December 2014




Intracameral antibiotics: Trends and practices

by Lauren Lipuma EyeWorld Staff Writer

Using Intracameral antibiotics diagram

When asked if they use intracamerals, 42% of the audience responded that they do, while about 33% said they do not, and 25% said they are considering it but are unsure what the best practices are. Source: ASCRS

This series of articles highlights the hot topics presented at the Cataract Dilemmas symposium at the 2014 ASCRS•ASOA Symposium & Congress. In this particular article, we review and discuss the pertinent points of the presentation of Neal Shorstein, MD, on intracameral antibiotics. The use of intracameral antibiotics continues to be a controversial topic for many ophthalmologists. The common questions that arise are: Should we be using an intracameral antibiotic, and if so, how can we safely compound or mix/dilute it? The risk of TASS is still there creating some background noise and uncertainties. Dr. Shorsteins review is very compelling to consider adopting the use of an intracameral antibiotic and the steps to take to pick the correct one and have it safely made.

Rosa Braga-Mele, MD, ASCRS Cataract Clinical Committee chair

The Cataract Dilemmas symposium at the 2014 ASCRS•ASOA Symposium & Congress highlighted current trends in intracameral antibiotic use among ophthalmologists in the U.S. Results from an audience response question during the symposium revealed that despite evidence in the literature supporting the efficacy of intracamerals, cataract surgeons remain split on the issue. When asked if they use intracamerals, 42% of the audience responded that they do, while 33% said they do not, and 25% said they are considering it but are unsure what the best practices are. In light of it not being commercially available, its great to see so many of the respondents are using it, said Neal Shorstein, MD, ophthalmologist and associate chief of quality, Kaiser Permanente, Walnut Creek, Calif., one of the panelists at the symposium. Im a real believer in intracameral antibiotics, and I think up until now the main barrier has been sourcing it and ensuring that if its compounded, its a safe product. Im hoping that those physicians and surgery centers employing intracameral antibiotics are spreading the word to their colleagues in local societies and at the ASCRS meetings about how to do it. After reading the results from the European Society of Cataract & Refractive Surgeons (ESCRS) report on the efficacy of intracamerals in 2007, Dr. Shorsteins department at Kaiser Permanente decided as a group to adopt the practice, a decision that was made easier with the support of their large organization and access to a pharmacy that was able to compound the drug safely. For me, it came down not to whether or not to use intracameral antibiotics to reduce infection, but which antibiotic to use, he said. His department started out with cefuroxime in 2007 because it was the most studied intracameral at the time, and incorporated moxifloxacin into their protocols in 2010. Today, cefuroxime is their first line antibiotic, which Dr. Shorstein uses in about 85% of patients. Moxifloxacin is used as a second line antibiotic, for the 14% of patients who are allergic to cefuroxime, and the remaining 1% who are allergic to both antibiotics are treated with vancomycin.


Dr. Shorstein discussed the advantages and disadvantages of each antibiotic in a presentation during the Cataract Dilemmas symposium in order to help physicians make informed decisions about intracamerals going forward. Cefuroxime is the most studied of the intracamerals, being the only agent that has been used as a part of a large randomized trial showing efficacy in reducing rates of endophthalmitis, Dr. Shorstein said in his presentation. The drawback of the drug, however, is that it requires a 2-step compounding process, leaving more room for error, and Dr. Shorstein mentioned reports of toxicity with the drug when compounding or dilution went wrong. Cefuroxime has excellent gram-positive coverage, but there are some gaps in its gram-negative and enteric coverage, he added. Dr. Shorstein discussed the use of moxifloxacin, which is sourced from commercially available Vigamox (Alcon, Fort Worth, Texas) topical drops and can be used straight out of the bottle or diluted easily in the operating room. The downside to using an existing drop, however, is that it is not manufactured to intravenous and intracameral standards, he said. Moxifloxacin has excellent coverage against gram negatives, but in his experience, it does not have as good gram-positive coverage as cefuroxime. It is effective against enterococcus. Vancomycin is extremely effective against gram positives but not against gram negatives, so it is good for those centers that have a high incidence of gram-positive infections, Dr. Shorstein said in his presentation. However, because vancomycin is used as treatment for enterococcal infections and because highly resistant enterococcus strains have emerged, the Centers for Disease Control and Prevention recommends against the routine use of vancomycin for prophylaxis.


I recommend that surgery centers and the surgeons who operate there take a look at the historical data for what types of organisms have caused endophthalmitis in patients who have been operated on there and see if there is a highly reputable compounding pharmacy that you can source antibiotics from, Dr. Shorstein concluded. With that information, surgeons can match the availability of appropriate antibiotics to the most common causative infectious agents, allowing them to take advantage of the intracameral method until an FDA-approved product becomes available.

Editors note: Dr. Shorstein has no financial interests related to his comments.

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For more on this topic, check out the Feature section of the January 2015 issue of EyeWorld.

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