ASCRS clinical advisory on intracameral moxifloxacin injection for infection prophylaxis.

Moxifloxacin solution is frequently injected at the conclusion of cataract surgery for endophthalmitis prophylaxis. 2 different concentrations are most commonly available in the United States for intracameral (IC) use: 0.5% (5 mg/mL) and 0.1% (1 mg/mL). The recommended volume to be injected is different for the 2 concentrations, and incorrect dosing can increase the risk of toxic anterior segment syndrome or endophthalmitis. In addition, the U.S. Food and Drug Administration recently published an alert regarding potential adverse events associated with intraocular compounded moxifloxacin. This clinical advisory reviews the optimal dosing of IC moxifloxacin based on current evidence.

Chlorhexidine and other alternatives for povidone-iodine in ophthalmic surgery: review of comparative studies.

Povidone-iodine (PVI) is a universally accepted antiseptic agent used in ophthalmic surgery. Insufficient antisepsis in patients with self-reported allergies to iodine has led to devastating complications. The aim of this study was to review the current evidence for alternatives to PVI in ocular surgery. Aqueous chlorhexidine has been used as a primary antiseptic agent in Sweden for several years and has proven efficiency and safety; in a study of a large series of intravitreal injections in Australia, the endophthalmitis rates were similar to those after the use of PVI. The evidence related to using other disinfectants such as picloxydine, hypochlorous acid solution, and polyhexanide is scarce. Single studies have shown lower patient discomfort after conjunctival lavage with chlorhexidine or hypochlorous acid than with PVI. No evidence was found to suggest changing from PVI to other antiseptic agents. Disinfectant solutions other than PVI or chlorhexidine will require further investigations to show their utility in ocular surgery.

Drop-free approaches for cataract surgery.

PURPOSE OF REVIEW: Routine prophylaxis for adverse events following cataract surgery is evolving. Prior reliance on topical eyedrop instillation by patients is giving way to surgeon directed injections at the time of cataract surgery. The benefit of this new approach is assured delivery of drugs in standardized doses which should optimize the healing process and reduce the incidence of untoward events with higher confidence. RECENT FINDINGS: Adoption rates of intracameral antibiotic injection amongst European and American cataract surgeons is increasing. Techniques to inject periocular corticosteroid for routine inflammation prophylaxis are also in development. In combination with intraoperative pharmacologic dilation, a drop-free modality can be achieved. SUMMARY: Intraoperative injections offer the patient and surgeon assured drug delivery and hold promise to avoid the pitfalls of patient adherence, incorrect topical instillation, and topical drop-associated corneal issues.

The use of povidone-iodine in ophthalmology.

PURPOSE OF REVIEW: Povidone-iodine (PVI) is a disinfectant and antiseptic agent used for preoperative preparation of the skin and mucous membranes, as well as for the treatment of contaminated wounds. Currently regimens for prophylaxis against postsurgical endophthalmitis are being modified, including a total withdrawal of antibiotics in intravitreal injections. The aim of this study was to evaluate the use of PVI in ophthalmology. RECENT FINDINGS: As a result of its broad spectrum of microbicidal activity, PVI is routinely used in ophthalmic surgery. However, various protocols are applied worldwide and within different procedures. Additional indications include prophylaxis against ophthalmia neonatorum, acute conjunctivitis, adenoviral conjunctivitis, bacterial keratitis or corneal ulcer, endophthalmitis, giant fornix syndrome, and antimicrobial prophylaxis in patients with Boston type I keratoprosthesis. SUMMARY: Despite the introduction of new antiseptics in surgery, PVI is still the preeminent antiseptic measure in ophthalmology. Its use is economically reasonable. There have been no reports of resistance to PVI or anaphylaxis with topical ophthalmic use. Furthermore, it does not induce resistance or cross-grztance to antibiotics. With these advantages the range of indications for topical use of antibiotics might decrease, with PVI as the sole perioperative antiseptic measure. Additional studies are required to assess the optimal timing, concentration and exposure time within different ophthalmic procedures.

Optimizing the antisepsis protocol: Effectiveness of 3 povidone-iodine 1.0% applications versus a single application of povidone-iodine 5.0.

