Endophthalmitis: sterile unit cefuroxime dose needed

If a sterile unit dose of cefuroxime were available it would become the world standard for endophthalmitis prophylaxis following the startling proof of its efficacy in the ESCRS endophthalmitis study last year. That was the conclusion of a debate for and against intracameral antibiotics at the JCRS Symposium, Controversies in Cataract & Refractive Surgery.

"The risk of TASS from kitchen pharmacy, and the litigious nature of medical practice in the United States, means that cefuroxime is not the prophylaxis of choice there," said Randall Olson, of the John A. Moran centre in the US, speaking against intracameral injection.

Dr Peter Barry, speaking for the protocol, recognised the problems associated with its use. "There are dilution and diluent problems, contamination and dosage risks, and that's why I would urge industry to supply us with a sterile unit dose," he said.

Dr Olson pointed out that pre- and postoperative topical antibiotics provided good coverage, and he would like to see a study testing the efficacy of pre- and postoperative topical application of fourth-generation fluoroquinolones. He added that gram-positive resistance to cefuroxime is increasing.

Dr Barry rejoined that such a study would prove extremely expensive and would encounter ethical dilemmas given a proven, safe treatment already exists. "We're getting an incidence of just 0.05% of endophthalmitis cases with intracameral cefuroxime, showing the best proven prophylaxis for endophthalmitis. It is effective against the majority of the organism.

He added that there are also organisms resistant to fourth-generation fluoroquinolones such as the enterococci and staphylococcus aureus.

Dr Olson concluded that the two were largely in agreement. "If we had a sterile unit dose, intracameral cefuroxime would be the world standard prophylaxis."