Clinical Experience of Using a Combination of Dexamethasone and Levofloxacin After Cataract Surgery.

Background: Where routine prophylactic antibiotics have been adopted following cataract surgery, rates of endophthalmitis have been decreasing. Intracameral and topical antibiotics are currently used to prevent endophthalmitis after cataract surgery. When applying topical antibiotics, there are different recommendations on the frequency and duration of therapy. The development of bacterial resistance to the excessive and long-term use of antibiotics is a growing problem worldwide. The goal is to achieve a good antibiotic effect with the shortest possible use of antibiotics. Objective: The aim of this study was to compare the effectiveness of a new combination therapy of dexamethasone and levofloxacin for seven days after cataract surgery with the previous regimen of dexamethasone, neomycin sulfate, and polymyxin B, which was given for 21 days. Methods: A retrospective analysis of medical records and administered a questionnaire was conducted to assess the effectiveness of postoperative therapy in our cataract surgery patients. The study involved 52 patients who underwent surgery within the last year, performed by a single surgeon at our institution. The findings can help us improve the quality of care we provide and optimize our patients' overall quality of life. Results: We conducted an in-depth study on 52 individuals who underwent cataract surgery at our institution. The prescribed therapeutic regimen for the participants included administering Ducressa solution four times daily for the first seven days and Maxidex solution three times daily for the subsequent 14 days. The study found that none of the participants experienced complications after surgery, and all found it easy to instill the medication. The prescribed regimen effectively managed the postoperative recovery of the participants, and the medication was well-tolerated. Conclusion: Our research found that a new combination of levofloxacin and dexamethasone, when used topically, may require a shorter treatment period, reducing the risk of antibiotic resistance and providing a safe alternative for endophthalmitis prevention.

Intracameral antibiotics during cataract surgery: efficacy, safety, and cost-benefit considerations.

PURPOSE OF REVIEW: We summarize evidence-based considerations regarding the use of intracameral antibiotics during cataract surgery. RECENT FINDINGS: The use of intraoperative intracameral antibiotics reduced the incidence of postcataract surgery endophthalmitis 3.5-fold, with an odds ratio ranging from 0.14 to 0.19. A survey of the American Society of Cataract and Refractive Surgery showed usage of intracameral injections of antibiotics increased by 16% in the United States between 2014 and 2021. The frequency of vancomycin usage has sharply dropped to 6%, while moxifloxacin is now the dominant choice at 83% among respondents. One analysis showed that 2500 patients need to be treated with intracameral antibiotics to prevent one case of endophthalmitis. A 500 µg intracameral moxifloxacin at $22 dollars per dose is cost-effective, including for patients with posterior capsular rupture (PCR). SUMMARY: Studies substantiate the safety and efficacy of intracameral antibiotics for endophthalmitis prophylaxis. Intracameral moxifloxacin and cefuroxime are the most common choices. While vancomycin shows potential for efficacy, further studies evaluating clinical outcomes are needed. Adverse events are rare and commonly due to errors in preparation. Topical antibiotics do not provide additional prophylactic benefits to intracameral regimens. Intracameral antibiotics given alone are cost-effective.

Comparison of Endophthalmitis Rates after Alcohol-Based Chlorhexidine and Povidone-Iodine Antisepsis for Intravitreal Injections.

OBJECTIVE: Intravitreal injections (IVIs) are the most frequently performed intraocular procedure in Canada. Povidone-iodine (PI) is the current gold standard for antisepsis for IVI and is widely used; chlorhexidine (CH) is a possible alternative antiseptic agent. This study aims to compare rates of endophthalmitis after IVI with 0.05% chlorhexidine with a 4% alcohol base antisepsis to rates of endophthalmitis after IVI with 10% PI antisepsis. DESIGN: Retrospective cohort study. SUBJECTS: Eyes that received IVI between May 2019 and October 2022 at a group retina practice in Edmonton, Canada. METHODS: Eyes at a single center received focal conjunctival application of either 10% PI antisepsis or 0.05% CH in 4% alcohol antisepsis for 30 seconds before each IVI. MAIN OUTCOME MEASURE: Rates of endophthalmitis between the PI and CH groups. RESULTS: A total of 170 952 IVIs were performed during the study period. A total of 31 135 were performed using CH prophylaxis compared with 139 817 with PI prophylaxis. Among all IVIs there were 49 total cases of endophthalmitis, 29 in the PI group (0.021%) and 20 in the CH group (0.064%). There was a statistically significant difference in the rates of endophthalmitis between the 2 groups (P < 0.001). The odds ratio for developing endophthalmitis with CH antisepsis was 3.1 (95% confidence interval, 1.9-5.2) compared with PI antisepsis. There were increased odds of developing endophthalmitis with aflibercept injection compared with bevacizumab (odds ratio, 3.48; 95% confidence interval, 2.09-7.24). CONCLUSIONS: There is a statistically significant difference in rates of endophthalmitis between alcohol-based CH and PI antisepsis for IVI in our patient population utilizing the methods discussed. In our center, alcohol-based CH is now considered a second-line antiseptic agent. Further studies are warranted to further assess the endophthalmitis rate utilizing these 2 antiseptic agents. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The impact of antibiotic prophylaxis with intracameral cefuroxime on postoperative infectious endophthalmitis rates in a high-volume cataract surgery center.

