Endophthalmitis

Hong Kong cataract surgeon Kendrick Shih MD was “delighted” to have no cases of endophthalmitis at his highvolume cataract surgery centre over a three year period after changing to intracameral cefuroxime to prevent postoperative endophthalmitis. A high-volume surgery centre was established as a pilot programme at the Grantham Hospital, Hong Kong, in November, 2009. Routine use of intracameral cefuroxime 1 mg/0.1 ml BSS, except in patients with known beta-lactam antibiotic allergy, was incorporated into the surgical protocol from the outset. Patients also underwent disinfection on the operating table with five per cent povidone iodine, but they received no topical or systemic antibiotics preoperatively. Postoperative treatment consisted of fixed combination dexamethasone/neomycin, one drop every four hours for four weeks.

Speaking at the 26th Asia-Pacific Association of Cataract & Refractive Surgeons Annual Meeting, Dr Shih reported that between November 1, 2009, and December 31, 2012, a total of 11,537 cataract surgeries were performed by 31 surgeons at the surgical centre. The majority of patients were aged 70 years or older, and 94 per cent of cases involved phacoemulsification through a clear corneal incision (2.2 or 2.75mm) with implantation of a single-piece hydrophobic acrylic IOL. Routine practice was to leave the incision unsutured.

No adverse events

Intracameral cefuroxime was used in 99.4 per cent of cases. Nearly all patients (98.0 per cent) completed all scheduled follow-up visits at one day, one week, and one month. In this very large, multi-surgeon series, there were no cases of postsurgical endophthalmitis, allergic reactions to cefuroxime, or other adverse events associated with its intracameral use.

“We are delighted with our results using intracameral cefuroxime, and while we recognise that the lack of a comparator group is a major limitation of our analysis, our experience compares well with historical data from other studies in Hong Kong for which the quoted incidence of postcataract surgery endophthalmitis ranges from 0.11 per cent to 0.20 per cent,” said Dr Shih, clinical assistant professor of ophthalmology, University of Hong Kong. He added, “We do not expect that the incidence of post-cataract surgery endophthalmitis will be maintained at zero forever. However, we hope this prospective audit will facilitate ongoing quality assurance and be a method for future risk factor identification for our centre.” Dr Shih said that based on accumulating evidence, he looks forward to seeing more centres adopt intracameral cefuroxime for postoperative endophthalmitis prophylaxis. However, he recognised that concerns relating to cefuroxime reconstitution remain a barrier.

At the Grantham Hospital centre, the cefuroxime used for intracameral administration is prepared in the sterile environment of the pharmacy’s total parenteral nutrition laboratory. Twice a week, on Monday and Thursday, reconstituted cefuroxime for intravenous injection is drawn up into 1.0ml syringes that are sealed in sterile packaging and stored at 4° C for up to one week. “Private surgeons in Hong Kong do not have the advantage of having access to material prepared under controlled sterile conditions, and for that reason, most private surgeons are not using intracameral cefuroxime,” Dr Shih said.