Post-cataract surgery endophthalmitis review favors intracameral cefuroxime

Boston-Based on available evidence, intracameral cefuroxime represents the best, safest, and most effective antimicrobial agent to use for prophylaxis of postcataract surgery endophthalmitis, said Peter J. Barry, MD, at the annual meeting of the American Society of Cataract and Refractive Surgery.

"Only cefuroxime has the scientific evidence-based background demonstrating its efficacy and safety for preventing endophthalmitis after cataract surgery, and there are appreciable problems with alternatives," said Dr. Barry, consultant ophthalmic surgeon, Royal Eye and Ear Hospital, Dublin, Ireland.

"The only major limitation of intracameral cefuroxime is that it is not commercially available as an FDA-approved, unit-dose product for use in cataract surgery," he said. "I would appeal to industry [please to] meet this need."

Discussing the pros and cons of intracameral cefuroxime and alternative antimicrobial agents as postcataract surgery endophthalmitis prophylaxis, Dr. Barry said that the results of the prospective, multicenter randomized European Society of Cataract and Refractive Surgeons (ESCRS) clinical trial provided the primary evidence to support his conclusion that intracameral cefuroxime is the best option.

Dr. Barry served as chairman for the study that recruited about 16,000 patients and had a 2 × 2 factorial design with intracameral cefuroxime and topical perioperative levofloxacin.

"The ESCRS trial is considered a gold standard study providing Level I data and documented unequivocally that intracameral cefuroxime was effective in reducing the rate of postoperative endophthalmitis," he said.

Overall, the results showed treatment with intracameral cefuroxime reduced the rates of both presumed and proven endophthalmitis by a factor of 5 and eliminated the occurrence of streptococcal endophthalmitis, as well as blindness (visual acuity of 20/200 or worse) related to the latter entity. These benefits were achieved with minimal risk of toxic anterior segment syndrome, Dr. Barry said.

Among the approximately 16,000 patients, there were 29 cases of endophthalmitis, including 20 proven and nine presumed cases. Among patients who did not receive intracameral cefuroxime, the rates of presumed and proven infectious endophthalmitis were 33/10,000 cases and 23/10,000 cases, respectively. The corresponding rates among patients who received intracameral cefuroxime were 6/10,000 cases and 4/10,000 cases, respectively.

Review of the main responsible pathogens for cases of proven endophthalmitis showed there were eight staphylococcal infections and eight streptococcal infections among the controls not treated with intracameral cefuroxime and three staphylococcal infections in the intracameral cefuroxime groups.

Visual outcomes varied based on endophthalmitis etiology. For the 11 cases of staphylococcal infection, final visual acuity ranged from 20/20 to 20/80, while among the eight eyes with a streptococcal infection, the final visual acuity ranged from 20/20 to no light perception.

"All five eyes in the study that wound up legally blind had a streptococcal infection and none had received intracameral cefuroxime," Dr. Barry said.

Beyond the data from the 8,000 patients treated with intracameral cefuroxime in the ESCRS trial, evidence of the efficacy and safety of intracameral cefuroxime is available from more than 425,000 recorded uses in the national cataract register in Sweden, a country where use of intracameral cefuroxime has become standard practice.

Objection

One objection that has been raised against use of cefuroxime relates to the risk of cross-reactivity with penicillin. However, such concerns are unfounded and do not provide a legitimate argument against using intracameral cefuroxime, according to Dr. Barry.

"While there is a risk for cross-reactivity between penicillin and some cephalosporins, the association depends on the side-chain of the molecule," Dr. Barry said. "Cefuroxime carries no risk and can be safely administered to patients with a history of penicillin allergy."

Limitations of alternatives

Dr. Barry observed that intracameral use of moxifloxacin has been touted by some investigators in what he described as "a drip feed of papers from industry over the last 3 years."

"I would argue the evidence from these studies is high in aspiration, but manifestly commercial and not strikingly strong," he said.

On the other hand, published studies describing microbial resistance to the fourth-generation fluoroquinolones raises concern about the efficacy of intracameral moxifloxacin as endophthalmitis prophylaxis. In addition, the safe dose of moxifloxacin is unknown, moxifloxacin is ineffective against methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis, and the widespread use of fourth-generation fluoroquinolones in the animal husbandry/food chain is jeopardizing the future efficacy of this group of antimicrobial agents.

FYI

Peter J. Barry, MD
E-mail: peterbarryfrcs@eircom.net

Dr. Barry has no financial interest in the products he discussed.