Intracameral Antibiotics During Cataract Surgery

Evidence and Barriers

Aravind Haripriya; David F. Chang

Disclosures

Curr Opin Ophthalmol. 2018;29(1):33-39. 

In This Article

Abstract and Introduction

Abstract

Purpose of review: There is continuing debate regarding the safety, efficacy, and necessity of intracameral antibiotics to prevent postoperative endophthalmitis. We summarize the most recent evidence-based publications that either support or caution against this practice.

Recent findings: Several additional large, international retrospective clinical studies found a significant reduction in endophthalmitis rates with intracameral antibiotic prophylaxis. Many surgeons are looking for alternatives to vancomycin for intracameral prophylaxis because of its association with the rare but sight-threatening complication of hemorrhagic occlusive retinal vasculitis. Although most efficacy data has been reported for intracameral cefuroxime, one of the largest clinical studies to date shows convincing efficacy with intracameral moxifloxacin prophylaxis. This same study reported a significant benefit with intracameral moxifloxacin following posterior capsular rupture, and surgeons should consider intracameral prophylaxis in these high risk cases.

Summary: Despite mounting evidence that routine prophylaxis with intracameral cefuroxime and moxifloxacin reduce the endophthalmitis rate following cataract surgery, many surgeons have not adopted this practice. Reasons include lack of level 1 evidence from randomized trials, and the potential risks from compounding or mixing antibiotic solutions when no approved formulations are commercially available. Countries with commercially approved intraocular antibiotic formulations have the highest adoption rates of routine intracameral prophylaxis.

Introduction

Postoperative endophthalmitis, although very rare, is one of the most serious, sight-threatening complications of ocular surgery. According to the Endophthalmitis Vitrectomy Study (EVS),[1] visual outcomes are often poor. One third of individuals do not gain vision better than counting fingers, and 50% do not recover vision better than 20/40.[2] A more recent study reported that 34% of affected patients achieved a final visual acuity of 20/200 or worse.[3]

With the significant increase in cataract surgery volume because of population aging worldwide, effective endophthalmitis prophylaxis is a rising global imperative. Along with aseptic surgical protocols, the use of perioperative povidone iodine and isolation of the eyelids and eyelashes with proper draping are effective in limiting the incidence of endophthalmitis after cataract surgery. In addition, increasing numbers of cataract surgeons have adopted intracameral antibiotic prophylaxis, in addition to or in lieu of topical perioperative antibiotics. In the present article, we review key publications supporting or questioning the efficacy and safety of intracameral antibiotic prophylaxis, and update and highlight new studies published from January 2016 to October 2017.

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