Relative efficacy of intracameral moxifloxacin injection methods.

PURPOSE: To determine the amount of moxifloxacin remaining in the anterior chamber (AC), immediately after its injection using 3 current injection methods, assuming mixing and fluid exchange with the AC contents during injection of the drug, and to determine the most desirable injection method. SETTING: Department of Ophthalmology and Vision Sciences and Institute of Biomedical Engineering, University of Toronto, Toronto, Canada. DESIGN: Mathematical modeling. METHODS: Mathematical modeling using first-order mixing methods were used to assess mixing. RESULTS: The Kaiser method of injecting 0.5 mL × 100 µg/0.1 mL does not achieve the desired 500 µg level of moxifloxacin in the AC. The "straight from the bottle" method of injecting 0.1 mL × 500 µg/0.1 mL is fraught with potential error, yielding a relatively unreliable final amount in the AC. Injecting 0.5 to 0.6 mL × 150 µg/0.1 mL yields a result closest to the desired goal. CONCLUSIONS: Based on the calculation, the most accurate of current methods to deliver 500 µg moxifloxacin intracamerally is the method of 150 µg/0.1 mL × 0.5 to 0.6 mL.

Immediately sequential bilateral cataract surgery: an academic teaching center's experience.

PURPOSE: To evaluate the safety and outcomes of immediately sequential bilateral cataract surgery (ISBCS) at a Canadian academic teaching center. SETTING: Tertiary university teaching hospital of Laval University, Quebec City, Canada. DESIGN: Retrospective cohort study. METHODS: 2003 consecutive patients (4006 eyes) who underwent ISBCS under topical anesthesia from January 2019 to December 2019 were included. All charts were retrospectively reviewed. Outcome measures included intraoperative and postoperative complications, postoperative uncorrected distance (UCVA) and pinhole (PHVA) visual acuities, and autorefraction measurements. RESULTS: 4006 eyes from 1218 (60.8%) female and 785 (39.2%) male patients with a mean age of 74 ± 8 years had a mean preoperative visual acuity of 0.503 logMAR (Snellen 20/63). The mean axial length was 23.53 ± 1.37 mm. Most eyes had monofocal intraocular lenses (IOLs) implanted (n = 3738, 93.3%) followed by toric (n = 226, 5.6%), multifocal (n = 25, 0.6%), and multifocal toric (n = 17, 0.4%) IOLs. Intraoperative complications included 14 (0.3%) posterior capsule ruptures with 5 (0.1%) requiring sulcus IOL placement, and 7 (0.2%) partial zonulysis, with 3 requiring capsular tension rings (0.07%). There were no cases of endophthalmitis or toxic anterior segment syndrome. Mean 5-week postoperative UCVA was 0.223 (Snellen 20/33), PHVA was 0.153 (Snellen 20/28) with a mean spherical equivalent of -0.21 diopters. CONCLUSIONS: ISBCS performed following International Society of Bilateral Cataract Surgeons recommended guidelines is a safe procedure. This cohort of 4006 eyes had very few complications, with none attributable to the surgery being done bilaterally. The UCVA, PHVA, and refractive outcomes were good.

Bilateral simultaneous postoperative endophthalmitis: review of cases reported over the past 50 years.

A detailed retrospective analysis and literature review were conducted for all previously published reports of bilateral simultaneous postoperative endophthalmitis (BSPOE) since 1970. There have been 7 (9, with 2 currently being reported elsewhere) cases of BSPOE after immediately sequential bilateral cataract surgery (ISBCS) reported over 50 years. Generally, in these cases, the surgical protocol recommended by the International Society of Bilateral Cataract Surgeons ( i SBCS) was breached or uncertain. Bacterial causes were Pseudomonas aeruginosa (3), Staphylococcus epidermidis (3), and Burkholderia cepacia complex (1). One case showed negative results for bacterial infection and 1 was not determined. Visual recovery was light perception, or worse, for Pseudomonas cases, generally good for Staphylococcus and Burkholderia cases, and mixed in cases of unknown etiology. Therefore, BSPOE is rare and causes vary. Strict adherence to the i SBCS General Principles of Excellence in ISBCS 2009 surgical protocol and care with operating room construction seem to considerably lessen the risk.

Aqueous level abatement profiles of intracameral antibiotics: A comparative mathematical model of moxifloxacin, cefuroxime, and vancomycin with determination of relative efficacies.

