The Advantages of Intracameral Moxifloxacin for Bacterial Prophylaxis in Cataract Surgery

1
The Advantages of Intracameral Moxifloxacin for
Bacterial Prophylaxis in Cataract Surgery
1
Poster P-7
ASCRS 2007 San Diego, California, USA
Steve A. Arshinoff MD FRCSC 1 Eye Associates,
Humber River Regional Hospital, University of
Toronto, Toronto, Ontario, Canada.

• Recently published post-cataract surgery
  endophthalmitis rates are excessive and
  unacceptable, compared to other ophthalmic
  surgeries
• 1,6Cataract 0.07 to 0.265, 1 / 3-500
• 3,5PKP 0.11 to 0.3, 1 / 500
• 1,32º IOL 0.30 to 0.37 1 / 300
• 1,4Glauc filter 0.06 to 0.20 1 / 800
• 4,1,3PP vit 0.03 to 0.05 1 / 2,500
• 80 of isolates are genetically identical to
  patients own flora. (Speaker M et al.
  Ophthalmology 1991.)

Principle The ESCRS study on intracameral
antibiotic prophylaxis has shown that
intracameral cefuroxime is effective in reducing
the incidence of post cataract surgery
endophthalmitis (POE), but it did not
definitively identify the best drug. This study
demonstrates that intracameral moxifloxacin may
offer the most advantages.
1 Kattan HM, et al. Ophthalmology 1991 98
227-238. 2Javitt JC, et al. Arch. Ophthalmol.
19911091085-1089. 3Aaberg TM Jr, et al.
Ophthalmology. 19981051004-1010. 4Eifrig CWG,
et al. Ophthalmic Surg Lasers. 200233373-378 5Ta
ban M, Behrens A, Newcomb R, et al.. Arch
Ophthalmol. 2005 123 605-609. 5Taban M,
Behrens A, et al. Arch Ophthalmol. 2005 123
613-620. (May)
1 Finalcial Disclosure The author
acknowledges no financial interest in any of the
agents discussed herein.
All intracameral use of antibiotics is
off-label in the United States
2
Purpose, Method Background
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Arshinoff Steve A. Intracameral Moxifloxacin
Purpose To review all available data, and
assemble the information in a manner that might
clarify the differences among the antibiotics
that have been used for intracameral
antibacterial prophylaxis in cataract surgery.
Method A literatue review was conducted at the
same time as a review of our own experience with
different agents. (We have used vancomycin and
moxifloxacin.)
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• Background
• Post-Cataract Surgery Endophthalmitis
• Endophthalmitis Vitrectomy Study (EVS 1996)1,2
• 69 of patients with bacterial endophthalmitis
  were culture-positive
• Bacteria unchanged in study of Kowalski et al. 8
  years later.Ophthalmology Clin N Am 2003.

Gram-negativeorganisms
OtherGram-positiveorganisms
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24
70
1. Han DP, Wisniewski SR, Wilson LA, et al.
Spectrum and susceptibilities of microbiologic
isolates in the endophthalmitis vitrectomy study.
Am J Ophthalmol 1996122(1)1-17. 2. Speaker MG,
Milch FA, Shah MK, et al. Role of external
bacterial flora in the pathogenesis of acute
postoperative endophthalmitis. Ophthalmology.
199198639-649.
Gram-positivecoagulase-negativeorganisms
(Staphylococcusepidermidis)
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Arshinoff Steve A. Intracameral Moxifloxacin
Results

• Changing Trends in Cataract POE
• Wills Eye Hospital, Philadelphia
• 1995 2000 vs 1989 1994. (497 cases)
• Gm increased 92 to 97
• Coag ve staph - resistance increased to
• Cipro 20 to 38 (all bacteria)
• Cefazolin 19 to 40
• 100 gram were sensitive to vancomycin.
• 100 gram were sensitive to ceftazidime.
• G4 FLQs not tested (not available then).

Archives of Ophthalmology Mar. 2005 123 341-346

• Techniques Proven to Reduce Risk of POE
• Preoperative Betadine 10 scrub 5 topical
  eyedrops.1
• Pre Post op topical antibiotics.2
• Tight wound closure.3
• Intracameral antibiotic as the final step of
  surgery4. - 80 reduction of POE with
  intracameral cefuroxime.

?
1. Speaker MG, Menikoff JA. Ophthalmology.
1991981769-1775. 2. Apt L, et al.
Ophthalmology. 198996289-292. 3. Taban M, et
al. Arch Ophthal 2005 123 613-620. 4. Barry
et al. ESCRS Endophthalmitis Study . JCRS 2006
32 396-407
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Arshinoff Steve A. Intracameral Moxifloxacin

• Intracameral Antibiotic POE Prophylaxis
  Drugs used reported to date Class
  Drug Dose / 0.1 cc Mechanism of
  Action Dependency
• Complex Glycopeptide - Vancomycin
  1 mg Inhibits Cell Wall
  Synthesis Time
• Cephalosporins - Cefazolin (G1)
  1- 2.5 mg Inhibits Cell Wall
  Synthesis Time -
  Cefuroxime (G2) 1 mg
  
• G4 fluoroquinolones - Gatifloxacin
  100 µg Inhibit DNA Gyrase
  Concentration - Moxifloxacin
  100 µg Topo Isomerase
  
• Montan PG, Wejde G, Setterquist H et al.
  Prophylactic intracameral cefuroxime. Evaluation
  of safety and kinetics in cataract surgery.
  JCRS 2002 28 982-987. ( Important
  Point aqueous drug concentration decreases 4x
  over 1st hr.)

