Despite numerous studies confirming that intracameral cefuroxime can be safely and effectively used to lower the rate of endophthalmitis after cataract surgery,1-62 However, the rate of adoption is much lower in other regions of Europe and in the United States as a result of several related concerns, including the development of resistance to antibiotics; fear of allergies; and, the biggest concern, the lack of a commercially available and regulatory-approved single dose of intracameral cefuroxime.
A TRUE CONTROVERSY?
Although these three concerns raise red flags for some surgeons, for others—myself included—the use of intracameral cefuroxime is not a controversy at all. For starters, I believe that administering a high dose of antibiotic into an essentially closed compartment of the eye is unlikely to create microbial resistance. Additionally, chance of an allergic reaction is low, as there is only one reported incident in the literature,7 and local Swedish pharmacies have been mixing intracameral cefuroxime for many years without incident.
However, I do recognize that, many years ago when Swedish cataract surgeons first began using intracameral cefuroxime as an endophthalmitis prophylaxis, there was greater acceptance of custom-made pharmaceuticals. Today, surgeons are more reluctant to use a nonapproved solution because, among other things, they worry about potential dilution errors and contamination.
In 2012, the European Medicines Agency (EMEA) approved in six European countries, including Sweden, the first premixed intracameral cefuroxime formulation for endophthalmitis prophylaxis. Aprokam (Laboratoires Théa) is a powder solution of cefuroxime mixed with 5 mL of sterile sodium chloride 0.9%. By later this year, it should be available in at least 12 more European countries.
Although I have always been comfortable using intracameral cefuroxime mixed by our local pharmacy, I switched to the premixed formulation in September 2012. Overall, not much has changed for me, as the nurses and operating room staff prepare the syringe of cefuroxime prior to my entering the operating room. However, they report being happy with the new protocol and find it easy to complete.
Aprokam is essentially the same mixture we used previously, and in this sense, there is no learning curve. The advantage to using this formulation versus a solution mixed at the local pharmacy is reliability: Surgeons can now be absolutely sure that it is the correct dosing, prepared the correct way. Additionally, each vial is labeled so that it can be recorded in a patient’s file. It is available for purchase in a single dose or in boxes of 10 doses.
Having a premixed solution such as Aprokam reduces fear of using the wrong dose or a contaminated batch of cefuroxime, and this may increase the number of surgeons worldwide who use it as a prophylaxis for endophthalmitis. I believe that the benefits of intracameral cefuroxime outweigh its risks, and therefore I use it in every cataract surgery procedure I perform. I predict that as this and perhaps other premixed solutions become available in more countries, many more surgeons will agree.
Anders Behndig, MD, PhD, practices in the Department of Clinical Science/Ophthalmology, Umeå University Hospital, Sweden. Dr. Behndig states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +46 90 785 37 31; fax +46 90 13 34 99; e-mail: firstname.lastname@example.org.
- Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. 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.
- Lundström M, Wejde G, Stenevi U, et al. Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location. Ophthalmology. 2007;114(5):866-870.
- García-Sáenz MC, Arias-Puente A, Rodríguez-Caravaca G, Bañuelos JB. Effectiveness of intracameral cefuroxime in preventing endophthalmitis after cataract surgery: ten-year comparative study. J Cataract Refract Surg. 2010;36(2):203-207.
- Barreau G, Mounier M, Marin B, et al. Intracameral cefuroxime injection at the end of cataract surgery to reduce the incidence of endophthalmitis: French study. J Cataract Refract Surg. 2012;38(8):1370-1375.
- 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.
- Shorstein NH, Winthrop KL, Herrinton LJ. Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a North California eye department. J Cataract Refract Surg. 2013;39(1):8-14.
- Villada JR, Cicente U, Javaloy J, Alió J. Severe anaphylactic reaction after intracameral antibiotic administration during cataract surgery. J Cataract Refract Surg. 2005;31:(3)620-621.