Low-concentration povidone-iodine for the prevention of intraocular infections in ophthalmic surgery.

PURPOSE OF REVIEW: Endophthamitis following intraocular surgery is rare using current antiseptic techniques, such as single application of 5% povidone-iodine to the ocular surface and adjuvant topical or intracameral antibiotics. Challenges remain, however, including increased multidrug-resistant bacterial endophthalmitis, increased fungal endophthalmitis, and the low but nonzero endophthalmitis rate attributable to the typical bacteria that colonize the ocular surface. RECENT FINDINGS: Povidone-iodine has a wide spectrum of activity, including activity against novel pathogens, such as SARS-CoV-2. Povidone-iodine alternatives, such as hypochlorous acid can have significantly less efficacy in vitro against endophthalmitis isolates. Repetitive application of dilute povidone-iodine has an excellent safety profile and strong evidence base for efficacy. SUMMARY: Povidone-iodine is widely available, inexpensive, and commonly used by ophthalmologists. The repetitive application of dilute povidone-iodine is a well studied, well tolerated, and efficacious way to transiently sterilize the ocular surface during intraocular surgery. Additional benefits include activity against multidrug-resistant bacteria, fungi, and lack of inducible resistance.

Endophthalmitis Prophylaxis Failures in Patients Injected With Intracameral Antibiotic During Cataract Surgery.

PURPOSE: To estimate the association of cefuroxime and moxifloxacin in relation to the occurrence of endophthalmitis following phacoemulsification cataract surgery. DESIGN: Retrospective clinical cohort study. METHODS: We studied patients with noncomplex phacoemulsification cataract surgery in Kaiser Permanente Northern California during 2014-2019. Data were obtained for acute, postoperative endophthalmitis within 90 days of phacoemulsification, including culture and antibiogram results, intracameral and topical antibiotic agent, and dose. In a post hoc analysis, we also examined preoperative anterior chamber depth (ACD) and postoperative anterior chamber volume (ACV). RESULTS: Of 216,141 surgeries, endophthalmitis occurred in 0.020% of moxifloxacin-injected eyes and 0.013% of cefuroxime eyes (relative risk 1.62 with 95% CI 0.82-3.20, P = .16). Of the 34 (0.016%) cases of endophthalmitis, cefuroxime 1 mg was injected into 13 eyes and moxifloxacin 0.1% into 21 eyes. Organisms with antibiograms were identified in 12 (35%) cases. Of these, bacteria recovered from cefuroxime-injected eyes were resistant to cefuroxime in all cases (4/4), with Enterococcus comprising half of these. In eyes injected with moxifloxacin 0.1%, 6 out of 7 organisms were sensitive to moxifloxacin injected with 0.1 mL and in 1 eye injected with 1 mL. Streptococcus was the most common organism recovered (6/9) in moxifloxacin-injected eyes. Preoperative ACD and postoperative calculated ACV were higher in eyes injected with moxifloxacin. CONCLUSIONS: Endophthalmitis cases with positive cultures were generally related to organism resistance in cefuroxime eyes but to sensitive organisms in moxifloxacin eyes. Moxifloxacin doses may have been insufficient in eyes with larger ACV.

Safety of intracameral moxifloxacin in the pediatric population: an equivalence study.

PURPOSE: To investigate whether the safety of intracameral moxifloxacin (IC-Mox) was equivalent to subconjunctival antibiotics (SC-Abs) in pediatric lens surgery. SETTING: The Hospital for Sick Children, Toronto, Canada. DESIGN: Retrospective consecutive cohort study. METHODS: This equivalence study compared 95% CI in the difference between the preoperative and postoperative safety variables of best corrected visual acuity (BCVA), intraocular pressure (IOP), central corneal thickness (CCT), endothelial cell density (ECD), corneal edema, and anterior chamber (AC) inflammation in IC-Mox with SC-Abs. The zone of clinical equivalence for BCVA was set at ±0.2 logarithm of the minimum angle of resolution, IOP at ±3 mm Hg, CCT at ±30 µm, and ECD at ±400 cells/mm. RESULTS: The charts of 358 patients undergoing lens-related surgeries were reviewed. Of 317 eyes (215 patients) included, 170 eyes received IC-Mox and 147 eyes had SC-Abs. The mean age was 4.9 and 5.1 years with a mean follow-up of 19 and 34.4 months (P < .001) in IC-Mox and SC-Ab groups, respectively. The 95% CIs for the change from preoperative to postoperative safety parameters between IC-Mox and SC-Abs were all in the zones of clinical equivalence (BCVA, P = 0.75; highest IOP in the first 6 weeks postoperatively, P = 0.27; IOP at the last visit, P = 0.74; CCT, P = 0.89; and ECD, P = 0.76). During the first 6 weeks postoperatively, there was no difference in corneal edema (P = .69) and AC flare (P = .4) between IC-Mox and SC-Ab groups, whereas AC cellular activity was significantly higher in the SC-Ab group (P = .028). CONCLUSIONS: IC-Mox prophylaxis in pediatric patients showed equivalent postoperative safety outcomes when compared with SC-Abs. The use of IC-Mox (250 µg) for endophthalmitis prophylaxis appears to be safe in the pediatric population.