PURPOSE: To determine the minimum effective concentration of povidone-iodine that reduces the bacterial load by 3-log10, the U.S. Food and Drug Administration requirement for antiseptic agents, and to study alternative dosing schedules of povidone-iodine to optimize its bactericidal effect. SETTING: Microbiology Laboratory, Evanston Hospital, Evanston, Illinois, USA. DESIGN: Experimental study. METHODS: A standard 0.5 McFarland solution of Staphylococcus epidermidis was applied to blood agar plates. The plates were treated with a single application of povidone-iodine solutions from 10.0% to 0.1% to define the range of interest. Another set of plates received 3 applications of various povidone-iodine solutions. Microbial growth was evaluated after 24 hours. Standard deviations with 99.0% and 99.9% confidence intervals for each concentration were estimated and used to estimate the minimum concentration that reduced the colony counts by at least 3-log10. RESULTS: Povidone-iodine at 2.5% and higher concentrations was effective in eliminating S epidermidis with a single application. Three 30-second applications of povidone-iodine at concentrations of 0.7% and higher resulted in at least a 3-log10 reduction of colonies. CONCLUSIONS: Povidone-iodine 5.0% has been the standard of care for preoperative ocular antisepsis for 3 decades. Povidone-iodine 0.7% was as effective as a bactericidal agent when applied multiple times. This suggests povidone-iodine 1.0%, applied in three 30-second applications for preoperative surface disinfection might be as effective for preoperative antisepsis.

Surgical simulators in cataract surgery training.

BACKGROUND: Virtual simulators have been widely implemented in medical and surgical training, including ophthalmology. The increasing number of published articles in this field mandates a review of the available results to assess current technology and explore future opportunities. METHOD: A PubMed search was conducted and a total of 10 articles were reviewed. RESULTS: Virtual simulators have shown construct validity in many modules, successfully differentiating user experience levels during simulated phacoemulsification surgery. Simulators have also shown improvements in wet-lab performance. The implementation of simulators in the residency training has been associated with a decrease in cataract surgery complication rates. CONCLUSIONS: Virtual reality simulators are an effective tool in measuring performance and differentiating trainee skill level. Additionally, they may be useful in improving surgical skill and patient outcomes in cataract surgery. Future opportunities rely on taking advantage of technical improvements in simulators for education and research.

Limited predictive accuracy of the Booklet Category Test in a criminal forensic sample.

A known-groups design was used to evaluate the clinical decision rules of the validity indicators of the Booklet Category Test for the detection of malingered neurocognitive dysfunction (MND) in an incarcerated male sample. Participants were 128 inmates who were classified into MND and presumed valid groups using the Slick, Sherman, and Iverson ( 1999 ) criteria. While errors on Subtests I and II had the best classification accuracy at 71.1% with 95.1% specificity and 49.3% sensitivity, the associated area under the curve (AUC) indicated only "acceptable" discrimination due to poor sensitivity. Logistic regression confirmed that errors on Subtests I and II were the only statistically significant validity indicator. The remaining validity indicators performed poorly with AUCs at < .70, indicating no discriminative power. The effectiveness of the clinical decision rules of the validity indicators in predicting the presence of MND evidenced limited support. A positive finding on Subtest I and II errors was clinically significant in this sample, but negative results revealed no utility. Validity indices composed from different items may yield more effective results among male prisoners referred for neuropsychological evaluation.

Optimizing the intracameral dilation regimen for cataract surgery: prospective randomized comparison of 2 solutions.

PURPOSE: To compare the efficacy of epi-Shugarcaine solution (epinephrine 0.025% and lidocaine 0.75% in fortified balanced salt solution [BSS Plus]) (epi-S) and Lundberg and Behndig's intracameral dilation solution (cyclopentolate 0.1%, phenylephrine 1.5%, and lidocaine 1%) (LB) for intracameral dilation for cataract surgery. SETTING: Private clinic, Lincolnwood, Illinois, USA. METHODS: In this paired-eye single-masked prospective study, the first eye scheduled for surgery was randomized to receive LB solution or epi-S solution intracamerally at the time of cataract surgery; the second eye to have surgery received the alternative solution. Each eye received 1 drop of tropicamide 1% at least 20 minutes before the start of surgery. Pupil measurements were made before the incision was created, 1 minute after intracameral solution injection, after the anterior chamber was filled with an ophthalmic viscosurgical device, and at the conclusion of the case. Pupil size was objectively graded via software operated by a video technician who was masked to which solution was used. RESULTS: Eighty-four eyes of 42 patients were enrolled in the study. At each time point after instillation, the pupil was statistically significantly larger with epi-S solution than with LB solution, averaging 0.528 mm larger 1 minute after instillation (mean 7.183 versus 6.665 mm) to 0.34 mm larger (mean 7.381 versus 7.040 mm) by the end of the case. CONCLUSION: When combined with 1 drop of tropicamide 1% preoperatively, both formulations provided safe and effective intracameral dilation for cataract surgery; however, the epi-S solution was the more efficacious at each step of the procedure.