Our purpose was to compare postoperative infectious endophthalmitis rates before and after the introduction of antibiotic prophylaxis via intracameral with cefuroxime (ATB-P IC) in a high-volume cataract surgery service. Retrospective cohort study considering patients who underwent cataract surgery at Ophthal Hospital Especializado, São Paulo, Brazil, from January/2011 to December/2019. Patients operated from 2013 to 2019 comprised the ATB-P IC group while those operated from 2011 to 2013 formed the control group without the ATB-P IC protocol. A total of 23,184 cataract surgeries were included, with 6,207 in the Control Group and 16,977 in the ATB-P Group. A significantly higher rate of endophthalmitis was observed in the control group (0.0967%) when compared to the ATB-P group (0.0177%) (p = 0.014). Surgeries performed with ATB-P showed 80% less chance of reported endophthalmitis (OR = 0.20; 95% CI 0.05-0.72; p = 0.014) than those without ATB-P. Of the six cases confirmed by culture in the control group, all tested positive for Pseudomonas aeroginosa and the only case confirmed by culture in the ATB-P group was positive for Staphylococcus epidermidis. Our findings strongly support the use of intracameral antibiotic prophylaxis with cefuroxime to reduce postoperative infectious endophthalmitis rates, and we recommend its incorporation into cataract surgery protocols.

Lowering the Incidence of Endophthalmitis Following Intravitreal Anti-VEGF Injection: An Analysis of Aseptic Protocol Adjustment.

BACKGROUND AND OBJECTIVE: The impact of anti-sepsis-anesthesia sequence in intravitreal injection (IVI)-associated endophthalmitis is unknown. We compared outcomes of patients who had 10% topical povidone-iodine before or after 2% topical lidocaine gel during IVIs. PATIENTS AND METHODS: A retrospective study of IVIs in nine clinical sites was undertaken. Group 1 had lidocaine gel applied first. This protocol was changed on March 1, 2020, with Group 2 having povidone-iodine applied first. Visual and micro-biological outcomes were compared. RESULTS: Among 72 cases (0.07%) from 102,908 IVIs, Group 1 had 59 cases from 65,307 IVI (0.09%) and Group 2 had 13 cases from 37,601 IVI (0.03%; P = 0.001). There was no significant difference in the best-corrected visual acuity between groups. Highly virulent bacteria were predominantly isolated in Group 1, but proportions of gram-positive bacterial growth were similar. CONCLUSIONS: Application of povidone-iodine before lidocaine gel, compared to after, significantly decreased rate of IVI endophthalmitis, with no significant changes in visual and microbiological outcomes. [Ophthalmic Surg Lasers Imaging Retina 2023;54:520-525.].

Modified-dropless protocol (nil intraocular) for micro-incision vitrectomy surgery (MIVS): a retrospective pilot study.