Validation of a Comprehensive Clinical Algorithm for the Assessment and Treatment of Microbial Keratitis.

PURPOSE: To validate a comprehensive clinical algorithm for the assessment and treatment of microbial keratitis (MK). DESIGN: Retrospective cohort study. METHODS: The "1, 2, 3 Rule" for the initial management of MK was conceived by Vital and associates in 2007 to inform the decision as to when to perform corneal cultures. The rule is invoked when any 1 of 3 clinical parameters is met: ≥1+ anterior chamber cells, ≥2 mm infiltrate, or infiltrate ≤3 mm distance from the corneal center. When the rule is met, we added the mandatory use of fortified topical antibiotics after cultures are obtained. We compared outcomes of cases presenting to Massachusetts Eye and Ear 2 years before (Group I, n = 665) and after (Group II, n = 767) algorithm implementation. The primary composite outcome was a vision-threatening complication, such as corneal perforation. RESULTS: At a median follow-up of 67.0 and 60.0 days, respectively, 172 patients experienced a vision-threatening complication (Group I, 12.9% vs Group II, 11.2%, P = .51). While the algorithm codified conventional management practice at either end of disease severity, the effect of algorithm-augmented care was best appreciated in patients with lesions satisfying only 1 criterion. In this group, there was an increase in the proportion of patients undergoing culture at presentation (54.6% vs 67.7%, P = .006), fortified antibiotic prescription (29.7% vs 53.9%, P < .001), and reduction in vision-threatening complications (9.7% vs 1.8%, P = .001). The proportion of patients who were not cultured at presentation but later required culturing decreased (13.4% vs 5.1%, P = .001), as did patients who did not meet any criteria but were nonetheless cultured (23.9% vs 8.5%, P < .001). Multiple logistic regression showed that all algorithm parameters were independently associated with outcome: ≥1+ anterior chamber cells (odds ratio [OR] 1.66, 95% confidence interval 1.09-2.52); ≥2 mm infiltrate (OR 4.74, 2.68-8.40); and ≤3 mm from corneal center (OR 2.82, 1.85-4.31), confirmed with comparison to a bootstrapped sample (n = 10,000). CONCLUSIONS: The implementation of this algorithm reduced vision-threatening complications for patients with lesions satisfying only 1 criterion, arguably the most difficult patients in whom to judge disease severity. Implementation also led to a decrease in patients receiving unnecessary care.

Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from 2 million consecutive cataract surgeries.

PURPOSE: To analyze the posterior capsule rupture (PCR) rates among staff and trainee cataract surgeons, and the postoperative endophthalmitis (POE) rates in uncomplicated and complicated eyes both with and without intracameral moxifloxacin prophylaxis (ICMP). SETTING: Ten regional Aravind Eye Hospitals in India. DESIGN: Retrospective multicenter clinical registry within a single hospital network. METHODS: POE rates with and without ICMP were statistically compared for all eyes and separately for trainees versus staff, for phacoemulsification versus manual small-incision cataract surgery (M-SICS), and for a subgroup of eyes complicated by PCR or requiring secondary surgery. RESULTS: All cataract surgeries (2 062 643) performed during the 8-year period from 2011 to 2018 at the 10 regional Aravind Eye hospitals were included in the analysis. With ICMP, the overall POE rate declined from 692 (0.07%) of 993 009 eyes to 185 (0.02%) of 1 069 634 eyes (P < .001). This was independently significant for phacoemulsification and for M-SICS (P < .001). The overall PCR rate was 28 352 (1.37%) of 2 062 643 eyes, and it was statistically higher for trainees irrespective of surgical method (P < .001). Both staff and trainee surgeons had higher PCR rates with phacoemulsification than with M-SICS (P < .001). Absent ICMP, PCR increased the overall POE rate by more than 7-fold to 63 (0.43%) of 14 505 eyes. ICMP reduced the POE rate after PCR to 25 (0.18%) of 13 847 eyes (P = .002). This ICMP benefit was separately significant for both M-SICS (0.54% vs 0.26%, P = .01) and phacoemulsification (0.29% vs 0.06%, P = .005). The POE rate was especially high after secondary IOL implantation (0.90% without ICMP vs 0.34% with ICMP; P = .10). CONCLUSIONS: ICMP reduced the POE rate overall, with phacoemulsification, with M-SICS, and in eyes with PCR.

