Subconjunctival antibiotics: an alternative to intracameral antibiotics for endophthalmitis prophylaxis in cataract surgery
Abstract
Background: There has been an increase in the use of routine intracameral antibiotics for endophthalmitis prophylaxis in cataract surgery. However, this can be associated with serious adverse events. Previously, subconjunctival antibiotics were the preferred route but there is minimal literature directly comparing the two. Hence, the safest and most efficacious route of prophylactic antibiotic administration remains controversial.
Purpose: To evaluate the efficacy and safety of subconjunctival with intracameral antibiotics for postoperative endophthalmitis (POE) prophylaxis in patients undergoing uncomplicated cataract surgery.
Methods: A literature review was conducted in Cochrane and PubMed for studies that compared the efficacy of prophylactic subconjunctival and intracameral antibiotics for post-cataract endophthalmitis. Searches were not limited to English or study design.
Results: Three observational studies showed that subconjunctival and intracameral antibiotics both reduced POE rates. Intracameral antibiotics demonstrated a high efficacy (OR = 0.25, 95% CI 0.13-0.46, p < 0.0001) but was also associated with increased potential complications. All studies were conducted in a sequential nature during which cataract surgery techniques and instrumentation have improved in recent years.
Conclusion: In institutions with a high incidence of endophthalmitis, routine intracameral antibiotic use would be more appropriate. However, in facilities with lower rates of POE, the subconjunctival route of delivery can be an alternative due to its better safety profile.
References
Hashemian H, Mirshahi R, Khodaparast M, Jabbarvand M. Post-cataract surgery endophthalmitis: Brief literature review. J Curr Ophthalmol. 2016;28(3):101-105. https://doi.org/10.1016/j.joco.2016.05.002
Niyadurupola N, Astbury N. Endophthalmitis: controlling infection before and after cataract surgery. Community Eye Health. 2008;21(65):9. PMCID: PMC2377381
Buzard K, Liapis S. Prevention of endophthalmitis. J Cataract Refract Surg. 2004;30(9):1953-1959. https://doi.org/10.1016/j.jcrs.2003.12.057
Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology. 1991;98(12):1769-1775. https://doi.org/10.1016/s0161-6420(91)32052-9
Liesegang TJ. Use of antimicrobials to prevent postoperative infection in patients with cataracts. Curr Opin Ophthalmol. 2001;12(1):68-74. https://doi.org/0.1097/00055735-200102000-00012
Han DC, Chee SP. Survey of practice preference pattern in antibiotic prophylaxis against endophthalmitis after cataract surgery in Singapore. Int Ophthalmol. 2012;32(2):127-134. https://doi.org/10.1007/s10792-012-9537-1
Ku JJ, Wei MC, Amjadi S, Montfort JM, Singh R, Francis IC. Role of adequate wound closure in preventing acute postoperative bacterial endophthalmitis. J Cataract Refract. Surg. 2012;38(7):1301-2; author reply 2. https://doi.org/10.1016/j.jcrs.2012.05.003
Dubey R, Brettell DJ, Montfort J, Coroneo MT, Francis IC. Obviating Endophthalmitis After Cataract Surgery: Excellent Wound Closure Is the Key. Arch Ophthalmol. 2011;129(11):1504-1505. https://doi.org/10.1001/archophthalmol.2011.322
Herretes S, Stark WJ, Pirouzmanesh A, Reyes JM, McDonnell PJ, Behrens A. Inflow of ocular surface fluid into the anterior chamber after phacoemulsification through sutureless corneal cataract wounds. Am J Ophthlmol. 2005;140(4):737-740. https://doi.org/10.1016/j.ajo.2005.03.069
Hammoudi DS, Abdolell M, Wong DT. Patterns of perioperative prophylaxis for cataract surgery in Canada. Can J Ophthalmol. 2007;42(5):681-688. https://doi.org/10.3129/i07-122
