EyeWorld Asia-Pacific December 2017 Issue

Views from Asia-Paci c Cesar ESPIRITU, MD Chairperson, Manila Doctors Hospital and Medical City South Luzon Room 207 Doña Salustiana Medical Tower, Manila Doctors Hospital, UN Avenue, Ermita, Metro Manila, Philippines 1000 Tel. no. +63-2-525-2260 espiritueyemd@mac.com I n the latter half of 2005, I started the use of prophylactic intracameral antibiotics in all my cataract surgeries. Our first publication on the safety of this mode of prophylaxis using Vigamox (moxifloxacin 0.5%, Novartis, Basel, Switzerland) came out in a 2007 issue of the Journal of Cataract and Refractive Surgery (“Safety of prophylactic intracameral moxifloxacin 0.5% ophthalmic solution in cataract surgery patients). Another similar study, this time using Oftaquix (levofloxacin 0.5%, Santen Pharmaceutical, Osaka, Japan) is awaiting publication in Clinical Ophthalmology (“Prophylactic Intracameral Levofloxacin In Cataract Surgery – An Evaluation of Safety”). Currently, I use either of these commercially available preservative-free topical preparations. The value of this mode of prophylaxis has been increasingly accepted worldwide as shown by articles and surveys coming out of Europe, Asia, and the United States in the last 10 years. The three most common antibiotics used are cefuroxime, moxifloxacin, and vancomycin. The use of vancomycin, however, has taken a severe hit with the 36 eyes of hemorrhagic occlusive retinal vasculitis (HORV) so far documented. Ophthalmologists, and specially the proponents of the intracameral route, will readily argue that this phenomenon is unique to vancomycin and that this can be avoided by using the other two antibiotics mentioned. There is a novel trend in cataract surgery prophylaxis that is getting increasing attention. As this gains more proponents, the intraoperative regimen may well become standard in the near future. I am referring to the “dropless cataract surgery” protocol which does away with postop topical antibiotics and corticosteroids by performing a transzonular injection of a preservative-free, single-use, compounded preparation containing both (e.g. moxifloxacin and triamcinolone, TriMoxi, Imprimis Pharmaceuticals, San Diego, California) into the anterior vitreous at the tail end of the procedure. The advantages are fourfold. First, it eliminates non-compliance issues common with topically applied meds. Second, patients will also appreciate the convenience of not having to bother with drops. Third, the reduced cost. Fourth, it preserves the corneal surface with less impact on an already compromised tear film common in almost 50% of cataract patients. Whether intracameral or intravitreal, the use of antibiotics and corticosteroids in cataract surgery is, I believe, a better alternative than topical meds. As long as issues such as sterility and accurate dosing that are linked to compounding are properly addressed, more and more ophthalmologists will incorporate this mode of prophylaxis in their regimen. Editors’ note: Dr. Espiritu is a consultant for Novartis and Santen. FAM Han Bor, MD Senior Consultant, NHG Eye Insitute 11 Jalan Tan Tock Seng, Level 1, Tan Tock Seng Hospital (TTSH) Medical Centre, Singapore 308433 Tel. no. +65-6357-7726 Fax no. +65-6357-7735 han_bor_fam@ttsh.com.sg S ince the ESCRS study of prophylactic antibiotics was published in 2006, 1 the use of intracameral antibiotics has become popular. One of the more popular antibiotics used in the United States was vancomycin. Vancomycin has broad- spectrum activity against common acute endophthalmitis causative organisms such as Streptococci and Staphylocci . It has worked well for many years. Unfortunately, since 2015, reports of cases of hemorrhagic occlusive retinal vasculitis (HORV) have surfaced. 2 The initial six cases reported have now expanded to 36 eyes. 3 HORV is a rare condition, postulated to be a type III hypersensitivity reaction to intraocular vancomycin after cataract surgery. Occurring in uneventful surgery, it is a delayed onset of painless sudden loss of visual acuity, usually between 1 to 26 days. The anterior chamber and vitreous inflammation are mild to moderate. The main findings are in the posterior segment as characterized by retinal vasculitis, predominantly venules; intraretinal hemorrhage; vascular occlusion with retinal ischemia; and macular edema. In most cases, the condition progresses to neovascular glaucoma. The prognosis is generally poor ending up with legal blindness. Most of the patients reported have bilateral afflictions. 4 In view of this unfortunate development, I agree with the advice of FDA 5 and Dr. Chang to reconsider the use of intracameral vancomyin as prophylaxis for cataract surgery. While the condition is rare, the consequence is severe. Fortunately, there are alternative antibiotics that can be used as prophylaxis. The ESCRS study has proven the benefits for intracameral antibiotics. Dr. Chang in his article has reaffirmed the benefits of intracameral antibiotics, particularly moxifloxacin. In our study, 6 we have managed to reduce the overall incidence of postoperative endophthalmitis from 0.064% (19/29,539 cataract surgeries) to 0.01% (2/20,638) with the use intracameral cefazolin (1.0 mg/0.1 ml). This was a 6-fold reduction, which was statistically significant (P=0.003). Cefazolin is a first-generation cephalosporin. It is relatively cheap, safe, and has good efficacy against gram-positive organisms. References 1. Barry P, Seal DV, et al. ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study. J Cataract Refract Surg. 2006;32:407–410. 2. Witkin AJ, Shah AR, Engstrom RE, Kron-Gray MM, et al. Postoperative hemorrhagic occlusive retinal vasculitis. Expanding the clinical spectrum and possible association with vancomycin. Ophthalmol. 2015;122:1438–1451. 3. Witkin AJ, Chang DF, Jumper JM, et al. Vancomycin-associated hemorrhagic occlusive retinal vasculitis: clinical characteristics of 36 eyes. Ophthalmol. 2017; 124:583–595. 4. Nicholson LB, Kim BT, Jardon J, et al. Severe bilateral ischemic retinal vasculitis following cataract surgery. Ophthalmic Surg Lasers Imaging Retina. 2014;45:338– 342. 5. FDA. October 3, 2017 A Case of Hemorrhagic Occlusive Retinal Vasculitis (HORV) Following Intraocular Injections of a Compounded Triamcinolone, Moxifloxacin, and Vancomycin Formulation. Web. https://www.fda.gov/Drugs/ GuidanceComplianceRegulatoryInformation/PharmacyCompounding/ucm578514. htm 6. Tan CSH, Wong HK, Yang FP. Epidemiology of postoperative endophthalmitis in an Asian population: 11-year incidence and effect of intracameral antibiotic agents. J Cataract Refract Surg. 2012;38:425–430. Editors’ note: Dr. Fam is a consultant for Johnson & Johnson Vision (Sta. Ana, California) and Zeiss (Jena, Germany). “ The value of this mode of prophylaxis has been increasingly accepted worldwide as shown by articles and surveys coming out of Europe, Asia, and the United States in the last 10 years. ” - Cesar Espiritu, MD 54 EWAP CATARACT/IOL December 2017 The latest – from page 52