Preparing Intracameral Cefuroxime for use in Cataract Surgery

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Preparing Intracameral Cefuroxime for use in
Cataract Surgery

• Frimley Park Hospital
• NHS Foundation Trust
• Surrey, UK
• Dr William R Tucker BSc MBBS

The author has no financial interest in the
subject matter of this poster
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Purpose

• Postoperative endophthalmitis is a rare but
  devastating complication of cataract surgery.
  Preoperative antiseptic with Povidone iodine
  combined with perioperative and postoperative
  antibiotics is a UK standard of care. However
  controversy exists over which antibiotics and
  route to use.
• A prospective randomised trial in 16,603 patients
  conducted by the ESCRS found nearly a 5 fold
  reduction in risk of postoperative
  endophthalmitis when using intracameral
  cefuroxime compared to controls1. A smaller study
  found the incidence of postoperative
  endophthalmitis was significantly lower in a
  group given intracameral cefuroxime compared to
  subconjunctival cefuroxime2.

1) Endophthalmitis study group, European Society
of Cataract Refractive Surgeons. Prophylaxis of
postoperative endophthalmitis following cataract
surgery results of the ESCRS multicentre study
and identification of risk factors. J Cataract
Refract Surg 2007 33(6)978 988 2) Yu-Wai-Man
et al. Efficacy of intracameral and
subconjunctival cefuroxime in preventing
endophthalmitis after cataract surgery. J
Cataract Refract Surg 2008 34(3)447 451
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Purpose

• Despite accumulating evidence that intracameral
  cefuroxime is both effective and safe3 the uptake
  among cataract surgeons has been poor. Chang et
  al surveyed 1312 surgeons of the ASCRS and found
  only 6 used intracameral cefuroxime4. They also
  found 82 would initiate use if a commercial
  preparation was available. We believe this
  represents concerns about making up home-made
  preparations in theatre.
• We therefore developed a visual, simple and step
  by step protocol for preparing cefuroxime at
  1mg/0.1ml before intracameral injection at the
  end of the case.
• We present a method for preparing intracameral
  cefuroxime and provide usage complication data
  for cataract operations performed over an 18
  month period at a UK hospital

3) Montan et al. Prophylactic intracameral
cefuroxime. Evaluation of safety and kinetics in
cataract surgery J Cataract Refract Surg 2002
28(6)982 987 4) Chang DF et al. Prophylaxis of
postoperative endophthalmitis after cataract
surgery results of the 2007 ASCRS member survey.
J Cataract Refract Surg 2007 331801 5
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Method

• We designed a flow-chart portfolio using the
  diagrams and instructions shown on the following
  pages. This was placed in theatre and used as a
  guide to preparing the intracameral cefuroxime
  doses.
• Please note this is an OFF-LABEL use of the drug
  in the UK
• After 18 months of use we collected usage and
  complication data for the local unit where it was
  utilised. A questionnaire was sent around the
  nursing staff and surgeons asking about any
  problems encountered with the technique.

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Method
Zinacef 250 mg 2.5 ml Syringe Saline 0.9 1
ml Syringes 10 ml Syringe Drawing up
needles Filter Needles
Double drape small trolley
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Method
Inject this into the Zinacef
Runner draws up 2.5 ml of saline into 2.5 ml
syringe
Withdraw 1 ml into 1 ml syringe Use a FILTER
NEEDLE
Shake THOROUGHLY until dissolved
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Method
First Scrub Nurse takes 10 ml Syringe
Fill 10ml syringe with Saline Using a FILTER
NEEDLE
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Method
Assistant fits NEW FILTER NEEDLE to the 1 ml
syringe of Zinacef injects into the 10 ml
syringe of Saline held by Scrub Nurse
Express Saline to 9 ml mark Withdraw plunger to
make room
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Method
Mix thoroughly
Withdraw 0.4 ml into 1 ml syringe
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Method
Place in instrument Tray. LEAVE RED DRAWING UP
NEEDLE ON SYRINGE UNTIL END OF CASE Surgeon will
inject 0.1 ml into lens bag at end of case
Repeat step for number of cases on list. Cap 10
ml syringe leave on trolley as reserve
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Result

• Over 18 months intracameral cefuroxime was
  prepared and used in 3768 routine
  phacoemulsification cataract operations.
• There were no cases of postoperative
  endophthalmitis over the period of use.
• Nursing staff and the surgeons reported no other
  complications and no difficulty in preparing the
  doses.
• However please note we cannot accept
  responsibility if another person uses this method
  and suffers complications

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Conclusion

• The use of intracameral cefuroxime is gaining
  credence as a effective method for reducing
  postoperative endophthalmitis rates.
• At present it seems to be held back by the lack
  of a commercial preparation and concern over the
  safest way to prepare it from available supplies.
  
• We have presented an easy to follow, step by
  step, visual method allowing surgeons to have
  confidence that a standard safe dose can be
  prepared by even the most inexperienced theatre
  staff.
• This off-label method of preparing Intracameral
  cefuroxime has proved to be a popular and safe
  method of administering prophylaxis against
  postoperative endophthalmitis