Archive October 2018 XIX, No. 10

New Ideas for Preventing Endophthalmitis

Intracameral antibiotics, proven to lower the rate of infection substantially, are catching on.

Desiree Ifft, Contributing Editor


Imprimis Pharmaceuticals
INJECTION Intracameral antibiotics for endophthalmitis prophylaxis, the standard of care in Europe, are gaining favor with U.S. surgeons as well.

Long the standard of care in Europe, use of intracameral antibiotics with cataract surgery to prevent endophthalmitis is becoming more popular among U.S. surgeons as well. The change in strategy means added peace of mind that you're doing everything possible to keep the dreaded complication at bay. It also means a likely increase in case costs. Here's what you need to know.

There is no consensus on best practice for endophthalmitis prophylaxis. Other than the proven use of povidone iodine, no antibiotic protocol, whether it be topical or intracameral, has been definitively shown to be superior in a prospective, randomized, placebo-controlled clinical trial. But evidence in favor of intracameral has mounted to the point where around 50% (and counting) of U.S. surgeons consider it the best option. Most notably, a prospective study from the European Society of Cataract & Refractive Surgeons (ESCRS) showed a 5-fold decrease in endophthalmitis rate with intracameral antibiotic compared with topical antibiotic. What's hindering wider adoption? For now, experts say, the lack of an FDA-approved drug for intracameral delivery and the resulting fears of toxic errors committed at compounding pharmacies.

Surgeon preference

Eric D. Donnenfeld, MD
If intracameral moxifloxacin is shown to be superior, we'll seek FDA approval of the formulation.

— Eric D. Donnenfeld, MD, FACS

In this landscape, surgeons base their choice of antibiotic for intracameral injection on known effectiveness against endophthalmitis-causing pathogens and consideration of the breadth of what's been reported about safety and efficacy for this use. They're most likely to want to use moxifloxacin or cefuroxime. Vancomycin had also been a common choice until it was associated with extremely rare yet visually devastating post-operative hemorrhagic occlusive retinal vasculitis (HORV). When choosing an antibiotic, surgeons might also consider your facility's infection profile.

  • Moxifloxacin. A popular off-label choice for intracameral injection is the commercially available, self-preserved formulation of moxifloxacin (Vigamox 0.5%, 3mL in a 4mL bottle). The simplest method: Draw 0.1mL of the solution (which is 0.5mg/0.1mL concentration) directly from the bottle, and it's ready to inject. Note that other branded or generic multi-use moxifloxacin formulations are not appropriate for this purpose.

Alternatively, if the surgeon prefers to inject a 0.25mg/0.1mL concentration, dilute the Vigamox 2-1 with BSS. A third approach, developed and reported by Steve A. Arshinoff, MD, FRCSC, associate professor in the Department of Ophthalmology & Vision Sciences at the University of Toronto, is to place the entire 3mL of Vigamox into a syringe and add 7mL of BSS. That results in a concentration of 0.15mg/0.1mL, which lets the surgeon inject more than 0.1mL, essentially replacing most of the aqueous with drug, without worrying that the concentration will be too high.

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