PURPOSE: To create a model of the abatement profiles of the three most commonly employed endophthalmitis prophylaxis intracameral (IC) antibiotics-cefuroxime, vancomycin, and moxifloxacin-to enable comparison of their durations of efficacy against common endophthalmitis pathogens. SETTINGS: Humber River Hospital and The Eye Foundation of Canada, Toronto, Ontario, the University of Toronto, Ontario, and McGill University, Montreal, Quebec, Canada. DESIGN: Literature review, as well as review of our clinical experience with 4797 consecutive cases with IC vancomycin, followed by 9185 consecutive cases with IC moxifloxacin. METHODS: A detailed review of the prophylactic antibiotic literature was performed. Exponential decay models of the selected IC antibiotics were updated from previous work by the study authors with decay constants adjusted to agree with the available published objective data. RESULTS: The graphs generated by the study data demonstrate the relative duration of IC bactericidal activity of moxifloxacin, cefuroxime, and vancomycin. They suggest that at present, IC moxifloxacin, when administered in appropriate doses, is the most effective agent in preventing postoperative endophthalmitis. Unlike vancomycin and cefuroxime, bacterial resistance to moxifloxacin is dose-dependent, and it is overcome in the vast majority of cases with doses that can safely be achieved intracamerally. The graphs can serve as a useful tool to assess the expected efficacy of each antibiotic in reference to local pathogen resistances. CONCLUSION: The model shows IC moxifloxacin, cefuroxime, and vancomycin durations of bactericidal efficacy post-cataract surgery, which correlate well with the published objective data.

Refractive Laser-Assisted Cataract Surgery versus Conventional Manual Surgery: Comparing Efficacy and Safety in 3144 Eyes.

PURPOSE: To report on outcomes of the efficacy and safety in 1 of the largest series of eyes undergoing either conventional manual cataract surgery (MCS) or refractive femtosecond laser-assisted cataract surgery (ReLACS). DESIGN: Retrospective, consecutive, interventional comparative case series. METHODS: This study included 3144 consecutive eyes, of which 1580 were treated via MCS, and 1564 were treated via ReLACS at Uptown Surgical Centre in Vaughan, Ontario, Canada. Preoperative characteristics, best corrected visual acuity (BCVA), mean absolute spherical error (MAE), rates of intraoperative posterior capsular rupture, and postoperative complications were evaluated. RESULTS: Across all eyes, ReLACS was superior to MCS for reducing surgical time (MCS: 7.7 ± 0.1 min vs ReLACS: 6.8 ± 0.1 min, P < 0.001); was less commonly associated with postoperative cystoid macular edema (OR = 0.36, 95% CI: 0.14-0.91, P = 0.031) and more commonly reduced MAE (MCS: 0.60 ± 0.02 diopters (D) vs ReLACS: 0.54 ± 0.02 D, P = 0.02). There were no differences in rates of posterior capsular rupture (P = 0.918), overall postoperative complications (P = 0.088) or final BCVA (P = 0.881). When analyzing a subgroup of more difficult cases (n = 833), ReLACS was superior to MCS for: 1) being more likely to yield an improvement of more than 0.1 logarithm of the minimum angle of resolution BCVA (OR = 1.80, 95% CI: 1.15-2.74, P = 0.01); 2) reducing MAE (MCS: 0.73 ± 0.3 D vs ReLACS: 0.60 ± 0.27 D, P = 0.04); and 3) being more likely to yield an MAE within 0.5 D (OR = 1.61, 95% CI: 1.11-2.33, P = 0.012). CONCLUSIONS: Across all eyes, our results support that ReLACS and MCS yield similar outcomes. However, our results show trends toward a more pronounced benefit of ReLACS compared to MCS when treating more difficult eyes.

Dose and administration of intracameral moxifloxacin for prophylaxis of postoperative endophthalmitis.

PURPOSE: To review current and past practices of intracameral antibiotic administration for infection prophylaxis in cataract surgery; to review the benefits and liabilities of available prophylactic drugs, dosage determination, and administration protocols; and to devise an optimum dose and administration protocol for intracameral moxifloxacin. SETTING: Humber River Hospital and the University of Toronto, Toronto, Ontario, Canada. DESIGN: Retrospective evaluation of treatment modality. METHODS: This study consisted of a detailed review of the history, drugs, and methods of intracameral prophylaxis and microbiological and pharmacodynamics analysis of options. A review of potential drug sources and doses was performed and 1 drug, dose, and administration protocol was selected. The current method's adoption reasons are described followed by the authors' experience. RESULTS: A single infection in 3430 cases occurred with a moxifloxacin-resistant strain of Staphylococcus epidermidis when moxifloxacin 100 mcg in 0.1 mL was used. Increasing the dose and changing the administration technique resulted in no infections in 4601 cases and no detrimental side effects or complications. CONCLUSION: Intracameral moxifloxacin prepared by dilution of 3 cc moxifloxacin 0.5% (Vigamox) with 7 cc balanced salt solution and with the administration of 0.3 to 0.4 cc (450 to 600 mcg.) as the final step in cataract surgery via the side port after the main incision has been sealed and hydrated showed advantages over alternative intracameral antibiotic prophylactic methods, with minimum risk. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.