Endophthalmitis Reduction with Intracameral Moxifloxacin Prophylaxis: Analysis of 600 000 Surgeries.

PURPOSE: To compare the postoperative endophthalmitis rate before and after initiation of intracameral (IC) moxifloxacin prophylaxis for both phacoemulsification and sutureless, manual small-incision cataract surgery (M-SICS), as well as in patients with posterior capsular rupture (PCR). DESIGN: Retrospective, clinical registry. PARTICIPANTS: All cataract surgeries (617 453) performed during the 29-month period from January 2014 to May 2016 at the 10 regional Aravind eye hospitals were included. METHODS: The electronic health record data for all study eyes were analyzed. Endophthalmitis rates before and after moxifloxaxin were statistically compared for all eyes and separately for both phacoemulsification and M-SICS, and for the eyes complicated by PCR. MAIN OUTCOME MEASURES: The postoperative endophthalmitis rates before and after initiation of IC moxifloxacin prophylaxis. RESULTS: Overall, 302 815 eyes did not receive IC moxifloxacin and 314 638 eyes did, and there was a significant decline in the endophthalmitis rate, from 0.07% (214/302 815) to 0.02% (64/314 638) (P < 0.001), with moxifloxacin. For the 194 252 phacoemulsification eyes, the endophthalmitis rate was 0.07% (75/104 894) without IC moxifloxacin prophylaxis, compared with 0.01% (11/89 358) with moxifloxacin (P < 0.001). For the 414 657 M-SICS eyes, the endophthalmitis rate was 0.07% (135/192 149) without IC moxifloxacin prophylaxis, compared with 0.02% (52/222 508) with moxifloxacin (P < 0.001). Approximately half of the 8479 eyes that had PCR received IC moxifloxacin, and half did not. Without IC moxifloxacin, PCR increased the endophthalmitis rate nearly 7-fold to 0.48% (20/4186); IC moxifloxacin reduced the endophthalmitis rate with PCR to 0.21% (9/4293) (P = 0.034). No adverse events were due to IC moxifloxacin. CONCLUSIONS: Routine IC moxifloxacin prophylaxis reduced the overall endophthalmitis rate by 3.5-fold (3-fold for M-SICS and nearly 6-fold for phacoemulsification). There was also a statistical benefit for eyes complicated by PCR, and IC antibiotic prophylaxis should be strongly considered for this high-risk population. These conclusions are strengthened by the high volume of cases analyzed at a single hospital network over a comparatively short time frame. Considering the association of hemorrhagic occlusive retinal vasculitis with vancomycin and the commercial unavailability of IC cefuroxime in many countries, moxifloxacin appears to be an effective option for surgeons electing IC antibiotic prophylaxis.

Pathogens and antibiotic sensitivities in endophthalmitis.

BACKGROUND: Antibiotic prophylaxis in cataract surgery is intended to minimize endophthalmitis. We describe pathogenic organisms, antibiotic sensitivities and antibiotic prophylaxis in culture-proven endophthalmitis cases. DESIGN: Retrospective consecutive case series and community-based setting were used. PARTICIPANTS: Two hundred fifteen cases of endophthalmitis after cataract surgery performed during 2007-2012 in Kaiser Permanente, California. METHODS AND MAIN OUTCOME MEASURES: Descriptive analysis of isolated organisms and antibiotic sensitivities in relation to antibiotic prophylaxis in culture-proven endophthalmitis cases. RESULTS: The majority of culture-confirmed organisms (n = 83) were Gram positive (96%), most notably coagulase-negative Staphylococci (n = 34, 52%), of which all that underwent testing were sensitive to vancomycin (n = 32). Among 19 cases that had received only topical antibiotic prophylaxis, seven (37%) were resistant to the antibiotic given: 50% of cases (5 of 10 isolates) that had received ofloxacin were resistant to this antibiotic, 40% (2 of 5 isolates) that had received gatifloxacin were resistant. In contrast, 100% of cases (n = 4) that had received aminoglycosides were susceptible. Few culture-confirmed cases occurred in patients who received intracameral antibiotic (n = 4). CONCLUSIONS: In cases where fluoroquinolones were administered as antibiotic prophylaxis, isolates demonstrated a degree of bacterial resistance. The majority of endophthalmitis cases isolated occured following topical antibiotic prophylaxis only and were attributed to Gram-positive organisms, while few occurred in association with intracameral antibiotic.

