other hand, uses undiluted Vigamox, which has a good profile for efficacy, is sterile and has a formulated pH of 6.8, which is compatible with the anterior chamber fluid. He injects 50 μL (.05 cc) of 0.5% undiluted Vigamox into the AC at the close of surgery.^13-15

Our practice protocol

The technique our practice uses is more complex and requires more controls. It may not be as easily adopted in small practices.

We draw up 16.64 ml of BSS and inject it into an empty sterile vial. We then add the following concentrations to the 16.64-ml bottle of BSS:
• 5.62 cc dexamethasone 4 mg/ml.
• 0.09 ml ceftazidime 50 mg/ml.
• 0.15 ml vancomycin 500 mg/10 ml.
Total volume is equal to 22.5 cc.

At the end of phacoemulsification, we draw up a dosage of 0.1 cc. We make the eye firm and then decompress it by about 0.1 cc of fluid. At that point, we inject 0.1 cc of fluid containing the antibiotics intracamerally with a 27-gauge cannula through the paracentesis into the anterior chamber reforming the eye.¹⁶ These preparations are quite demanding. Making them would not be an efficient protocol unless we were performing a large number of surgeries in a day.

We use this technique in conjunction with a neutralized Betadine (Purdue Products LP, Stamford, Conn.) rather than topical antibiotics. The approach has resulted in no incidents of endophthalmitis, which brings up the question if any postoperative topical antibiotics are necessary when using intracameral antibiotics.

ACCEPTABLE FORMS OF PROPHYLAXIS

Moxifloxacin is gaining favor

It appears a marked reduction in endophthalmitis occurs with the use of intracameral antibiotics. Although the European studies show a significant reduction in endophthalmitis with cefuroxime, it is not the antibiotic of choice for treatment of endophthalmitis by intracameral injection.

Vancomycin alone, mixtures of vancomycin and ceftazidime, or moxifloxacin are all more acceptable forms of prophylaxis. Large clinical studies have shown that all three of these medicines work well in preventing endophthalmitis. Worth noting is that most practices adopting intracameral prophylaxis are choosing moxifloxacin. This is largely due to the ease of preparation, but its safety and broad spectrum of coverage also are factors.

Groups who use a mixture of vancomycin and ceftazidime are somewhat smaller in number because the mixture is time consuming and more costly to prepare. Our group uses this method, but we arrive two hours before surgery to prepare the medicines and double check for accuracy. These steps are absolutely essential for quality control and patient safety.

Any choice better than nothing

Statistics from clinical observations suggest that intracameral antibiotics are effective in preventing the devastating complication of postoperative endophthalmitis with little or no adverse reactions. Although cefuroxime is a valid option, it is not as good as any of the currently available and widely accepted prophylactic choices such as vancomycin, or vancomycin in with ceftazidime, or moxifloxacin.

Still undetermined is which preparation or antibiotic has the best clinical application. However, any one of these options appears to be better than using no intracameral prophylactic at all. OM

References

1. Arshinoff SA, Bastianelli PA. Incidence of postoperative endophthalmitis after immediate sequential bilateral cataract surgery. J Cataract Refract Surg. 2011; 37:2105-2114.

2. Gimbel HV, Sun R, DeBrof BM. Prophylactic intracameral antibiotics during cataract surgery: the incidence of endophthalmitis and corneal endothelial cell loss. Eur J Implant Refract Surg 1994; 6:280-285.

3. Lane SS, Osher RH, Masket S, Belani S. Evaluation of the safety of prophylactic intracameral moxifloxacin in cataract surgery. J Cataract Refract Surg. 2008; 34:1451-1459.

4. Arshinoff SA, Bastianelli PA. Incidence of postoperative endophthalmitis after immediate sequential bilateral cataract surgery. J Cataract Refract Surg. 2011; 37:2105-2114.

5. O’Brien TP, Arshinoff SA, Mah FS. Perspectives on antibiotics for postoperative endophthalmitis prophylaxis: potential role of Moxifloxacin. J Cataract Refract Surg. 2007; 33:1790-1800.

6. Basak S. e-mail communication with Gills JP. February 12, 2013.

7. Barreau G, Mounier M, Marin B, Adenis JP, Robert P. Intracameral cefuroxime injection at the end of cataract surgery to reduce the incidence of endophthalmitis: French study. J Cataract Refract Surg 2012; 38:1370-1375.

8. Yu-Wai-Man P, Morgan SJ, Hildreth AJ, Steel DH, Allen D. Efficacy of intracameral and subconjunctival cefuroxime in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg 2008; 34:447-451.

9. García-Sáenz MC, Arias-Puente A, Rodriguez-Caravaca G, Banuelos JB. Effectiveness of intracameral cefuroxime in preventing endophthalmitis after cataract surgery: ten-year comparative study. J Cataract Refract Surg 2010; 36:203-207.

10. Chang DF, Braga-Mele R, Mamalis N, et al. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey; the ASCRS Cataract Clinical Committee. J Cataract Refract Surg 2007; 33:1801-1805.

11. Davis EA, Donnenfeld ED, Schultz MC, Stonecipher KG, Trattler WB. The intracameral antibiotic debate. Cataract Refract Surg Today. 2013;13(2):21-22.

12. Arshinoff SA. Intraocular surgery: Medications. Course presented at: American Society of Cataract and Refractive Surgeons; April 20-24, 2012; Chicago, IL.

13. Espiritu C, Caparas V, Bolanio J. Safety of prophylactic intracameral moxifloxacin 0.5% ophthalmic solution in cataract surgery patients. J Cataract Refract Surg 2007;33:63-68.

14. Kowalski R, et al. Intracameral Vigamox (moxifloxacin 0.5%) is non-toxic and effective in preventing endophthalmitis in a rabbit model. Am J of Ophthal 2005;140:497.

15. Masket S. Preventing endophthalmitis for safer cataract surgery. Course presented at: American Society of Cataract and Refractive Surgeons; San Diego, CA; March 25-29, 2011.

16. Gills JP. Topical anesthesia protocol, St. Luke’s Cataract & Laser Institute.