Tri-soft shell technique.

Soft-shell techniques exist for lower viscosity dispersive with higher viscosity cohesive ophthalmic viscosurgical devices (OVDs) (soft-shell technique [SST]), viscoadaptive OVDs with balanced salt solution (ultimate soft-shell technique), intraoperative floppy-iris syndrome (soft-shell bridge), and many specific modifications for disinserted zonular fibers, frayed iris strands, Fuchs endothelial dystrophy, small holes in the posterior capsule with protruding vitreous, capsular dye use, and others. Soft-shell techniques exist because it is rheologically impossible to control the surgical environment with a single OVD as well as with an ordered combination of rheologically different OVDs. Surgeons frequently confuse these techniques because of their multitude. This paper unifies all SSTs into a single improved tri-soft shell technique (TSST), from which basic specific applications to unusual circumstances are simple and intuitive. As shown with previous SSTs, the TSST allows surgeons to perform complex tasks with greater surgical facility and to protect endothelial cells better than with single OVDs.

Same-day cataract surgery should be the standard of care for patients with bilateral visually significant cataract.

Same-day, or immediately sequential, bilateral cataract surgery (ISBCS) is being practiced with increasing frequency worldwide. It provides many advantages including convenience for the patient and the patient's family. ISBCS repairs the visual system, not merely one eye, restoring normal binocularity as well as unilateral clarity, creates a much more relaxed surgical atmosphere in harried operating rooms, and saves money for society. It is often preferred by busy professionals. The purported risks of ISBCS have been unsupported by the literature, including bilateral retinal detachment, bilateral corneal decompensation, bilateral diabetic macular edema, bilateral severe cystoid macular edema, significant IOL power errors in the first eye that could be refined and thereby prevented in the second eye, and toxic anterior segment syndrome. The greatest fear of ISBCS has been possible simultaneous bilateral endophthalmitis, which did not occur in a series of nearly 100,000 ISBCS cases and has only occurred elsewhere when complete separation of the two eyes and strict sterile protocol were not followed. The International Society of Bilateral Cataract Surgeons (www.isbcs.org) has prepared the "iSBCS General Principles for Excellence in ISBCS," which should be followed for safe ISBCS.

Incidence of postoperative endophthalmitis after immediate sequential bilateral cataract surgery.

PURPOSE: To determine a best estimate of the incidence of endophthalmitis after immediately sequential bilateral cataract surgery (ISBCS) and assess the benefit of prophylactic intracameral antibiotics. SETTING: Eye Foundation of Canada, Toronto, Ontario, Canada. DESIGN: Cohort study. METHODS: A detailed literature search was performed to obtain recently reported frequencies of postoperative endophthalmitis with or without the use of prophylactic intracameral antibiotics. Members of the International Society of Bilateral Cataract Surgeons were surveyed. The data were collected to determine the results of unilateral and bilateral cataract surgeries performed by experienced bilateral cataract surgeons. The data were statistically analyzed. RESULTS: In recently published European prophylactic intracameral cephalosporin studies, the incidence of postoperative endophthalmitis after unilateral cataract surgery weight-averaged to 1 in 331 (0.3%) without prophylactic intracameral antibiotics and to 1 in 1977 (0.05%) with prophylactic intracameral antibiotics, whereas studies in the United States using only topical antibiotics reported infection rates as low as 0.028%. Four cases of bilateral simultaneous endophthalmitis after ISBCS have been reported in the past 60 years, all with breaches of aseptic protocol. No bilateral simultaneous endophthalmitis occurred in the 95 606 ISBCS cases collected. The overall rate of postoperative endophthalmitis after ISBCS was 1 in 5759. Infection rates were significantly reduced with intracameral antibiotics to 1 in 14 352 cases. CONCLUSIONS: The risk for postoperative endophthalmitis in ISBCS appears to be at least as low as and possibly lower than published rates for unilateral surgery, particularly when recommended precautions are taken. Intracameral antibiotics significantly reduced the risk for postoperative endophthalmitis.