EyeWorld India December 2017 Issue

EWAP CATARACT/IOL December 2017 55 a larger incision to manually remove an undivided nucleus, fol- lowed by implantation of a rigid PMMA IOL. Because of a histori- cally higher rate of postoperative endophthalmitis with MSICS, routine IC moxifloxacin prophy- laxis was started for all char- ity patients at one of AECS’s 11 regional hospitals in August 2014. During a 14-month study period, comparison of 38,160 consecutive cases done immediately prior to this change with the first 37,777 consecutive eyes that received IC moxifloxacin showed a four-fold reduction in the rate of postopera- tive endophthalmitis rate with IC antibiotic prophylaxis. Following this study, AECS initiated routine IC moxifloxacin prophylaxis in all cataract pa- tients at all 11 of its hospitals. An analysis of 617,453 consecutive cases during a 29-month period was published in June. There was a 3.5-fold reduction in the en- dophthalmitis rate in the 314,638 eyes that received IC moxifloxa- cin, compared to the 302,815 eyes that did not. The reduction was three-fold among MSICS eyes and six-fold among phaco eyes. Auromox is a 1 ml solution containing 5 mg of moxifloxa- cin that is approved and com- mercially available in India. It is manufactured by Aurolab, which is a pharmaceutical company af- filiated with AECS, and does not require any mixing. All patients in the study received 0.5 mg of Auromox moxifloxacin (0.1 ml) as a direct intracameral injection at the conclusion of surgery. The published study includes cases performed through May 2016. For Dr. Chang’s presentation at the 2017 ASCRS•ASOA Symposium & Congress, he updated the data to include all IC moxifloxacin cases performed through March 2017. “We now have 1,087,907 consecu- tive eyes performed during the 51 months starting in January 2013. The endophthalmitis rate was 0.02% in the 555,550 eyes that received IC moxifloxacin prophylaxis, compared to 0.07% in the 532,357 eyes that did not,” he reported. Dr. Chang explained that randomized controlled stud- ies for IC antibiotic prophylaxis are extremely expensive and dif- ficult to perform, and their main benefit would be to prevent other potential surgical co-variables aside from the antibiotic from separately reducing the endoph- thalmitis rate. 7 “What makes the Aravind study so strong is the fact that such a high volume of cases was done in a relatively short period of time,” he said. “In addi- tion, to maximize efficiency and cost-effectiveness, all of the cata- ract surgical protocols are highly standardized at and between every AECS hospital, including use of the same viscoelastics and instruments, and the same steri- lizers and draping methods,” he added. “For these reasons, I think that this is one of the strongest studies to date supporting the ef- ficacy of IC antibiotics in general, and moxifloxacin in particular.” Intracameral moxifloxacin options in the U.S. In the U.S., there is no commer- cially available antibiotic solution that is FDA approved for intraocu- lar prophylaxis. “Many surgeons directly inject moxifloxacin drawn up in the operating room from the unpreserved Vigamox [Novartis, Basel, Switzerland] topical bottle,” Dr. Chang said. He recommended a review ar- ticle published in the Journal of Cataract & Refractive Surgery 8 that outlines the method and ration- ale of this practice. “One must be careful not to use generic topical moxifloxacin for this purpose, which contains adjuvants that are toxic when injected into the eye,” he said. Dr. Chang uses a com- pounding pharmacy for IC moxi- floxacin prophylaxis. “For any compounded drug that is to be in- jected into the eye, I prefer using a 503B FDA-registered outsourcing pharmacy,” he said. “Compared to 503A pharmacies, the 503B outsourcing facilities must meet much more stringent regulatory requirements.” Shortly after the 2017 ASCRS•ASOA Symposium & Congress, Imprimis Pharmaceuti- cals (San Diego) began offering a compounded moxifloxacin solu- tion in the same concentration (5 mg/1 ml) as Auromox, which was used in the Aravind studies. Dr. Chang said there are also many studies supporting the safety and efficacy of intracam- eral cefuroxime prophylaxis in a 1 mg/0.1 ml dose. This can also be obtained through compounding facilities. EWAP References 1. Chang DF, et al. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey. J Cataract Refract Surg. 2007;33:1801–5. 2. Chang DF, et al. Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: Results of the 2014 ASCRS member survey. J Cataract Refract Surg. 2015;41:1300–5. 3. Witkin AJ, et al. Postoperative hemorrhagic occlusive retinal vasculitis: Expanding the clinical spectrum and possible association with vancomycin. Ophthalmol. 2015;122:1438– 51. 4. Witkin AJ, et al. Vancomycin- associated hemorrhagic occlusive retinal vasculitis: Clinical characteristics of 36 eyes. Ophthalmol. 2017;124:583–595. 5. Haripriya A, et al. Efficacy of intracameral moxifloxacin endophthalmitis prophylaxis at Aravind Eye Hospital. Ophthalmol. 2016;123:302–8. 6. Haripriya A, et al. Endophthalmitis reduction with intracameral moxifloxacin prophylaxis: Analysis of 600,000 surgeries. Ophthalmol. 2017;124:768–775. 7. Javitt JC. Intracameral antibiotics reduce the risk of endophthalmitis after cataract surgery: Does the preponderance of the evidence mandate a global change in practice? Ophthalmol. 2016;123:226–31. 8. Arshinoff SA, et al. Dose and administration of intracameral moxifloxacin for prophylaxis of postoperative endophthalmitis. J Cataract Refract Surg. 2016;42:1730–41. Editors’ note: Dr. Chang has no financial interests related to his comments. Contact information Chang: dceye@earthlink.net