ASCRS News
December 2021
by David F. Chang, MD
The results of the ESCRS intraocular cefuroxime prophylaxis randomized clinical trial (RCT) were first reported in 2006.1 This landmark study demonstrated the safety and efficacy of intracameral cefuroxime injection and led to the European Medicines Agency (EMA), but not U.S. FDA, approval of a commercial cefuroxime solution. Fifteen years following publication of this study, the necessity and method of intraocular antibiotic prophylaxis remains controversial, in large part due to the lack of approved commercial antibiotic formulations in most countries.
To assess the effect of the ESCRS RCT on antibiotic prophylaxis practice patterns, the ASCRS Cataract Clinical Committee conducted a member survey in 2007.2 Of the more than 1,300 respondents, 30% were using intraocular antibiotic prophylaxis. Half of them placed the antibiotic in the irrigation bottle, and half directly injected the antibiotic into the anterior chamber (AC). Vancomycin was employed by 60% of these cataract surgeons and a cephalosporin by 23%. A significant shift in practice pattern was noted when we repeated the ASCRS member survey in 2014.3 With 1,147 total respondents, the percentage of surgeons employing intraocular antibiotic prophylaxis increased from 30% to 50%. Furthermore, most of them (84%) were now directly injecting intracameral antibiotic into the AC, as opposed to placing antibiotic in the irrigating solution (16%). The antibiotic preference for those using direct intraocular injection was divided among cefuroxime (26%), moxifloxacin (33%), and vancomycin (37%).
Following another 7-year interval, we repeated the survey earlier this year. To allow comparison of trends over time, we used identically worded questions from the two earlier surveys whenever possible. A link to the anonymous, 19-question online survey was emailed to all ASCRS members worldwide, and it was completed by 1,205 respondents. Of these, 76% were from the United States, 8% from Latin America/Mexico, 6% from Europe, 7% from Asia/Australia, and 3% from Canada. This was comparable to the total number of respondents for the 2007 and 2014 surveys. Survey findings have been published as a special report in the Journal of Cataract & Refractive Surgery.4
Results
The percentage of respondents using preoperative (73%) and postoperative (86%) topical antibiotic prophylaxis decreased compared to 90% and 97%, respectively, in the two prior surveys (Table 1). Consistent with the earlier surveys, approximately half of those prescribing preoperative antibiotic drops initiated them 3 days before surgery. The rest initiated topical antibiotic prophylaxis either on the day of or the day prior to surgery. Several studies have reported no additional benefit to topical antibiotics if intraocular antibiotic prophylaxis was employed.5 Among those using intracameral antibiotic prophylaxis in the 2021 survey, approximately 25% did not prescribe any topical antibiotic postoperatively. This is significant because it means that using intracameral antibiotic instead of topical antibiotic is not violating some consensus “standard of care.” Of those respondents prescribing postoperative topical antibiotics, approximately 70% discontinued them after 1 week in all three surveys, while the remainder continued them for several weeks postoperatively.
There was virtually no change in topical antibiotic preferences compared to 2014. Fluoroquinolones accounted for 90% of the topical antibiotics used; 57% preferred gatifloxacin or moxifloxacin, 25% preferred ofloxacin or ciprofloxacin, and 9% preferred besifloxacin. However, this represented a marked shift from 2007 when 9 times as many surgeons preferred gatifloxacin or moxifloxacin to the two earlier generation fluoroquinolones.
There was a steady increase in the adoption of IC antibiotic during three survey timepoints (Table 1); two-thirds of surgeons employed this in 2021, compared to 50% in 2014 and 30% in 2007. The majority (95%) are now directly injecting the antibiotic into the AC versus placing it in the infusion bottle (5%). Compared to 2007, there was a four-fold increase in the overall number of respondents directly injecting antibiotic into the AC at the end of surgery (63% vs. 16%). Of these respondents, 38% started doing so within the last 2 years. Although some ophthalmologists have touted the benefits of “drop-free” cataract surgery, pars plana or transzonular intravitreal antibiotic injection was reported by less than 3% of all survey respondents.