Reported Staph. aureus kill rates Cefuroxime
1 mg in 0.1 cc. Moxifloxacin 100 µg in
0.1 cc. Peak intracameral dose achievable with
injection1 2,700 µg / mL 270 µg / mL
Staph aureus kill - sustained 1,000 µg /
mL kills - sustained 50 µg / mL
kills gt3 log units lt1log unit ß-lactamase
sensitive FLQ resistant S. aureus
in lt3 hours.3 S. aureus in 3 hours.
2 1Montan PG, Wejde G, Setterquist H et al.
Prophylactic intracameral cefuroxime. Evaluation
of safety and kinetics in cataract surgery. JCRS
2002 28 982-987. 2Stratton CW, Liu C, Weeks LS.
Activity of LY146032 compared with that of
methicillin, cefazolin, cefamandole, cefuroxime,
ciprofloxacin, vancomycin against
staphlococci as determined by kill-kintic
studies. Antimicrob Agents Chemother 1987 31
1210-5. 3OBrien TP, Arshinoff SA, Mah FS.
Intracameral antibiotics ESCRS Postoperative
Endophthalmitis (POE) Study Perspective. JCRS
2007 in press
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Arshinoff Steve A. Intracameral Moxifloxacin

• Intracameral Antibiotic POE Prophylaxis
  Coverage Spectrum Allergy Issues Class
  Drug Pathogens not covered
  Reported Allergic Responses
• Complex Glycopeptide - Vancomycin
  Gram negatives (5 POE) none reported
• Cephalosporins - Cefazolin (G1)
  30 Coag neg Staph (20 POE)
  Anaphylaxis to 30 mg. subconjunctival inj.
  - Cefuroxime (G2) MRSA, MRCNS,
  enterococci Anaphylaxis to 1 mg
  intracameral
• G4 fluoroquinolones - Gatifloxacin
  very rare resistance none reported
  - Moxifloxacin (Cipro resistant
  Pseudomonas)
• Berocal AM, Schuman JS,. Subconjunctival
  cephalosporin anaphylaxis. Ophth. Surg. Lasers
  2001 32 79-80
• Villada JR, Vincente U, Jevaloy J, Alio JL.
  Severe anaphylactic reaction after intracameral
  antibiotic administration during cataract
  surgery. JCRS 2005 31620-621.

• Intracameral Antibiotic POE Prophylaxis
  Drug Preparation Issues Class
  Drug 0.22 millipore filter neded
  Dilution Difficulty Identifiability
• Complex Glycopeptide - Vancomycin
  yes complex clear
• Cephalosporins - Cefazolin (G1)
  yes complex
  clear - Cefuroxime (G2) yes
  complex faint yellow
• G4 fluoroquinolones - Gatifloxacin
  gtts contain BAK, no other format available
  simple clear - Moxifloxacin
  no simple faint
  yellow
• The faint yellow color makes it easier for the
  surgeon to be sure he was handed the correct
  syringe, reducing errors.

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Arshinoff Steve A. Intracameral Moxifloxacin
Summary Score card for Intracameral Antibiotic
Performance (Each item scored out of 5, from
preceding information)
TD time dependent, DD doe dependent, LU log
unit. Scores Low 1 ? 5 High

• Conclusions
• Moxifloxacin, available as Vigamox non-preserved
  eye drops 0.5, emerges as the best agent for
  intracameral use, when compared to others
  available tried.
• Moxifloxacin has been demonstrated to be gentle
  to endothelial cells1.
• I have used intracameral Vigamox 100µg / 0.1 cc
  for 1,500 eyes to date since Oct 04, withno
  cases of endophthalmitis or apparent toxicity.
  (Recipe available by by request via email.)2
• 1Cesar Ramon G. Espiritu, MD, Victor L. Caparas,
  MD, MPH, Joanne G. Bolinao, MDSafety of
  prophylactic intracameral
• moxifloxacin 0.5 ophthalmic solution in cataract
  surgery patients. J Cataract Refract Surg 2007
  336368.
• 2Arshinoff Steve A. Intracameral Moxifloxacin for
  Antibacterial Prophylaxis in Cataract Surgery. A
  review of my experiences. Cataract Refractive
  Surg. Today. 2007 April 81-3.

Steve A. Arshinoff MD FRCSC ifix2is_at_sympatico.ca T
hank you