EyeWorld Asia-Pacific March 2015 Issue

March 2015 8 EWAP FEATURE Intracameral antibiotics versus topical by Maxine Lipner EyeWorld Senior Contributing Writer AT A GLANCE • One prospective study shows a 5-fold decrease in endophthalmitis with the intracameral approach. • In Europe the intracameral approach is favored in many countries, with studies from the region bolstering support for this. • While the literature also backs use of topical antibiotics, with retrospective and surrogate evidence, so far there has been no prospective support. Best practices: What is the evidence? F or practitioners performing cataract surgery, keeping endophthalmitis at bay is on everyone’s mind. However, while some swear by intracameral antibiotics, others continue using the topical approach. EyeWorld is honing in on just what the scientific evidence supports. Audrey Talley Rostov, MD , Northwest Eye Surgeons, Seattle, thinks the evidence clearly shows that the intracameral approach is superior. She views the ESCRS prospective, randomized study, published in March 2006 in the Journal of Cataract & Refractive Surgery (JCRS), as a landmark trial. 1 Patients in the study were placed in one of four groups to receive topical medication, intracameral antibiotics, both antibiotics, or no antibiotics. With the intracameral approach, patients had a five-fold decrease in endophthalmitis, she said. Meanwhile, the first large-scale U.S. study, conducted by Neal Shorstein, MD , and published in the January 2013 issue of JCRS, also favored the intracameral approach, she said. 2 “There was a 2.2-fold decline in endophthalmitis during the first 2 years of the 5-year retrospective study following the introduction of intracameral cefuroxime,” she said. “A further 10-fold decrease was observed during the next 2 years of the study when all patients received either intracameral cefuroxime, moxifloxacin, or vancomycin.” Likewise, Peter Barry, MD, consultant, Royal Victoria Eye and Ear Hospital, and St. Vincent’s University Hospital, Dublin, is convinced that the intracameral method is superior in staving off endophthalmitis. He also views the ESCRS study, in which he was lead author, as a pivotal one. While a concern with the study was that the background rate of endophthalmitis was too high, Dr. Barry argues that this is not so. “The Shorstein study from northern California last year had a 0.35% rate that they were running when they decided to switch to the intracameral route, which is exactly the same as the control group in the ESCRS study,” he said. In addition, a Swedish national study, which was also published in the January 2013 issue of JCRS, looked at 1 million consecutive patients in their database. 3 In this study, endophthalmitis rates rose to the 0.3% mark without the intracameral antibiotics, Dr. Barry said. European preference In Europe, many physicians are convinced that the intracameral approach is the way to go based on the evidence of the studies, even beyond the landmark ESCRS trial, Dr. Barry said. “There have been many studies done in France and Spain where institutions have made the decision to switch and have recorded their results,” he said. “In every study you read from Europe or elsewhere around the world where the intracameral approach was adopted, when endophthalmitis rates were high, they got very low and when they were low they got even lower,” Dr. Barry said. He credits the ESCRS trial with spurring additional work in the area, which ultimately led to a change in European practice patterns. “I think it would be wrong to give the ESCRS study entire credit, but I think that it was the overwhelming driving force, and it resulted in a large volume of studies being conducted in Spain, France, and other European countries,” Dr. Barry said. However, the Swedes used the intracameral approach before anyone else. “I think that Per Montan and coworkers at St. Eriks in Stockholm are the father figures of intracameral antibiotic prophylaxis,” 4 he said, adding that Spanish ophthalmologists, who started a survey of the use of intracameral cefazolin back in 2002, also had an important role in this. Currently the only intracameral drug for which there is an evidence base is intracameral cefuroxime, Dr. Barry said. The French product Aprokam (cefuroxime, Thea Group, Clermont-Ferrand, France) is approved by the European Medicines Agency, he noted. In a recent ESCRS survey published in the January 2014 issue of JCRS, which Dr. Barry authored, To stave off endophthalmitis cases such as this one, many are weighing the evidence for whether an intracameral approach is better than a topical one. Source: David G. Heidemann, MD