EyeWorld Asia-Pacific December 2016 Issue

EWAP SECONDARY FEATURE 27 December 2016 doesn’t egress easily, and when it does come out, it usually comes out all at once,” he said. This approach for endophthalmitis prophylaxis can be more difficult to administer during cataract surgery in certain types of eyes. “It can be challenging to give the intravitreal injection in an eye that has IFIS or a smaller eye that doesn’t have a lot of volume to take it up,” Dr. Hamilton said, adding that it’s important to make sure that you have the chamber formed. Since these eyes can be more difficult, sometimes he does the injections in another way. “I’ve had cases like this where I’ll give it through the pars plana, like they give intravitreal injections in the clinic,” he said. “I know I can’t do it otherwise—with IFIS or a smaller eye, you’re not going to be able to get it done.” Instead he goes through the pars plana with a 30-gauge needle. “In a shallow or small eye, if I think I’m going to have trouble, I’ll do it that way,” he said. Dr. Hamilton also advises against using toric IOLs with the dropless approach since theoretically it could move the lens out of position. “I don’t use it with toric IOLs because I’m afraid it may shift the lens,” he said. Despite such challenges, he strongly favors the dropless approach over use of topical drops alone for staving off endophthalmitis. This is particularly true in high-risk cases. “If I had a capsular violation or a monocular patient, I would give Tri-Moxi even if I’m going to put the patient on topicals because in my opinion the best way to prevent endophthalmitis is to put the antibiotic inside the eye,” Dr. Hamilton said. Considering concerns Not everyone agrees that the intracameral approach should be embraced for staving off endophthalmitis following cataract surgery. Andrew Schachat, MD, vice chairman, Cole Eye Institute, Cleveland Clinic, has reservations about the approach. He cited an editorial in Ophthalmology as highlighting many of his own concerns. 1 “This article summarizes for me the anxieties about doing this,” he said. One such concern is cost. “Based on this analysis, we would have to treat 2,500 patients to prevent one (endophthalmitis) case,” Dr. Schachat said. “If the drugs cost [US]$100, then 2,500 doses would cost a quarter of a million dollars to avoid one case.” There is also some risk to using these intracameral antibiotics, he pointed out. “There is some risk in general in increasing resistance by treating 2,500 people who didn’t need it, when only one needed it,” he said, adding that it requires huge randomized trials to teach about the role of intracameral antibiotics for endophthalmitis prophylaxis. Currently, he doesn’t think that there is enough data to make a decision. “For me it remains controversial whether intracameral antibiotics should be used for surgical prophylaxis for cataract surgery,” he said. Dr. Hamilton also sees the need for more research here. “I think that with time this will pan out as the way to go when we have enough data,” he said. “Once [researchers] do thousands of cases, then I think we’ll have more data that pushes us that way,” Dr. Hamilton said. “But at this point it’s all anecdotal.” EWAP Reference 1. Schwartz SG, et al. Intracameral antibiotics and cataract surgery: Endophthalmitis rates, costs, and stewardship. Ophthalmology . 2016;123:1411–1413. Editors’ note: Drs. Hamilton and Schachat have no financial interests related to their comments. Contact information Hamilton : SHamiltonMD@comcast.net Schachat : schacha@ccf.org