BACKGROUND: Perioperative infection and inflammation prophylaxis after ocular surgery has evolved over the years along with improvements in surgical equipment and a growing interest in alternatives to the standard topical eye drops. The purpose of this study is to evaluate the outcomes of a novel, modified-dropless protocol for 23-gauge (23-G), 25-gauge (25-G) and 27-gauge (27-G) micro-incision vitrectomy surgery (MIVS) that omits any intraocular injections of antibiotics or steroids. METHODS: This Institutional Review Board-approved, single-surgeon retrospective study reviewed MIVS post-surgical outcomes in patients who received a modified-dropless protocol from February 2020 to March 2021. A total of 158 charts were reviewed, of which 150 eyes met the eligibility criteria. After each case, patients were administered a 0.5 cc subconjunctival injection of a 1:1 Cefazolin (50 mg/cc):Dexamethasone (10 mg/cc) in the inferior fornix and 0.5 cc of posterior Sub-Tenon's Kenalog (STK). No intravitreal injections were administered, and no pre- or postoperative antibiotic or steroid eye drops were prescribed. For patients allergic to penicillin, separate subconjunctival injections of 0.25 cc each of Vancomycin (10 mg/cc) and Dexamethasone (10 mg/cc) were administered. The primary safety parameter was postoperative cases of endophthalmitis. Secondary endpoints consisted of Best-Corrected Distance Visual Acuity (BCVA), intraocular pressure (IOP), and postoperative complications (retinal detachments, inflammation, need for additional surgery) within three months of surgery. Statistical analysis was performed using chi-square (χ²) tests for categorical values, and a Student's t-test to compare continuous outcomes. RESULTS: The majority of surgeries (96%) were performed with the 27G MIVS platform. There were no cases of postoperative endophthalmitis. Mean logMAR BCVA improved from 0.71 (± 0.67) to 0.61 (± 0.60) post-operatively (p = 0.02). Excluding patients who had silicone oil tamponade, postoperative BCVA improved from 0.67 (± 0.66) to 0.54 (± 0.55) (p = 0.003). Mean IOP increased from 14.6 (± 3.8) to 15.3 (± 4.1) (p = 0.05). Ten patients required further medication therapy for an increase in IOP, one had inflammatory signs, and 14 required a second surgical intervention mostly due to recurrences of initial surgical indication. CONCLUSION: A modified-dropless postoperative protocol involving subconjunctival and posterior sub-Tenon's injections only may be a safe and convenient alternative to topical eye drops for patients undergoing MIVS, but additional and larger studies are needed.

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.

Incidence of post vitrectomy endophthalmitis in India - A multicentric study by VRSI study Group.

INTRODUCTION: The incidence of post vitrectomy endophthalmitis (PVE) is reported to be between 0.02 and 0.84%. Resterilization of single use instruments is a common practice amidst developing countries to make it more affordable to the patients by reducing the cost of the surgery and also reduce the environmental hazard. The aim of our study is to evaluate the incidence of PVE amidst existing sterilization practices of reused instruments in multiple vitreoretinal centres in India. METHODOLOGY: Centres with an endophthalmitis tracking system were invited to participate in a survey. Twenty-five centres were sent a questionnaire via email. The questionnaire included details about the institution, number of vitrectomies performed in a year, sterilization practices followed pre-operatively, intraoperatively and postoperatively, incidence of endophthalmitis and instrument reuse policies. RESULTS: A total of 29 cases of endophthalmitis were reported out of the 47,612 vitrectomies performed across various centres. The mean incidence of endophthalmitis was 0.06%. There was no difference in the rates of endophthalmitis based on various pre-operative, intraoperative or postoperative prophylactic measures. Nearly 80% of the centres change most of the instruments after every case, while the rest reused. The mean number of times a cutter was being reused until discarded was 4.7. Nearly 76% followed a performance-based protocol, and the remaining 24% had a fixed protocol for the number of times an instrument can be reused before discarding it. CONCLUSION: PVE rates are not significantly different in India despite the multiuse of single use instruments. The purpose of this paper is not to suggest an alternate protocol but to creating one in the future with these results in mind, to rationalise the use of single use instruments, make VR surgery more affordable and also have a positive impact on the carbon footprint of consumables in surgery.

[Chinese expert consensus on the prophylaxis and management of traumatic infectious endophthalmitis (2023)].

Traumatic infectious endophthalmitis refers to the inflammation of one or multiple layers of the eyeball wall and intraocular contents caused by pathogen invasion after open globe injury. Its incidence rate is about 4% to 16%. There are various factors related to the occurrence, development and prognosis of traumatic infectious endophthalmitis, including the types of ocular trauma, the properties of pathogens, the presence of intraocular foreign body and the treatment timing. Reasonable preventive measures, accurate diagnosis and timely and effective treatment are critical for the recovery of visual function and even the preservation of the eyeball in high-risk patients. In order to further clarify and standardize the prophylaxis and management of traumatic infectious endophthalmitis, the experts of the China Ocular Trauma Society have reached consensus opinions after discussions, thus providing reference for ophthalmologists in clinical practice.

Efficacy and safety of intravitreal injection of triamcinolone-moxifloxacin after cataract surgery in a low to middle income country - a one-year audit.