Tan CS, Wong HK, Yang FP. Epidemiology of postoperative endophthalmitis in an Asian population: 11-year incidence and effect of intracameral antibiotic agents. J Cataract Refract Surg. 2012;38(3):425-430. https://doi.org/10.1016/j.jcrs.2011.09.040
Myneni J, Desai SP, Jayamanne DG. Reduction in postoperative endophthalmitis with intracameral cefuroxime. J Hosp Infect. 2013;84(4):326-328. https://doi.org/10.1016/j.jhin.2013.05.009
Yu-Wai-Man P, Morgan SJ, Hildreth AJ, Steel DH, Allen D. Efficacy of intracameral and subconjunctival cefuroxime in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg. 2008;34(3):447-451. https://doi.org/10.1016/j.jcrs.2007.10.041
Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33(6):978-988. https://doi.org/10.1016/j.jcrs.2007.02.032
Ng JQ, Morlet N, Bulsara MK, Semmens JB. Reducing the risk for endophthalmitis after cataract surgery: population-based nested case-control study: endophthalmitis population study of Western Australia sixth report. J Cataract Refract Surg. 2007;33(2):269-280. https://doi.org/10.1016/j.jcrs.2006.10.067
Lehmann OJ, Roberts CJ, Ikram K, Campbell MJ, McGill JI. Association between nonadministration of subconjunctival cefuroxime and postoperative endophthalmitis. J Cataract Refract Surg. 1997;23(6):889-893. https://doi.org/10.1016/s0886-3350(97)80249-0
Ang GS, Barras CW. Prophylaxis against infection in cataract surgery: a survey of routine practice. Eur J Ophthalmol. 2006;16(3):394-400. https://doi.org/10.1177/112067210601600306
Moshirfar M, Feiz V, Vitale AT, Wegelin JA, Basavanthappa S, Wolsey DH. Endophthalmitis after uncomplicated cataract surgery with the use of fourth-generation fluoroquinolones: a retrospective observational case series. Ophthalmology. 2007;114(4):686-691. https://doi.org/10.1016/j.ophtha.2006.08.038
Lloyd JC, Braga-Mele R. Incidence of postoperative endophthalmitis in a high-volume cataract surgicentre in Canada. Can J Ophthalmol. 2009;44(3):288-92. https://doi.org/10.3129/i09-052
Hatch WV, Cernat G, Wong D, Devenyi R, Bell CM. Risk factors for acute endophthalmitis after cataract surgery: a population-based study. Ophthalmology. 2009;116(3):425-430. https://doi.org/10.1016/j.ophtha.2008.09.039
Herrinton LJ, Shorstein NH, Paschal JF, Liu L, Contreras R, Winthrop KL, et al. Comparative Effectiveness of Antibiotic Prophylaxis in Cataract Surgery. Ophthalmology. 2016;123(2):287-294. https://doi.org/10.1016/j.ophtha.2015.08.039
Haripriya A, Chang DF, Namburar S, Smita A, Ravindran RD. Efficacy of Intracameral Moxifloxacin Endophthalmitis Prophylaxis at Aravind Eye Hospital. Ophthalmology. 2016;123(2):302-308. https://doi.org/ 10.1016/j.ophtha.2015.09.037
Gower EW, Lindsley K, Tulenko SE, Nanji AA, Leyngold I, McDonnell PJ. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database Syst Rev. 2017;2(2):CD006364. https://doi.org/10.1002/14651858
Bowen RC, Zhou AX, Bondalapati S, Lawyer TW, Snow KB, Evans PR, et al. Comparative analysis of the safety and efficacy of intracameral cefuroxime, moxifloxacin and vancomycin at the end of cataract surgery: a meta-analysis. Br J Ophthalmol. 2018;102(9):1268-1276. https://doi.org/10.1136/bjophthalmol-2017-311051
George NK, Stewart MW. The Routine Use of Intracameral Antibiotics to Prevent Endophthalmitis After Cataract Surgery: How Good is the Evidence? Ophthalmol Ther. 2018;7(2):233-245. https://doi.org/10.1007/s40123-018-0138-6
Andreev AN, Svetozarskiy SN. [Serous retinal detachment after phacoemulsification with intracameral cefuroxime (a case-control report)]. Vestn Oftalmol. 2018;134(3):73-77. https://doi.org/10.17116/oftalma2018134373
Delyfer MN, Rougier MB, Leoni S, Zhang Q, Dalbon F, Colin J, et al. Ocular toxicity after intracameral injection of very high doses of cefuroxime during cataract surgery. J Cataract Refract Surg. 2011;37(2):271-278. https://doi.org/10.1016/j.jcrs.2010.08.047
