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Up Front | Sep 2008

Lessons From the ESCRS Study on Endophthalmitis Prophylaxis

Although no antibiotic for prophylaxis is perfect, I believe that all roads lead back to cefuroxime as the gold standard for cataract surgery.

As the chair of the European Society of Cataract and Refractive Surgeons (ESCRS) Endophthalmitis Study Group,1-3 I am deeply involved in the study of the prophylaxis of endophthalmitis. When our results came out, we were the subject of robust challenge and debate in many roundtables and numerous discussions. This experience has given me the ability to take a step back and put what I have learned about endophthalmitis and its prevention into perspective.

The ESCRS study aimed to answer two questions: (1) Do perioperative antibiotics prevent endophthalmitis? (2) Should antibiotics be administered intracamerally, topically, or both? Of 15,971 patients enrolled from 23 clinics across nine European countries, half received 1 mg of intracameral cefuroxime in 0.1 mL of normal saline solution. All patients received povidone-iodine preoperatively and also were randomized to receive either topical levofloxacin or placebo drops. Post-operatively, all patients received topical levofloxacin drops four times a day for 6 days starting on postoperative day 1.

At the close of the ESCRS endophthalmitis study, I reflected on what the study accomplished. First and foremost, it reasonably and accurately defined the true ratio of endophthalmitis. Our rate of endophthalmitis, 0.35% in patients who did not receive perioperative antibiotics, was a surprise to the study members as well as the general ophthalmic community. Many perceived the rate of endophthalmitis to be lower than 0.35% and questioned our outcomes; however, the Swedish study of 225,000 patients confirmed our results.4-6 The rates of endophthalmitis in the groups that received cefuroxime were 0.048% in the Swedish study and 0.05% in the ESCRS study. If you look at the subgroup of Swedish patients who did not receive the cefuroxime, the rate of endophthalmitis was exactly the same as our group A, 0.35%. In my opinion, this verifies that the background rate of endophthalmitis at 0.35% is closer to the truth than what most ophthalmologists want to believe.

Second, the study unequivocally demonstrated the effect of cefuroxime. In patients who received 1 mg intracamerally in 0.1 mL of normal saline solution at the end of surgery, the incidence of endophthalmitis was reduced by fivefold. This finding left us with the ironic situation of providing what could be perceived as a successful clinical trial of a drug that is not commercially available in a single dose. (See The Use of Cefuroxime.) We did, however, prove the efficacy and safety of cefuroxime, which has existed for 25 years. I know that it will not be effective against methicillin-resistant Staphylococcus aureus (MRSA), Enterococcus, or Pseudo-monas; however, that does not mean that I will not continue to use it and believe in it. I do use it and I do believe in it. If cefuroxime were commercially available in a single, sterile, ophthalmic unit dose, it would become the gold standard and the ultimate triumph for the ESCRS and its study participants.

Manufacturers are currently investigating the creation of a single unit dose of cefuroxime. Until such a preparation of cefuroxime becomes commercially available, surgeons are left questioning the appropriate prophylaxis of endophthalmitis following cataract surgery. In the United States, the standard of care is use of a fourth-generation fluoroquinolone. Investigations have supported that the pre- and postoperative topical use of fourth-generation flluoroquinolones has the same efficacy (0.05%) as intracameral cefuroxime. I respect that work; however, several studies have reported a resistance to these drugs.7

Can we be sure that using vancomycin as prophylaxis for endophthalmitis does not contribute to this resistance? The argument of cataract surgeons who still use vancomycin is that it is not a mechanism that induces microbial resistance because each patient receives a maximum of two doses, one for each eye.

In my opinion, the continuous ophthalmic use of vancomycin does a serious disservice to our nonophthalmic colleagues, who have the everyday problem of treating patients with MRSA. This is one more reason why my belief in cefuroxime is reaffirmed despite its shortcomings.

No antibiotic for prophylaxis is ever going to be perfect; however, any way that we look at it in the year 2008, all roads lead back to cefuroxime. The ultimate reward for the ESCRS, and especially for those society members who put so much effort into taking elderly patients through a laborious informed consent process for this study, will be delivered when a single-dose cefuroxime product is commercially available worldwide. That will be the ultimate accolade.

Peter Barry, FRCS, is Chairman of the ESCRS Endophthalmitis Study Group, and a Consultant Ophthalmic Surgeon at Royal Victoria Eye and Ear and St. Vincent’s University Hospitals, Dublin, Ireland. Mr. Barry states that he has no financial interest in the products or companies mentioned. Mr. Barry may be reached at tel: +353 1 2091100; e-mail: carol.fitzpatrick@escrs.org.

Seal DV, Barry P, Gettinby G, et al. ESCRS study of prophylaxis of post-operative endophthalmitis after cataract surgery: case for a European multicenter study. J Cataract Refract Surg. 2006;32(3):396-406.

Barry P, Seal D, Gettinby G, et al. ESCRS study of prophylaxis of post-operative endophthalmitis after cataract surgery: preliminary report of principal results from a European multicentre study. J Cataract Refract Surg. 2006;32:407-410.

ESCRS Endophthalmitis Study Group. Prophylaxis of post-operative endophthalmitis following cataract surgery: results of the ESCRS multicentre study and identification of risk factors. J Cataract Refract Surg. 2007;33(6):978-988.

Lundström M, Wejde G, Stenevi U, Thorburn W, Montan P. Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location. Ophthalmology. 2007;114(5):866-870.

Montan PG, Wejde G, Koranyl G, Rylander M. Prophylactic intracameral cefuroxime: efficacy in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg. 2002;28:977-981.

Wejde G, Montan PG, Lundström M, et al. Endophthalmitis following cataract surgery in Sweden: national prospective survey 1999-2001. Acta Ophthalmol Scand. 2005;83(1):7-10.

Deramo VA, Lai JC, Fastenberg DM, Udell IJ. Acute endophthalmitis in eyes treated prophylactically with gatifloxacin and moxifloxacin. Am J Ophthalmol. 2006;142(5):721-725.