Clinical outcomes after injection of a compounded pharmaceutical for prophylaxis after cataract surgery: a large-scale review.

PURPOSE OF REVIEW: To evaluate relevant clinical outcomes following a transzonular intravitreal injection of a compounded triamcinolone-moxifloxacin-vancomycin (TMV) formulation for postoperative prophylaxis after cataract surgery in a retrospective review of medical records from a private practice, single-specialty ambulatory center in New Jersey, USA. RECENT FINDINGS: The analysis included 1541 cases from 922 patients who underwent cataract surgery with an intravitreal injection of TMV from November 2013 to December 2014. Cataract surgery was performed by a standard clear corneal phacoemulsification technique. Transzonular injection was used to deliver TMV directly into the anterior vitreous after implantation of an intraocular lens. SUMMARY: There were no major intraoperative complications associated with the transzonular injection technique. There were no cases of postoperative endophthalmitis. Nearly 92% of cases (n = 1413/1541) did not require supplemental medication after surgery. The rate of breakthrough inflammation at Days 14-21 was 9.2% (n = 132/1429). The rate of visually significant postoperative cystoid macular edema was 2.0% (n = 28/1429). The rate of clinically significant postoperative intraocular pressure increase was low: 0.9% (n = 13/1425) of cases had an at least 10 mmHg increase at Days 14-21 or 90. Four of these cases had intraocular pressure at least 30 mmHg. The rates of infection and inflammation reported in this retrospective review of a transzonular injection of TMV for prophylaxis after cataract surgery appear similar to reported rates with alternative prophylactic therapies such as topical drops. The transzonular injection of TMV may have advantages in terms of patient compliance.

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.

SYSTEMIC ORAL ANTIBIOTICS AS A PROPHYLACTIC MEASURE TO PREVENT ENDOPHTHALMITIS IN PATIENTS WITH OPEN GLOBE INJURIES IN COMPARISON WITH INTRAVENOUS ANTIBIOTICS.

PURPOSE: To compare the use of systemic oral and intravenous antibiotics as a prophylactic measure to prevent endophthalmitis in patients with open globe injuries. METHODS: This prospective study was conducted on 1,255 consecutive patients with open globe injuries due to sharp or blunt trauma in a hospital setting in Tehran, Iran from January, 2011 to May, 2013. The patients were randomly divided into two groups and either received intravenous or oral systemic antibiotics as a measure to prevent endophthalmitis. The patients who developed endophthalmitis were followed for 1 year. RESULTS: In the first group, 12 patients (1.8%) developed endophthalmitis until postoperative Day 3 and 2 more patients (0.3%) developed endophthalmitis until the end of Week 1. These numbers in group receiving oral antibiotics were 8 (1.3%), 5 (0.8%), and 13 patients, respectively, showing no statistically significant difference between the 2 groups. There was also no statistically significant difference in the visual acuity of patients developing endophthalmitis in these 2 groups 1 year postoperatively. CONCLUSION: No statistically significant difference in the occurrence of postoperative endophthalmitis or the visual acuity 1 year after operation among patients with open globe injuries receiving intravenous or oral systemic antibiotics as a prophylactic measure was observed.

Efficacy of Intracameral Moxifloxacin Endophthalmitis Prophylaxis at Aravind Eye Hospital.