Sül S, Karalezli A. Development of Retinal Infarct Due to Intracameral Cefuroxime Injection Following Complicated Cataract Surgery. Turk J Ophthalmol. 2018;48(6):317-319. https://doi.org/10.4274/tjo.61580
Witkin AJ, Chang DF, Jumper JM, Charles S, Eliott D, Hoffman RS, et al. Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: Clinical Characteristics of 36 Eyes. Ophthalmology. 2017;124(5):583-595. https://doi.org/10.1016/j.ophtha.2016.11.042
Motlagh MN, Javid CG. Rapid and progressive decline despite early intervention in a case of bilateral hemorrhagic occlusive retinal vasculitis. Am J Ophthalmol Case Rep. 2020;17:100595. https://doi.org/10.1016/j.ajoc.2020.100595
Leung V, Weaver T, Fraser-Bell S, Roberts TV. Acute retinopathy and loss of vision following routine cataract surgery. Clin Experiment Ophthalmol. 2019;47(2):294-296. https://doi.org/10.1111/ceo.13407
Çakır B, Celik E, Aksoy N, Bursalı Ö, Uçak T, Bozkurt E, et al. Toxic anterior segment syndrome after uncomplicated cataract surgery possibly associated with intracamaral use of cefuroxime. Clin Ophthalmol. 2015;9:493-497. https://doi.org/10.2147/OPTH.S74249
Javitt JC. Intracameral Antibiotics Reduce the Risk of Endophthalmitis after Cataract Surgery: Does the Preponderance of the Evidence Mandate a Global Change in Practice? Ophthalmology. 2016;123(2):226-231. https://doi.org/10.1016/j.ophtha.2015.12.011
Haripriya A, Chang DF, Ravindran RD. Endophthalmitis Reduction with Intracameral Moxifloxacin Prophylaxis: Analysis of 600 000 Surgeries. Ophthalmology. 2017;124(6):768-775. https://doi.org/10.1016/j.ophtha.2017.01.026.
Schwartz SG, Flynn HW, Jr., Grzybowski A, Relhan N, Ferris FL, 3rd. Intracameral Antibiotics and Cataract Surgery: Endophthalmitis Rates, Costs, and Stewardship. Ophthalmology. 2016;123(7):1411-1413. https://doi.org/10.1016/j.ophtha.2016.03.024
Friling E, Lundström M, Stenevi U, Montan P. Six-year incidence of endophthalmitis after cataract surgery: Swedish national study. J Cataract Refract Surg. 2013;39(1):15-21. https://doi.org/10.1016/j.jcrs.2012.10.037
Montan PG, Wejde G, Koranyi G, Rylander M. Prophylactic intracameral cefuroxime: Efficacy in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg. 2002;28(6):977-981. https://doi.org/10.1016/S0886-3350(01)01269-X
Shorstein NH, Liu L, Carolan JA, Herrinton L. Endophthalmitis prophylaxis failures in patients injected with intracameral antibiotic during cataract surgery. Am J Ophthalmol. 2021;227:166-172 https://doi.org/10.1016/j.ajo.2021.02.007
Liesegang TJ. Prophylactic Antibiotics in Cataract Operations. Mayo Clin Proc. 1997;72(2):149-159. https://doi.org/10.4065/72.2.149
Behndig A, Cochener B, Güell JL, Kodjikian L, Mencucci R, Nuijts RM, et al. Endophthalmitis prophylaxis in cataract surgery: overview of current practice patterns in 9 European countries. J Cataract Refract Surg. 2013;39(9):1421-1431. https://doi.org/10.1016/j.jcrs.2013.06.014
Schwartz SG, Grzybowski A, Flynn HW, Jr. Antibiotic prophylaxis: different practice patterns within and outside the United States. Clin Ophthalmol. 2016;10:251-256. https://doi.org/10.2147/OPTH.S100429
Schimel AM, Alfonso EC, Flynn HW, Jr. Endophthalmitis prophylaxis for cataract surgery: are intracameral antibiotics necessary? JAMA Ophthalmol. 2014;132(11):1269-1270. https://doi.org/10.1001/jamaophthalmol.2014.2052
Mamalis N. Intracameral medication: is it worth the risk? J Cataract Refract Surg. 2008;34(3):339-340. https://doi.org/10.1016/j.jcrs.2008.01.001
Olson RJ. Has the Time Come for All to Routinely Use Intracameral Antibiotic Prophylaxis at the Time of Cataract Surgery? Am J Ophthalmol. 2016;166:xii-xiv. https://doi.org/10.1016/j.ajo.2016.04.013
