EyeWorld Asia-Pacific September 2019 Issue

EWAP SEPTEMBER 2019 67 PHARMACEUTICALS by Maxine Lipner EyeWorld Senior Contributing Writer Intracameral antibiotics at the end of cataract surgery Contact information Donnenfeld: ericdonnenfeld@gmail.com Lindstrom: rllindstrom@mneye.com W hen it comes to protecting cataract patients from postop infection, many practitioners rely on intracameral injections at the end of surgery to stave off endophthalmitis, according to Richard Lindstrom, MD. ˜ ̅i 1°-°] “œÝˆyœÝ>Vˆ˜ ˆÃ the staple, while in Europe most practitioners use cefuroxime, Dr. Lindstrom noted. This is because the European Society of Cataract & Refractive Surgeons (ESCRS) study used intracameral cefuroxime to forestall bacteria such as Staphylococcus epidermidis, but in the U.S. the ˆ“«ÀiÃȜ˜ ˆÃ ̅>Ì “œÝˆyœÝ>Vˆ˜ ˆÃ LiÌÌiÀ vœÀ ̅ˆÃ° º œÝˆyœÝ>Vˆ˜ has been used in studies in Latin America, India, and elsewhere with good outcomes, and most U.S. surgeons were ÕȘ} > y՜ÀœµÕˆ˜œœ˜i >Ài>`Þ topically,” Dr. Lindstrom said. Eric Donnenfeld, MD, pointed out that until 1.5 years ago vancomycin was commonly used in the U.S. intracamerally. “Then there were some papers on the development of hemorrhagic occlusive retinal vasculitis (HORV), and the use of vancomycin has decreased dramatically,” Dr. Donnenfeld said, adding that this rare condition can potentially lead to bilateral blindness since its delayed onset generally doesn’t occur until after the second eye has been treated. Many now think this is not worth the risk. The problem with intracameral antibiotics in the U.S. is that no medication has been FDA >««ÀœÛi` vœÀ ̅ˆÃ° º Þ `iw˜ˆÌˆœ˜ they’re all off-label compounded medications, and there’s always the risk of contamination with a compounded medication as well as of dilution errors,” Dr. Donnenfeld said. “However, “œÝˆyœÝ>Vˆ˜ ˆÃ «>À̈VՏ>ÀÞ Ã>vi in that it’s tolerant of higher concentrations.” There haven’t been any immune responses or any vasculitis, he continued, adding that there have been some reports of pigmentary changes to the iris. “But the risk/reward À>̈œ vœÀ “œÝˆyœÝ>Vˆ˜ ˆÃ ˆ˜ v>ۜÀ of the reward,” Dr. Donnenfeld said. “Using it can have a È}˜ˆwV>˜Ì ˆ“«>VÌ œ˜ Ài`ÕVˆ˜} the risk of endophthalmitis.” Dr. Lindstrom pointed out that most errors occur when the injection is prepared by the physician or nurse instead of a compounding facility. “If ÞœÕ ÜœÀŽ ܈̅>…ˆ}…µÕ>ˆÌÞ] reputable compounding pharmacy with a long track ÀiVœÀ` œv µÕ>ˆÌÞ ÜœÀŽ] >“ comfortable with it,” he said. “I’ve used compounded ˆ˜iV̈œ˜Ã œv “œÝˆyœÝ>Vˆ˜ “>`i by the Phillips Eye Institute, Imprimis, and Leiters.” The biggest risk with “œÝˆyœÝ>Vˆ˜ ˆ˜…ˆÃ ۈiÜ ˆÃ ̅>Ì at too high a concentration, this can be endothelial cell toxic. Two ways this can be avoided are to inject a small amount of 0.1 ml or less into the eye or to make sure this is properly `ˆÕÌi`° º Àœ“ µÕˆÌi > LˆÌ œv research, it appears that in a concentration of 500 mg per ml, which is a 10-to-1 dilution, it is This article originally appeared in the June 2019 issue of EyeWorld . It has DGGP UNKIJVN[ OQFKƂGF CPF CRRGCTU here with permission from the ASCRS Ophthalmic Services Corp. Studying intracameral prophylaxis W hile no FDA trial has taken place in the U.S., there’s a plethora of evidence that intracameral injections are effective in forestalling postoperative cataract infection. • In Europe, the ESCRS trial comparing no drops or topical drops to intracameral cefuroxime injections or intracameral injections plus drops showed an overwhelming reduction in the risk of endophthalmitis, Dr. Donnenfeld noted. “There were approximately 14,000 patients enrolled, and there was a 5-fold reduction in endophthalmitis with use of intracameral cefuroxime,” he said. • Kaiser Permanente did a study of intracameral “œÝˆyœÝ>Vˆ˜ ÛiÀÃÕà ̜«ˆV>° Ì Ã…œÜi` > ÃÌ>̈Ã̈V>Þ È}˜ˆwV>˜Ì Ài`ÕV̈œ˜ ˆ˜ i˜`œ«…Ì…>“ˆÌˆÃ ܈̅̅i injections, Dr. Lindstrom noted. • Several prospective clinical trials studied safety and ivwV>VÞ œv ˆ˜ÌÀ>V>“iÀ> “œÝˆyœÝ>Vˆ˜ ˆ˜ À>∏ >˜` >Ì the Aravind Eye Center in India and highlighted the effectiveness of this approach, Dr. Lindstrom said.