PURPOSE: To compare the rate of postoperative endophthalmitis before and after initiation of intracameral (IC) moxifloxacin for endophthalmitis prophylaxis in patients undergoing cataract surgery. DESIGN: Retrospective, clinical registry. PARTICIPANTS: All charity and private patients (116 714 eyes) who underwent cataract surgery between February 15, 2014, and April 15, 2015, at the Madurai Aravind Eye Hospital were included. Group 1 consisted of 37 777 eyes of charity patients who did not receive IC moxifloxacin, group 2 consisted of 38 160 eyes of charity patients who received IC moxifloxacin prophylaxis, and group 3 consisted of 40 777 eyes of private patients who did not receive IC moxifloxacin. METHODS: The electronic health record data for each of the 3 groups were analyzed, and the postoperative endophthalmitis rates were statistically compared. The cost of endophthalmitis treatment (groups 1 and 2) and the cost of IC moxifloxacin prophylaxis (group 2) were calculated. MAIN OUTCOME MEASURES: Postoperative endophthalmitis rate before and after initiation of IC moxifloxacin endophthalmitis treatment cost. RESULTS: Manual, sutureless, small incision cataract surgery (M-SICS) accounted for approximately all of the 75 937 cataract surgeries in the charity population (97%), but only a minority of the 40 777 private surgeries (21% M-SICS; 79% phacoemulsification). Thirty eyes in group 1 (0.08%) and 6 eyes in group 2 (0.02%) were diagnosed with postoperative endophthalmitis (P < 0.0001). The group 3 endophthalmitis rate was 0.07% (29 eyes), which was also higher than the second group's rate (P < 0.0001). There were no adverse events attributed to IC moxifloxacin in group 2. The total cost of treating the 30 patients with endophthalmitis in group 1 was virtually identical to the total combined cost in group 2 of routine IC moxifloxacin prophylaxis and treatment of the 6 endophthalmitis cases. CONCLUSIONS: Routine IC moxifloxacin prophylaxis achieved a highly significant, 4-fold reduction in postoperative endophthalmitis in patients undergoing M-SICS. Compared with previous studies, having such a high volume of patients undergoing surgery during a relatively short 14-month time period strengthens the conclusion. This study provides further evidence that moxifloxacin is an effective IC prophylactic antibiotic and suggests that IC antibiotics should be considered for M-SICS and phacoemulsification.

PLGA Implants containing vancomycin and dexamethasone: development, characterization and bactericidal effects.

Post-operative endophthalmitis is an infection and an inflammation of the eye following a surgical procedure. Its treatment is based on drug injections into the eye. However, this treatment can lead to ocular complications. Intraocular implants could substitute the conventional therapy. Poly(lactic-co-glycolic acid) (PLGA) implants comprising on vancomycin and dexamethasone were evaluated as drug delivery system to treat endophthalmitis after cataract surgery. Implants were characterized by drug content uniformity, Fourier Transform Infrared Spectroscopy (FTIR), Differential Scanning Calorimetry (DSC), Wide Angle X-ray Scattering (WAXS), Scanning Electron Microscopy (SEM) and in vitro drug release. The bactericidal effect of vancomycin, eluted from the implants, was demonstrated against Staphylococcus aureus and Staphylococcus epidermidis. The drugs were uniformly distributed in the polymer. The analytical techniques revealed the chemical integrity of the drugs incorporated into the polymer and the modification of dexamethasone semi-crystalline nature. Drugs were controlled released from implants; and the eluted vancomycin showed bactericidal effects. In conclusion, PLGA implants containing vancomycin and dexamethasone may represent a therapeutic alternative to treat post-operative endophthalmitis.

Budget impact assessment of Aprokam® compared with unlicensed cefuroxime for prophylaxis of post-cataract surgery endophthalmitis.

