21 EyeWorld Asia-Pacific | March 2025 CATARACT “Educating the patient on these differences can sometimes be tricky, but can usually be done in a manner that emphasizes the concerns the patient has with the reason it does not qualify as a true allergy,” Dr. DelMonte said. “For example, patients may cite an allergy to steroids, but steroid compounds are a natural and necessary product produced by the human body, so the described reaction is either due to a preservative, other additive, or simply a side effect. Steroids are actually used to treat true allergies due to their immune control properties,” he added. While allergies to medications and materials used in ophthalmic surgery are relatively uncommon, Alice Epitropoulos, MD, stressed the importance of certain considerations for ophthalmic surgeons. She pointed out that some cataract surgery patients may be sensitive or allergic to betadine, as well as to lidocaine or other anesthetics in the “caine” family. “We often hear patients claim they are allergic to betadine or iodine, but it’s not always a true allergy,” Dr. Epitropoulos said. She explained that while patients may be sensitive to it, this doesn’t necessarily contraindicate its use. In many cases, the procedure can continue as long as the betadine is rinsed off after the preparation. Dr. Epitropoulos explained that not using betadine could potentially increase the risk of infection, since it is the only treatment proven to reduce the risk of infection or endophthalmitis before cataract surgery, and there are no good alternatives. “Usually, when the nursing staff informs Dr. DelMonte injects intracameral moxifloxacin at the end of cataract surgery to prevent endophthalmitis. He prefers to use intracameral antibiotics even in cases of a reported systemic allergy to a similar medication due to the unique immune response inside the eye and the known benefit of this practice. Source: Derek DelMonte, MD me the patient is allergic to betadine, I advise them to still proceed with the prep, but ensure the betadine is rinsed off afterward. In the rare event of an allergic reaction, the patient is in a controlled setting with an IV, and we can manage it. I’ve never encountered a true, serious allergic reaction to betadine, but I’d rather handle an allergic reaction than deal with endophthalmitis.” Dr. DelMonte agreed that allergies to betadine are commonly reported by patients, but large amounts of data strongly support the use of this product. “I think we should use betadine on just about everyone, whether they report a shellfish/contrast allergy or not,” Dr. DelMonte said. “Oftentimes, the rash or swelling can be managed by thoroughly washing the betadine off after the procedure. It is so valuable in preventing endophthalmitis that I think the risk of a small local reaction outweighs the risk of endophthalmitis.” Alternatives to steroids, such as NSAIDs, and alternatives to betadine, such as chlorhexidine, can be used in place of these medications, but Dr. DelMonte said he tries to use the best available product and educates the patients on why he chooses this path. “When discussing allergies to medications and products used inside the eye, I explain to the patient that the intraocular space is an ‘immune privileged’ space, meaning medications or products used intraocularly during surgery do not necessarily illicit the same response that a medication used orally or on other parts of the body might,” he said. “This is also very important when explaining to patients why I might recommend using an antibiotic intracamerally during surgery, despite a known reaction to this medication systemically.” Dr. DelMonte routinely uses intracameral moxifloxacin in every patient and thinks this is the best way to prevent vision-compromising complications, and the risk of a reaction is exceedingly low. Occasionally, he’ll have a patient bring up an antibiotic allergy in the OR, and the nurse may ask if he still wants to use moxifloxacin in the eye. “Often I say yes, and I describe to the patient why, and most of the time, they have no problem with it.” Occasionally, he has a patient with a lidocaine allergy, Dr. DelMonte said. Most of them say it was used during a dental procedure, and they had cardiac issues after injected lidocaine. Usually, it’s because it was right in the
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