Intracameral antibiotics debate

Modern surgery raises new questions regarding the use of intracameral antibiotics.

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In this age of modern cataract surgery with improved surgery and sterile techniques, is the use of intracameral antibiotics still necessary to reduce the incidence of endophthalmitis? That was the question addressed in a debate held at the 37th Congress of the ESCRS in Paris, France. Arguing in favour of intracameral antibiotics was one of the early proponents of the practice, Prof Anders Behndig MD, PhD, Umeå University Hospital, Umeå, Sweden. “I have been a cataract surgeon since 1993. I’ve used intracameral antibiotics in every single case since 1999 and I wouldn't dare to do anything else,” Prof Behndig said. He pointed out that in the 15 years since the publication of the ESCRS endophthalmitis prophylaxis study, decreased rates of postoperative endophthalmitis (POE) have accompanied the adoption of intracameral antibiotics by ophthalmic surgery practices around the world. He noted that Swedish cataract surgeons had already adopted intracameral cefuroxime because the Swedish National Cataract Register (NCR) – which has registered endophthalmitis after cataract surgery (POE) since 1998 – showed that intraocular antibiotics such as cefuroxime, moxifloxacin and ampicillin can significantly reduce the POE rate. The reports from the Swedish NCR were the inspiration behind the ESCRS endophthalmitis study, he noted. The prospective randomised controlled trial involved 16,603 cataract patients who underwent cataract surgery at 24 centres throughout Europe from September 2003 to January 2006. It showed that the POE rate among patients randomised to receive intracameral cefuroxime was only 0.03% in those who also received levofloxacin drops, and only 0.05% in those who received placebo drops. That compared to POE rates of 0.17% and 0.25% in the same respective groups who did not receive the intracameral antibiotic. Since that time, the near universal adoption of intracameral antibiotics in France has coincided with a reduction in the incidence of POE from 0.145% in 2005 to 0.044% in 2014 (Creuzot-Garcher C, et al. Ophthalmology. 2016;123:1414-20). In a very recent study from India, a review of 2,062,643 cataract surgeries showed that the rate of POE was only 0.02% in patients that received intracameral moxifloxacin compared to 0.07% in those who did not receive it (A Haripriya et al, J Cataract Refract Surg. 2019 Jul 29. [Epub ahead of print]). “Intracameral antibiotics have been used in many millions of cataract procedures and they reduce endophthalmitis rates by three- to seven-fold in different studies and side-effects are extremely rare,” Dr Behndig added. The fear factor Prof Antoine Brézin MD, Université Paris Descartes, Paris, France, maintained that intraocular antibiotics should not be mandatory in cataract surgeries, as in France where there is now an official recommendation in favour of the prophylaxis approach. “Doubtless the incidence of endophthalmitis after cataract surgery has gone down dramatically over the past 15 years, but is it really due to the use of intracameral antibiotics? I think we have been brainwashed to believe it is cefuroxime, but I think there are a number of other factors to consider,” he said. He argued that although the ESCRS study showed that intracameral cefuroxime reduced the rates of POE, it also confirmed that surgical complications were a major risk factor for POE. Other studies have shown rates of POE after cataract surgery without intracameral antibiotics as low as those achieved with them in the ESCRS study. He cited a Japanese study that showed that among 63,244 cataract patients the rate of POE was only 0.025%, even though only 11.8% received intracameral antibiotics (T Inoue et al Jpn J Ophthalmol 2018; 62:24-30). Other surgical factors may therefore may play a more important role in preventing the complication. He noted, for example, in the ESCRS study the risk of the POE was more greatly elevated by the use of clear corneal incisions instead of scleral tunnel incisions than it was by the absence of intracameral antibiotics (5.8-fold vs 4.9-fold), Dr Brézin said. Prof Brézin added that the studies cited in support of the ESCRS study are almost all based on before-and-after comparisons, which overlook the many advances in cataract surgery that may have also contributed to the reduction of the complication. Such advances include smaller incisions that are less prone to leakage, shorter surgical times and fewer complications like posterior capsule rupture. Other factors include improved surgical theatre air filtration and pre-loaded IOL cartridges. He noted that a study prospectively comparing the outcome of cataract surgery with and without intracameral antibiotics in 15,000 cataract patients showed that the prophylaxis did not significantly reduce the incidence of POE (0.108% vs 0.15%, p=0.57) (Sharma et al, J Cataract Refract Surg 2015;41:393-399). “In 2019, do I inject because of the science? No, I inject because of the official recommendation. I inject because of the fear factor, because, like everyone else, I’m afraid of lawyers. But if we could turn the page back, I think I would no longer do so,” Prof Brézin concluded. Anders Behndig: anders.behndig@umu.se Antoine Brézin: antoine.brezin@aphp.fr
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