BACKGROUND: Intracameral cefuroxime is recommended as prophylaxis against postoperative endophthalmitis (POE) following cataract surgery. Aprokam is the only licensed product for prophylaxis of POE, although unlicensed intracameral cefuroxime may be administered using pre-filled syringes (PFS), either prepared in hospital by reconstituting cefuroxime via serial dilution (prepared PFS), or commercially purchased (purchased PFS). This study aimed to estimate the potential budget impact of using Aprokam over unlicensed cefuroxime for intracameral administration. METHODS: A budget impact model (BIM) was developed from UK NHS hospital perspective to estimate the economic impact of adopting Aprokam compared with purchased PFS or prepared PFS for the prophylaxis of POE following cataract surgery over a 5-year time horizon. The BIM incorporated direct costs only, associated with the acquisition, delivery, storage, preparation, and administration of cefuroxime. Resource utilisation costs were also incorporated; resource utilisation was sourced from a panel survey of hospital pharmacists, surgeons, and theatre nurses who are involved in the delivery, storage, preparation, quality assurance, or administration of cefuroxime formulations. Unit costs were sourced from NHS sources; drug acquisition costs were sourced from BNF. The model base case used a hypothetical cohort comprising of 1000 surgeries in the first year and followed a 5.2 % annual increase each year. RESULTS: The model predicts Aprokam is cost saving compared with purchased PFS, with a modest increase compared prepared PFS over 5 years. There are total savings of £ 3490 with Aprokam compared with purchased PFS, driven by savings in staff costs that offset greater drug acquisition costs. Compared with prepared PFS, there are greater drug acquisition costs which drive an increased total cost over 5 years of £ 13,177 with Aprokam, although there are substantial savings in staff costs as well as consumables and equipment costs. CONCLUSIONS: The lower direct costs of using Aprokam compared with purchased PFS presents a strong argument for the adoption of Aprokam where purchased PFS is administered. The additional benefits of Aprokam include increased liability coverage and possible reduction in dilution errors and contaminations; as such, in hospitals where unlicensed prepared PFS is used, modest additional resources should be allocated to adoption of Aprokam.

Intracameral antibiotics: Safety, efficacy, and preparation.

UNLABELLED: Endophthalmitis is a rare but potentially devastating complication of cataract surgery. This article presents an overview of endophthalmitis prophylaxis and the use of intracameral antibiotics. It highlights available intracameral antibiotics with respect to pharmacology, spectrum of activity, dosage and preparation, safety, and efficacy profiles, as well as toxic anterior segment syndrome risks to better define the potential use of these medications in the prevention of endophthalmitis. FINANCIAL DISCLOSURE: Proprietary or commercial disclosures are listed after the references.

Conjunctival flora antibiotic resistance patterns after serial intravitreal injections without postinjection topical antibiotics.

PURPOSE: To report conjunctival bacterial flora antibiotic resistance patterns after serial intravitreal injections performed using a povidone-iodine preparation without the use of preinjection or postinjection topical antibiotics. DESIGN: Prospective, interventional case series. SETTING: Single-center clinical practice in Pennsylvania. STUDY POPULATION: Thirteen eyes of 13 treatment-naïve patients undergoing serial intravitreal anti-vascular endothelial growth factor (VEGF) injections for exudative age-related macular degeneration or macular edema attributable to retinal vein occlusion. INTERVENTION: Conjunctival cultures from the treatment eye were performed prior to each injection preparation. A minimum of 3 monthly conjunctival cultures were obtained per eye over the course of the study. Ocular surface preparation consisted of topical anesthetic and povidone-iodine 5% without the use of preinjection or postinjection topical antibiotics. MAIN OUTCOME MEASURES: Conjunctival flora growth patterns and antibiotic resistance patterns to several common antibiotics tested over the course of the study. RESULTS: A total of 48 cultures were performed with a 77% culture positivity rate. Over the course of the serial conjunctival cultures in each patient, there was no evidence for emergence of resistant bacteria to any of the tested antibiotics (including fluoroquinolones and azithromycin) or significant alteration from baseline conjunctival flora. Of the 47 bacterial isolates, the most commonly isolated organism was coagulase-negative Staphylococcus both at baseline (73%) and following serial intravitreal injections (78%, P = .73). CONCLUSIONS: Ocular surface preparation for intravitreal injection using povidone-iodine 5% alone in the absence of postinjection topical antibiotics does not appear to promote bacterial resistance or a discernible change in conjunctival flora.

Prospective clinical evaluation of 1.5% levofloxacin ophthalmic solution in ophthalmic perioperative disinfection.

PURPOSE: Gram-positive cocci and Propionibacterium acnes are widely reported agents of infectious postoperative endophthalmitis. This multicenter study was conducted to evaluate the eradication effectiveness and safety profile of levofloxacin 1.5% ophthalmic solution (LVFX 1.5%) for use in perioperative disinfection. METHODS: Patients who were scheduled for cataract surgery were enrolled. The perioperative regimen of LVFX 1.5% was administered 3 times daily as follows: preoperative 3 days; the day of surgery (in the morning, 1 h before surgery, and immediately after surgery); and postoperative 2 weeks. Conjunctival sac scrapings were collected 3 times in the observation period; before preoperative administration, before iodine eyewash on the day of surgery, and after completion of postoperative administration. Isolated and identified microbial strains were assessed for antibacterial susceptibility. RESULTS: One hundred patients were enrolled and data obtained from 96 patients (mean age, 72.7 ± 8.9 years). The preoperative eradication rate was 86.7% in total microbes. In the case of gram-positive cocci, the preoperative eradication rate was 100%, even though there were LVFX-registrant methicillin-resistant Staphylococcus aureus and methicillin-resistant coagulase-negative Staphylococcus, which had a high minimum inhibitory concentration against LVFX, such as 32 µg/mL. On the other hand, that of P. acnes was 78.3%. No acquired drug resistance was suspected in all strains. Adverse drug reactions occurred in 4.2% patients, and all were slight. CONCLUSIONS: For ophthalmic perioperative disinfection, the LVFX 1.5% ophthalmic solution showed a good safety profile, and critical eradication of gram-positive cocci, including the fluoroquinolone-resistant strains.

