Are topical antibiotics needed after cataract surgery? Maybe

Topical antibiotics are unnecessary after routine cataract surgery, but intracameral antibiotics must be used to prevent endophthalmitis. 

Let us be more specific, topical antibiotics after cataract surgery are not necessary, according to Alexander James Silvester, MBCHB, as long as surgeons tick off all the boxes on the safety check list.

To lessen the postoperative burden on patients who underwent cataract surgery by eliminating the topical antibiotic regimen, Dr. Silvester emphasized that the surgery must be uncomplicated and have no dropped nucleus or posterior capsular rupture.

And, importantly, instillation of intracameral antibiotics is a must. Surgeons in the UK have a licensed intracameral antibiotic to rely on, Aprokam (Cefuroxime), that is used in all cases. 

Related: Weigh risks, benefits of cataract surgery for your patients 

While the endophthalmitis rate in the UK is only 0.03% after cataract surgery, the fear is that superbugs will surge ahead and dramatically increase that incidence rate. 

“Overuse or inappropriate use of antibiotics is the largest cause of antibiotic resistance,” said Dr. Silvester, an ophthalmologist and medical director of the SpaMedica group of eye hospitals, Bolton, UK.

Post-op antibiotics
Studies over the past eight years; a systematic review (Kessel et al. 2015), a retrospective study of 15,000 eyes (Raen et al. 2013), and review of the Swedish National Cataract Registry (Behndig et al. 2011), supported the notion of eliminating antibiotic drops after cataract surgery.

Related: Postop endophthalmitis rates similar despite dissimilar practice patterns 

“All found that topical postoperative antibiotics are not important in preventing endophthalmitis after cataract surgery when the patients have received intracameral antibiotics,” Dr. Silvester said.

Published guidelines from the European Society of Cataract and Refractive Surgeons (ESCRS) in 2018 issued a statement that topical antibiotic drops confer no added benefit over intracameral cefuroxime.

Related: How to evaluate the guidelines for antibiotic reactions in surgery 

Analysis
Dr. Silvester pointed out that SpaMedica stopped using topical antibiotics following cataract surgery in September 2018.

Dr. Silvester and co-investigator Anil Pitalia, MBCHB, retrospectively analyzed the Medisoft database that contained almost 30,000 cataract surgeries performed by 28 surgeons in 10 of SpaMedica’s UK hospitals between Jan. 6, 2018, and March 3, 2019.

Related: Study targets therapies for endophthalmitis 

The primary outcome was the incidence rate of endophthalmitis. The secondary outcomes were the incidence of postoperative uveitis, cystoid macular edema, corneal edema, and visual loss of more than three lines of Snellen vision, Dr. Silvester recounted.

A total of 13,873 patients were included who had been treated with a combination topical corticosteroid and antibiotic postoperatively and 16,124 patients who only received a topical corticosteroid. All patients had been treated with intracameral cefuroximea and followed for up to four weeks postoperatively. 

“No cases of endophthalmitis developed in either group of patients,” he reported.

Regarding the secondary outcomes, he reported that there were no clinical or statistical differences between the two groups. Anterior uveitis was the most frequent complication that occurred by 3.9% and 3.8%, respectively, in the two patient groups. According to Dr. Silvester, topical antibiotics are not necessary following routine cataract surgery. 

Related: Understanding the surgical learning curve 

“A power analysis suggested that a sample of 35,000 patients would be necessary to show that topical antibiotics are unnecessary,” he said. Since September 2018, 36,661 cataract surgeries have been performed at SpaMedica without the use of postoperative topical antibiotics, and no cases of endophthalmitis have developed in that newer larger cohort. There also were no changes in the complications or visual outcomes.

Dr. Silvester concluded by strongly suggesting that topical antibiotics are not needed post-routine cataract surgery, with the caveat that intracameral antibiotics are necessary to reduce endophthalmitis risk.

Read more cataract surgery content 

Alexander James Silvester, MBCHB
E: alexander.silvester@spamedica.co.uk
Dr. Silvester has no financial interest in any aspect of this report.Anil Pitalia, MBCHB
E: anil.pitalia@spamedica.co.uk
Dr. Pitalia has no financial interests in any aspect of this report.