OBJECTIVE: To evaluate the safety and efficacy of intravitreal injection of triamcinolone and moxifloxacin regime administered immediately following cataract surgery. METHODS: The retrospective study was conducted from January to June 2021 at a tertiary care referral centre in Karachi and comprised record of all patients who underwent dropless cataract surgery from April 2018 to June 2019. Data included slit lamp examination, dilated fundal exam, uncorrected visual acuity, best corrected visual acuity, and intraocular pressure. Cataract assessment and anterior chamber reaction were graded according to the World Health Organisation cataract grouping system. Efficacy of the regime was defined as the ability to prevent postoperative endophthalmitis. Stratification analysis was done to note if gender has any role in terms of effectiveness. Data was analysed using Microsoft Excel version 16.0 and IBM SPSS version 27. RESULTS: Of 240 eyes of 161 patients analysed, 114(47.5%) were of men who had a mean age of 57.89±14.32 years, and 126(52.5%) were of females with a mean age of 58.02±10.85 years. Overall, 2(1.75%) male subjects and 1(0.8%) female subject developed breakthrough inflammation within one week of the procedure. They were treated with anti-inflammatory drops and in 1(33%) of the cases antibiotic drop for 1 week. At day 90, no patient had residual inflammation or new onset inflammation. Also, 15(6.25%) patients developed raised intraocular pressure from day 7 to day 30. Most cases 10(66.7%) resolved within 1 week of using intraocular pressure-lowering drops. No patient developed endophthalmitis postoperatively. CONCLUSIONS: Dropless cataract regime was found to be an effective and safe alternative that was easy to administer.

Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery.

PURPOSE: To determine whether four new operating room (OR) protocols instituted because of COVID-19 reduced the cataract surgical postoperative endophthalmitis rate (POE). DESIGN: Retrospective, sequential, clinical registry study. METHODS: 85 552 sequential patients undergoing cataract surgery at the Aravind Eye Hospitals between 1 January 2020 and 25 March 2020 (56 551 in group 1) and 3 May 2020 and 31 August 2020 (29 011 in group 2). In group 1, patients were not gowned, surgical gloves were disinfected but not changed between cases, OR floors were not cleaned between every case, and multiple patients underwent preparation and surgery in the same OR. In group 2, each patient was gowned, surgical gloves were changed between each case, OR floors and counters were cleaned between patients, and only one patient at a time underwent preparation and surgery in the OR. RESULTS: Group 1 was older, had slightly more females, and better preoperative vision. More eyes in group 2 underwent phacoemulsification (p=0.18). Three eyes (0.005%) in group 1 and 2 eyes (0.006%) in group 2 developed POE (p=0.77). Only one eye that underwent phacoemulsification developed POE; this was in group 1. There was no difference in posterior capsule rupture rate between the two groups. CONCLUSIONS: Adopting a set of four temporary OR protocols that are often mandatory in the Western world did not reduce the POE rate. Along with previously published studies, these results challenge the necessity of these common practices which may be needlessly costly and wasteful, arguing for the reevaluation of empiric and potentially unnecessary guidelines that govern ophthalmic surgeries.

Legal obligation in the general population: face mask influence on endophthalmitis after intravitreal injection.

PURPOSE: To investigate whether compulsory face masking in public life changes the incidence or pattern of post-injection endophthalmitis (PIE). PATIENTS AND METHODS: All injections of bevacizumab, ranibizumab, aflibercept, dexamethasone or triamcinolone between 01/01/2015 and 12/31/2021 at the University Eye Clinic of Tuebingen were included in this retrospective analysis. The injection procedure itself was unchanged since 2015 and included the use of a sterile drape covering the head up to the shoulders which prevents airflow toward the eye. Furthermore, all staff wore a face mask and gloves at all times. The two study periods were defined by the introduction of a compulsory face masking rule in public life (01/01/2015 until 04/27/2020 vs. 04/28/2020 until 12/31/2021). RESULTS: A total of 83,543 injections were performed in the tertiary eye clinic, associated with a total of 20 PIE (0.024%, 1/4177 injections). Of these, thirteen PIE were documented during the pre-pandemic period (0.021%, 1/4773 injections) and seven PIE during the pandemic period (0.033%, 1/3071 injections). No significant difference in PIE risk was observed (p = 0.49), and there was no case of oral flora associated PIE. CONCLUSION: Although some potential confounders (wearing time, skin flora) could not be considered, there was no clear signal that the introduction of compulsory face masking in public life did alter the risk for PIE in our patient population. Three and six months after PIE, no difference in visual acuity was detectable between the two study periods.

Surface modification of commercial intraocular lens by zwitterionic and antibiotic-loaded coating for preventing postoperative endophthalmitis.