Efficacy and safety of prophylactic intracameral moxifloxacin injection in Japan.

PURPOSE: To report endophthalmitis rates after cataract surgery and the incidence of complications after intracameral moxifloxacin injection. SETTING: Nineteen clinics in Japanese institutions. DESIGN: Retrospective survey cohort study. METHODS: The number of surgeries and endophthalmitis cases in the past 4 years before and after the introduction of intracameral moxifloxacin was evaluated. The survey was performed by mail or interview in February 2013. RESULTS: All institutions used total-replacement administration rather than small-volume injection. At 3 institutions, 50 to 100 µg/mL moxifloxacin; at 9 institutions, 100 to 300 µg/mL moxifloxacin; and at 7 institutions, 500 µg/mL moxifloxacin was administered. The highest concentration (500 µg/mL) was administered in 14,124 cases. Endophthalmitis cases occurred 1 month or sooner postoperatively in 8 of 15,958 cases (ie, 1 in 1955) without intracameral moxifloxacin administration and in 3 of 18,794 cases (ie, 1 in 6265) with intracameral moxifloxacin administration. CONCLUSIONS: Intracameral moxifloxacin (50 to 500 µg/mL) administration decreased the risk for endophthalmitis by 3-fold. In more than 18,000 cases, moxifloxacin administration of 500 µg/mL or less did not result in severe complications, such as toxic anterior segment syndrome or corneal endothelial cell loss.

Antibiotic resistance of ocular surface flora with repeated use of a topical antibiotic after intravitreal injection.

IMPORTANCE: Treatment with intravitreal (IVT) injections has increased during the last several years as evidence has accumulated demonstrating the efficacy of anti-vascular endothelial growth factor agents in the treatment of neovascular age-related macular degeneration (AMD) and various retinal vascular diseases. Although IVT injections are generally safe, infectious endophthalmitis is a rare but devastating complication, and the risk of morbidity and vision loss from endophthalmitis is high. OBJECTIVE: To examine the change in antibiotic resistance of ocular surface flora with repeated prophylactic use of antibiotics after IVT injection for AMD. DESIGN AND SETTING: Prospective, nonrandomized cohort study in 2 tertiary academic hospitals. PARTICIPANTS: Patients 65 years and older with newly diagnosed AMD were recruited by 7 retinal specialists from July 1, 2010, through December 31, 2011. INTERVENTION: The study group received topical moxifloxacin hydrochloride for 3 days after each monthly IVT injection. MAIN OUTCOME MEASURE: Resistance to moxifloxacin and ceftazidime in cultured isolates at baseline and monthly for 3 months by change in minimal inhibitory concentration (MIC) of culture isolates was studied. RESULTS: The study group consisted of 84 patients, and the control group had 94 patients. In the study group, the baseline adjusted MIC increased (from 1.04 to 1.25 µg/mL; P = .01) as did the MIC for 50% of isolates (MIC50) (from 0.64 to 1.00 µg/mL) and the MIC for 90% of isolates (MIC90) (from 0.94 to 4.00 µg/mL). In both groups, the culture-positive rate did not change significantly when adjusted for baseline. No significant change was found in the MIC level, culture-positive rate, MIC50 level, and MIC90 level in the control group. Subgroup analysis found diabetes mellitus to be noncontributory to both the MIC and culture-positive rate. No endophthalmitis or adverse events were reported. CONCLUSIONS AND RELEVANCE: Repeated use of topical moxifloxacin after IVT injection significantly increases antibiotic resistance of ocular surface flora. We recommend that routine use of prophylactic antibiotics after IVT injection be discouraged. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01181713.