Sharma S, Sahu SK, Dhillon V, Das S, Rath S. Reevaluating intracameral cefuroxime as a prophylaxis against endophthalmitis after cataract surgery in India. J Cataract Refract Surg. 2015;41(2):393-399. https://doi.org/10.1016/j.jcrs.2014.05.038
Ness T, Kern WV, Frank U, Reinhard T. Postoperative nosocomial endophthalmitis: is perioperative antibiotic prophylaxis advisable? A single centre’s experience. J Hosp Infect. 2011;78(2):138-142. https://doi.org/10.1016/j.jhin.2011.02.004
Inoue T, Uno T, Usui N, Kobayakawa S, Ichihara K, Ohashi Y. Incidence of endophthalmitis and the perioperative practices of cataract surgery in Japan: Japanese Prospective Multicenter Study for Postoperative Endophthalmitis after Cataract Surgery. Jpn J Ophthalmol. 2018;62(1):24-30. https://doi.org/10.1007/s10384-017-0545-6
Lertsumitkul S, Myers PC, O’Rourke MT, Chandra J. Endophthalmitis in the western Sydney region: a case-control study. Clin Experiment Ophthalmol. 2001;29(6):400-405. https://doi.org/10.1046/j.1442-9071.2001.d01-20.x
Colleaux KM, Hamilton WK. Effect of prophylactic antibiotics and incision type on the incidence of endophthalmitis after cataract surgery. Can J Ophthalmol. 2000;35(7):373-378. https://doi.org/10.1016/s0008-4182(00)80124-6
Panahibazaz M, Moosavian M, Khataminia G, Feghhi M, Yazdi F, Abbasi Montazeri E. Sub-Conjunctival Injection of Antibiotics vs. Povidone-Iodine Drop on Bacterial Colonies in Phacoemulsification Cataract Surgery. Jundishapur J Microbiol. 2014;7(9):e13108. https://doi.org/10.5812/jjm.13108
Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based update. Ophthalmology. 2002;109(1):13-24. https://doi.org/10.1016/s0161-6420(01)00899-5
Walsh A, Go CZQ, Liu Y, McCluskey P. Current antibiotic prophylaxis for cataract surgery in Sydney. Clin Experiment Ophthalmol. 2017;45(6):643-645. https://doi.org/10.1111/ceo.12932
Lim MY, Ong, K. (in press). Is zero incidence of post-operative endophthalmitis after cataract surgery achievable? Asian Journal of Ophthalmology. 2021.
Rudnisky CJ, Wan D, Weis E. Antibiotic choice for the prophylaxis of post-cataract extraction endophthalmitis. Ophthalmology. 2014;121(4):835-841. https://doi.org/10.1016/j.ophtha.2013.08.046
Jenkins CD, Tuft SJ, Sheraidah G, McHugh DA, Buckley RJ. Comparative intraocular penetration of topical and injected cefuroxime. Br J Ophthalmol. 1996;80(8):685-688. https://doi.org/10.1136/bjo.80.8.685
Lehmann OJ, Thompson JP, White LO, Keys MF, Campbell MJ. Half-life of intracameral gentamicin after phacoemulsification. J Cataract Refract Surg. 1997;23(6):883-888. https://doi.org/10.1016/s0886-3350(97)80248-9
Montan PG, Wejde G, Setterquist H, Rylander M, Zetterström C. Prophylactic intracameral cefuroxime. Evaluation of safety and kinetics in cataract surgery. J Cataract Refract Surg. 2002;28(6):982-987. https://doi.org/10.1016/s0886-3350(01)01270-6
Pande M. Postoperative conjunctival chemosis in cataract surgery caused by subconjunctival gentamicin injection. Br J Ophthalmol. 1991;75(11):660-662. https://doi.org/10.1136/bjo.75.11.660
Chapman JM, Abdelatif OM, Cheeks L, Green K. Subconjunctival gentamicin induction of extraocular toxic muscle myopathy. Ophthalmic Res. 1992;24(4):189-196. https://doi.org/10.1159/000267167
Judson PH. Aminoglycoside Macular Toxicity After Subconjunctival Injection. Arch Ophthalmol. 1989;107(9):1282-1283. https://doi.org/10.1001/archopht.1990.01070110022002
Goulstine DB, Marmion VJ. Subconjunctival gentamicin. Br J Ophthalmol. 1971;55(7):478-480. https://doi.org/10.1136/bjo.55.7.478
Copyright (c) 2021 Rachel Xuan, Elizabeth Wong, Keith Ong
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication, with the work twelve (12) months after publication simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).