After cataract surgery, to prevent possible postoperative endophthalmitis (POE) caused by attached pathogenic bacteria onto the surface of implanted intraocular lens (IOL), various antibiotic-loaded IOLs have been proposed and widely studied to inhibit bacterial infection. However, most of these developed antibiotic-loaded IOLs still suffer from shortcomings such as insufficient drug loading, short release time, poor biocompatibility, and risk of secondary infection. Herein, we propose a zwitterionic and high-drug loading coating for surface modification of commercial hydrophobic IOL with both antifouling and antibacterial properties to effectively prevent POE. In this strategy, zwitterionic poly(carboxylbetaine-co-dopamine methacrylamide) copolymers (pCBDA) and dopamine (DA) were first robustly co-deposited onto IOL surface via facile mussel-inspired chemistry, resulting in a hydrophilic coating (defined as PCB) without sacrificing the high light transmittance of the native IOL. Subsequently, amikacin (AMK), an amine-rich antibiotic was reversibly conjugated onto the coating through the acid-sensitive Schiff base bonds formed by the reaction between amino and catechol groups, with high-drug payload over ∼35.5 µg per IOL and 30 days of sustained drug release under weak acid environment. Benefiting from the antifouling property of zwitterionic pCBDA copolymers, the intraocularly implanted PCB/AMK-coated IOL could effectively resist the adhesion and proliferation of residual LECs to inhibit the development of posterior capsule opacification (PCO) without affecting the normal ocular tissues, demonstrating excellent in vivo biocompatibility. Moreover, the synergy of zwitterionic pCBDA and conjugated AMK with acidic-dependent release behavior endowed this PCB/AMK-coated IOL strong antibacterial activity against both in vitro biofilm formation and in vivo postoperative Staphylococcus aureus infection, suggesting its promising application in preventing POE.

Effect of cefuroxime intracameral injection antibiotic prophylactic on postoperative endophthalmitis wound post-cataract: A meta-analysis.

To assess the impact of cefuroxime injection of intracameral prophylaxis antibiotic on after endophthalmitis operative wound following surgery of cataract, we conducted a meta-analysis. A thorough review of the literature up to July 2022 revealed that there were 1 167 197 participants with surgery of cataract at the start of the research; 1 004 425 of these subjects received an injection of intracameral of cefuroxime, while 162 772 did not get an antibiotic as a control. Using dichotomous approaches and a random or fixed-effect model, odds ratios (OR) with 95% confidence intervals (CIs) were estimated to evaluate the impact of cefuroxime injection of intracameral prophylaxis antibiotic on after endophthalmitis operative wound following surgery of cataract. When comparing no antibiotic in participants who had surgery of cataract, the cefuroxime injection of intracameral significantly reduced the after endophthalmitis operative wound (OR, 0.14; 95% CI, 0.07-0.29, P = 0.001) with high heterogeneity (I2 = 95%). When comparing participants who received no antibiotic after surgery of cataract, the after endophthalmitis operative wound from the cefuroxime injection of intracameral was considerably lower. Although none of the 22 studies encompassed in the meta-analysis had a study with a small sample size, it is nevertheless advisable to proceed with caution when analysing the results.

Evaluation of the effect of gentamicin in surgical perfusion solution on cataract postoperative endophthalmitis.

OBJECTIVE: To evaluate the effect of gentamicin in surgical perfusion solution on endophthalmitis incidence after cataract surgery. METHODS: A retrospective analysis of endophthalmitis incidence was conducted in two groups of patients who underwent cataract surgery, with (Group B) or without gentamicin (Group A) in the surgical perfusion solution. Endophthalmitis incidence, the isolated pathogenic bacteria strains and their antibiotic sensitivity, and the drug-resistant genotype of the pathogens were examined. RESULTS: The incidence of endophthalmitis in patients of group A was 0.8‰. Thirteen pathogenic bacterial strains were isolated from the patient samples in group A, including 8 strains of Staphylococcus epidermidis, 1 Staphylococcus aureus, 1 Streptococcus pneumoniae, 1 Streptococcus bovis, 1 Enterococcus faecium and 1 Morganella sp. The incidence of endophthalmitis in group B patients was 0.2‰, which was significantly lower than that in group A (P<0.05). Five strains of pathogenic bacteria were successfully isolated, including 2 strains of Enterococcus faecium, 1 Enterococcus faecalis, 1 Staphylococcus epidermidis and 1 Staphylococcus aureus. There was no significant difference in the proportion of Staphylococcus strains in all isolated bacteria between the two groups (P > 0.05). However, the proportion of Enterococci isolated in group B samples was higher than that in group A (P < 0.05). There were more gentamicin-sensitive strains than levofloxacin-sensitive strains identified (P < 0.05). Interestingly, aminoglycoside-inactivating enzyme resistance gene was detected in Enterococcus strains. CONCLUSION: Our data suggest that gentamicin-containing perfusion solution can reduce the incidence of postoperative endophthalmitis in cataract patients. However, the selective pressure imposed by gentamicin may facilitate the development of aminoglycoside-resistant Enterococcos strains.