ASCRS online poll finds U.S. patterns relatively unaffected by ESCRS study

New Orleans-Results of the European Society of Cataract and Refractive Surgeons (ESCRS) study of endophthalmitis prophylaxis do not appear to have had a significant effect on the practices of U.S. cataract surgeons. The findings are according to an online survey conducted by the American Society of Cataract and Refractive Surgery (ASCRS) Cataract Clinical Committee, reported by David F. Chang, MD, at Spotlight on Cataracts 2007, a symposium held during the annual meeting of the American Academy of Ophthalmology.

"One can only speculate why the ESCRS study has not had more of an impact, but the fact that 82% of respondents indicated that they at least would consider using intracameral antibiotics if a product were commercially available is an important message to our partners in industry," said Dr. Chang, who co-chaired the session, which focused on current controversies in cataract surgery. Dr. Chang is clinical professor of ophthalmology, University of California, San Francisco.

The ASCRS survey included 14 questions that took about 2 minutes for respondents to complete. A link to the online survey was sent via e-mail to the approximately 4,000 ASCRS members globally in January 2007, and more than 1,300 surgeons participated. Respondents predominantly were U.S. surgeons (69%), but they represented a broad distribution of surgical volumes.

Of the survey respondents, 16% said that they already were using an intracameral antibiotic prior to the ESCRS study. Only 7% of responding surgeons said that they had started using an intracameral antibiotic based on the study results, whereas 77% said that they still were not administering antibiotics intracamerally.

When asked whether they would consider using an intracameral antibiotic if a product for direct injection were available commercially, 47% of respondents said that they would, and another 35% said that they might, depending on the cost.

Most common practice

The most common practice for antibiotic prophylaxis among the survey participants, Dr. Chang added, involved use of a topical fourth-generation fluoroquinolone started 1 to 3 days preoperatively and resumed immediately after surgery.

"In the ESCRS study, levofloxacin [Quixin, Vistakon] was used as the topical antibiotic, and it was not started until the morning after surgery," he said. "One-half of the control group received no preoperative antibiotic, and the other half received topical levofloxacin immediately before surgery," he explained. "Therefore, the ESCRS study did not answer the question of whether intracameral cefuroxime [Ceftin, GlaxoSmithKline] is as good as, better than, or a useful adjunct to the most commonly used topical antibiotic protocols in this country."

According to the survey, about 90% of respondents were administering a topical antibiotic to patients for endophthalmitis prophylaxis around the time of cataract surgery. Gatifloxacin (Zymar, Allergan) or moxifloxacin (Vigamox, Alcon Laboratories) were being administered by 81% of the survey participants; 52% were starting the antibiotic 3 days prior to surgery, and the rest waited until the day before or the day of surgery to initiate treatment.

Most surgeons (90%) were administering some antibiotic at the close of surgery; 83% of those surgeons were using a topical agent, whereas only 15% were administering intracameral medication. Subconjunctival antibiotic injection was being performed by 13% of survey respondents, and only 3% were using an antibiotic-soaked collagen shield. The percentages total more than 100 because some surgeons combine several methods. "Among the surgeons administering an intracameral antibiotic, vancomycin was the most popular choice (61%), and surgeons were about equally split between those delivering it by direct injection versus adding it to the irrigating solution," Dr. Chang said. "Only 6% of all respondents were injecting intracameral cefuroxime."

Among the surgeons not using an intracameral antibiotic, the most common reason cited (89%) was a need for further study. Forty-five percent, however, said they were concerned about risk, and 11% said they were concerned about cost. "The concerns about risk may be valid, considering that 14% of those respondents using intracameral antibiotics felt they had seen a complication associated with the use of a 'homemade' intracameral antibiotic formulation," Dr. Chang said.

Start times varied

Two-thirds of responding surgeons indicated that they started postoperative topical antibiotic treatment on the day of surgery, whereas the rest said they instructed their patients to wait until the next morning to begin instilling the drops. Three-fourths of surgeons tapered off the treatment within the first postoperative week.

Ninety percent of survey participants reported that the rate of endophthalmitis in their practices was one case per 1,000 cataract surgeries or less.

"Interestingly, only 3% of the survey participants reported that their rate of endophthalmitis was as high as that recorded in the control group in the ESCRS prospective study (≥0.3%)," Dr. Chang said.

The ASCRS survey results were published in October (Chang DF, Braga-Mele R, Mamalis N, et al. Prophylaxis of postoperative endophthalmitis after cataract surgery: Results of the 2007 ASCRS member survey. J Cataract Refract Surg. 2007;33:1801-1805).OT