EyeWorld India December 2013 Issue

43 EWAP CORNEA December 2013 Preventing endophthalmitis by Michelle Dalton EyeWorld Contributing Writer Some argue intracameral injections are best, while others are using topical drops instead W ith seemingly overwhelming evidence from large cohort studies that intracameral injections can help deter endophthalmitis in the postop cataract patient, more and more European surgeons are embracing the studies and using intracameral cefuroxime. Yet in the U.S., skepticism remains high. “There are no antibiotics currently approved for intracameral use in the U.S. But there are also no topical antibiotics approved for post-cataract surgery prophylaxis either. I’m not sure why there is so much resistance to intracameral, especially considering the strong data,” said Christina Rapp Prescott, MD , PhD , assistant professor of ophthalmology, Division of Cornea, Cataract, and External Diseases, Wilmer Eye Institute, Baltimore, Md., USA. Prior ASCRS surveys cited two main reasons for the disinterest in the U.S.: “further study was needed and compounds were not commercially available,” said Neal Shorstein, MD , Kaiser Permanente, Walnut Creek, Calif., USA. “That said, if there was a commercially available product at a reasonable cost, 80% would use intracameral injections.” Cefuroxime—the compound used in the ESCRS endophthalmitis study—has a two-part dilution, which adds to the discomfort level about potential errors, Dr. Shorstein said. John D. Sheppard, MD , president, Virginia Eye Consultants, Norfolk, Va., USA, expanded the explanation, saying there is no consensus on patient selection and choice of medication in the U.S., and “these huge landmark clinical trials we rely upon are of necessity understandably flawed by design: the prospective ESCRS trial by a relatively high base incidence and delayed topical antibiotic administration until the first postoperative day, and the Shorstein study 1 by a retrospective design with randomly chosen intracameral medications.” Peter Barry, FRCS , head of the Department of Ophthalmology, St. Vincent’s University Hospital, Dublin, Ireland, and senior retinal surgeon, Royal Victoria Eye and Ear Hospital, Dublin, Ireland, found the Shorstein study “impressive. Their endophthalmitis rates were around 0.3%, which was very similar to the ESCRS study.” In that study, 2 the base incidence at 0.35% “was higher than anticipated but we consider that it is a true rate that is supported by the Swedish Cataract Register.” More impressively, once Kaiser Permanente began using intracameral injections, “the rate of endophthalmitis was reduced more than 22-fold,” he said. European acceptance, U.S. indifference? In Europe, “more than 200 surgeons across 30 European countries were surveyed and 74% use intracameral injections,” Dr. Barry said. “That’s a rather high acceptance rate.” Although the majority of Europeans have converted to intracameral use, “we are still waiting for FDA approval in the U.S.,” Dr. Prescott said. “There are issues related to off-label use and potential toxicity with intracameral injections,” but those same issues exist for topical antibiotics. “American surgeons may have more cost constraint issues with a much higher volume performed in private ASCs,” Dr. Sheppard said. “I find that in the U.S., locations where malpractice is out of control tend to use intracameral injections more aggressively, as a defensive More and more European surgeons are using intracameral cefuroxime to deter endophthalmitis (shown here), but in the U.S. skepticism remains high. Source: Nick Mamalis, MD Continued on page 44