Opinion

VIEWPOINT

Andrew M. Schimel, MD Center For Excellence in Eye Care, Miami, Florida. Eduardo C. Alfonso, MD Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Harry W. Flynn Jr, MD Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida.

Corresponding Author: Harry W. Flynn Jr, MD, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th St, Miami, FL 33136 ([email protected] .edu).

Endophthalmitis Prophylaxis for Cataract Surgery Are Intracameral Antibiotics Necessary? Endophthalmitis prophylaxis for elective cataract surgery is a subject of considerable debate. The use of perioperative povidone-iodine and an eyelid speculum and drape with isolation of eyelids and eyelashes as well as meticulous sterile preparation and procedures are effective in limiting the incidence of endophthalmitis after cataract surgery.1 The rapid evolution of cataract surgical techniques, including clear-corneal incision, small-incision surgery, and femtosecond lasers, makes it difficult for the published literature to remain relevant to current clinical practices. As many cataract surgeons consider adopting intracameral antibiotics, it becomes important that we recognize the salient issues involved in this important decision. There are a couple of methods of intracameral antibiotic administration. Despite its frequent use, no level I evidence exists to support mixing antibiotics into the irrigating infusion bottle as a method of intracameral prophylaxis during cataract surgery. However, many studies support the use of an intraocular antibiotic injected as a bolus directly into the anterior chamber.2 Mixing antibiotics into the irrigating infusion bottle during cataract surgery is a method popularized by Gills adding vancomycin (20 μg/mL) and/or gentamycin (8 μg/mL).3 Vancomycin works by inhibiting cell wall synthesis and must have prolonged contact with bacteria to yield cell death. An in vitro study evaluated a suspension of Staphylococcus aureus and Staphylococcus epidermidis incubated in balanced salt solution with vancomycin (20 μg/mL) and demonstrated no decrease in the number of viable bacteria for up to 120 minutes. With an intracameral medication half-life of approximately 70 minutes due to aqueous turnover, vancomycin would not have the necessary time to kill susceptible bacteria in the aqueous if instilled at the usual 20 μg/mL from the infusion. A thorough statistical analysis of the data in the Gills study3 does not identify a significant difference among treatment groups. The alternative to mixing antibiotics into the irrigating bottle is a direct intracameral injection at the end of cataract surgery. There have been multiple retrospective as well as one prospective study suggesting the efficacy of this practice.2 However, in an era of increased awareness of compounding errors, it is important to recognize that vancomycin, cefuroxime, and moxifloxacin are not available in a prepackaged form for intracameral use in the United States. Vancomycin and cefuroxime must be reconstituted from powder form in the operating room, creating significant risk of dilution errors and contamination. Cases of dilutional errors with intracameral cefuroxime and vancomycin have resulted in severe complications including macular thickening, chronic cystoid macular edema, serous retinal detachment,

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macular infarction, toxic anterior segment syndrome, and a large outbreak of Fusarium endophthalmitis. Given the rarity of severe vision loss (visual acuity

Endophthalmitis prophylaxis for cataract surgery: are intracameral antibiotics necessary?

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