There was a dramatic shift in antibiotic preference among those employing intraocular prophylaxis. Moxifloxacin preference more than doubled from 33% in 2014 to 73%, while vancomycin preference fell to 2%. Among American surgeons, moxifloxacin preference was up to 83% (31% in 2014), while vancomycin preference fell from 52% in 2014 to 6%. This shift is presumably due to the association of vancomycin with hemorrhagic occlusive retinal vasculitis and the American Academy of Ophthalmology Cataract Preferred Practice Pattern panel and the FDA discouraging its use for routine surgical prophylaxis.6 Increasing preference for moxifloxacin would be supported by recently published population data on the safety and efficacy of moxifloxacin prophylaxis for endophthalmitis at the Aravind Eye Hospital.7
A commercial intraocular product was used by only 5% of global respondents injecting IC moxifloxacin, with the remainder evenly divided between using compounded moxifloxacin (49%) or topical Vigamox (moxifloxacin, Novartis) (46%) as the source. Those who knew what moxifloxacin concentration they employed were equally divided between the 0.5% and 0.1% concentrations.
The percentage of respondents who are not using intracameral antibiotics continues to decrease. They cited compounding risk (66%), cost (42%), and being unconvinced of the need (48%) as reasons (Table 2). However, 80% of all respondents now think that it is important to have an approved commercial antibiotic for direct intracameral injection compared to 75% in 2014 and 54% in 2007. If a reasonably priced commercial solution was available, intracameral antibiotic adoption would increase to 93% of respondents, compared to 83% and 82% in the two prior surveys. ASCRS and the U.S. Veterans Health Administration are working to organize a multicenter, prospective randomized clinical trial in the U.S. with the goal of getting a commercial antibiotic solution approved. The TIME (Topical vs. Intracameral Moxifloxacin to prevent Endophthalmitis) study would test the efficacy of intracameral moxifloxacin in reducing the cataract surgical endophthalmitis rate compared to using topical moxifloxacin alone.
| Regimen | 2021 | 2014 | 2007 |
|---|---|---|---|
| Perioperative topical antibiotics | 82% (987/1206) | 90% | 91% |
| Preoperative topical antibiotics | 73% (882/1206) | 85% | 88% |
| Postoperative topical antibiotics | 86% (1030/1204) | 97% | 98% |
| Intracameral antibiotics | 66% (802/1208) | 50% | 30% |
| Irrigation vs. direct injection (if using): | |||
| Direct injection | 95% (764/802) | 84% | 52% |
| Irrigation bottle | 5% (38/802) | 16% | 48% |
| Importance of approved commercial antibiotic? | 2021 | 2014 | 2007 |
|---|---|---|---|
| Important | 80% (962/1204) | 75% | 54% |
| Not important | 7% (88/1204) | 9% | 11% |
| Not sure | 13% (154/1204) | 16% | 35% |
| Would still not use intraocular antibiotic* | 7% (82/1204) | 17% | 18% |
| Why not using IC antibiotic?* | 2021 | 2014 | 2007 |
|---|---|---|---|
| Mixing/compounding risk | 66% (251/382) | 49% | 45% |
| Cost | 32% (122/382) | 19% | 17% |
| Not convinced of need | 48% (182/382) | 65% | 89% |
Table 2. Opinions about intracameral antibiotic prophylaxis
Source (all): David F. Chang, MD
References
- Barry P, et al. 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.
- Chang DF, et al. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the 2007 ASCRS member survey. J Cataract Refract Surg. 2007;33:1801–1805.
- Chang DF, et al. Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2014 ASCRS member survey. J Cataract Refract Surg. 2015;41:1300–1305.
- Chang DF, Rhee DJ. Antibiotic prophylaxis of postoperative endophthalmitis following cataract surgery: Results of the 2021 ASCRS member survey. J Cataract Refract Surg. 2021. Online ahead of print.
- Herrinton LJ, et al. Comparative effectiveness of antibiotic prophylaxis in cataract surgery. Ophthalmology. 2016;123:287–294.
- Witkin AJ, et al. Vancomycin-associated hemorrhagic occlusive retinal vasculitis: clinical characteristics of 36 eyes. Ophthalmology. 2017;124:583–595.
- Haripriya A, et al. Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from 2 million consecutive cataract surgeries. J Cataract Refract Surg. 2019;45:1226–1233.
Contact
Chang: dceye@earthlink.net
