ESCRS study has little impact on US practice

Results of the European Society of Cataract and Refractive Surgeons (ESCRS) study of endophthalmitis prophylaxis do not appear to have had a significant impact on the practices of US cataract surgeons, according to the findings of an online survey conducted by the American Society of Cataract and Refractive Surgery (ASCRS) Cataract Clinical Committee.¹ The survey results were reported by David F. Chang, MD, at the Spotlight on Cataracts 2007 symposium held during the annual meeting of the American Academy of Ophthalmology.

Asking the right questions

The ASCRS survey included 14 questions that took about two minutes to complete. A link to the online survey was e-mailed to the approximately 4,000 ASCRS members globally in January 2007 and more than 1,300 surgeons participated. Respondents were predominantly US surgeons (69%), but they represented a broad distribution of surgical volumes.

When asked whether they would consider using an intracameral antibiotic if a product for direct injection were available commercially, 47% said that they would and another 35% said that they might, depending on the cost.

What is common practice?

The most common practice for antibiotic prophylaxis among the survey participants involved use of a topical fourth-generation fluoroquinolone started one to three days preoperatively and resumed immediately after surgery. "In the ESCRS study, levofloxacin was used as the topical antibiotic and it was not started until the morning after surgery," said Dr Chang.

"One-half of the control group received no preoperative antibiotic and the other half received topical levofloxacin immediately before surgery," he explained. "Therefore, the ESCRS study did not answer the question of whether intracameral cefuroxime is as good as, better than, or a useful adjunct to the most commonly used topical antibiotic protocols in the US."

According to the survey, about 90% of respondents were using a topical antibiotic for endophthalmitis prophylaxis around the time of cataract surgery. Gatifloxacin or moxifloxacin were being used by 81% of the survey participants; 52% were starting the antibiotic three days prior to surgery, and the rest waited until the day before or the day of surgery to initiate treatment.

Topical administration the preferred route

Most surgeons (90%) were administering some antibiotic at the close of surgery; 83% of those surgeons were using a topical agent, whereas only 15% were administering intracameral medication. Subconjunctival antibiotic injection was being performed by 13% of survey respondents, and only 3% were using an antibiotic-soaked collagen shield. The percentages total more than 100 because some surgeons combine several methods.

"Among the surgeons administering an intracameral antibiotic, vancomycin was the most popular choice (61%), and surgeons were about equally split between those delivering it by direct injection versus those adding it to the irrigating solution," said Dr Chang. "Only 6% of all respondents were injecting intracameral cefuroxime."

Among the surgeons not using an intracameral antibiotic, the most common reason cited (89%) was a need for further study. Forty-five percent, however, said they were concerned about risk, and 11% said they were concerned about cost. "The concerns about risk may be valid, considering that 14% of those respondents using intracameral antibiotics felt they had seen a complication associated with the use of a 'homemade' intracameral antibiotic formulation," Dr Chang said.

Two-thirds of responding surgeons indicated that they started postoperative topical antibiotic treatment on the day of surgery, whereas the rest said they instructed their patients to wait until the next morning to begin instilling the drops. The treatment was tapered off within the first postoperative week by three-quarters of surgeons. Ninety percent of survey participants reported that the rate of endophthalmitis in their practices was one case per 1,000 cataract surgeries or less.

"Interestingly, only 3% of the survey participants reported that their rate of endophthalmitis was as high as that recorded in the control group in the ESCRS prospective study (≥0.3%)," said Dr Chang.

References

1. D.F Chang, et al. J. Cataract Refract. Surg. 2007;33:1801-1805.