Comparative evaluation of intracameral Moxifloxacin and Cefuroxime in prevention of endophthalmitis in surgical outreach camps in India.

1
Comparative evaluation of intracameral
Moxifloxacin and Cefuroxime in prevention of
endophthalmitis in surgical outreach camps in
India.

• Dr Harminder P. Singh
  MD
• Dr Priyanka Galhotra
  MD
• India
• Authors have no financial interest of any
  kind in the present study

2
Out reach camps in developing countries- Why we
need intracameral antibiotics?

• Bulk surgeries.
• Preoperative screening and preparation a
  challenge.
• Intraoperative factors e.g instrumentation,
  irrigating fluids,IOL etc. always a threat.
• Postoperative care and medications are always
  doubtful because of socio-economic factors.
• Intracameral route is more preferred
• Immediate, high antibiotic levels above MIC that
  are sustained for a period of time.
• Less chances of bacterial resistance development
• Results of the European Society of Cataract
  Refractive Surgeons study A nearly 5-fold
  decrease in postoperative endophthalmitis in
  patients who received intracameral injection of
  antibiotic.

3
Purpose

• To compare the effectivity and safety of
  intracameral Moxifloxacin and Cefuroxime in
  prevention of endophthalmitis during surgical
  outreach camps.
• Moxifloxacin- Available as preservative free 0.5
  solution with a ph of 6.8 and osmolality of 290
  mOsm/kg
• Cefuroxime Available as 500mg injection vials
  which need fresh reconstitution on the day of
  surgery. Final solution has a ph of 7.4 and
  osmolality of 311 mOsm/kg
• Aqueous pH is 7.4, Osmolality 305mOsm/kg
• Intracameral injection of moxifloxacin is an
  off label use.

4
Methods

• Non-randomized retrospective study
• No. of cases- 336 306 patients
• Place of study- Surgical outreach camps in
  northern India.
• Routine outreach camp protocol
• Basic examination and screening is done at some
  area of need having difficult access to proper
  healthcare.
• After screening procedure patients are
  transported to main hospital for surgery.
• Assistance of various NGOs is sought for out of
  hospital activities.
• Study patients divided into 2 groups
• Group 1 Cefuroxime group done in 2006
• Group 2 Moxifloxacin group done in 2007

5
Methods

• Day care surgery
• Preoperative assessment
• General physical examination
• Ocular examination-
• - Visual acuity
• - Nucleus grading LOCS 3
• - Endothelial cell counts
• - Fundus 90D Examination
• - IOL work-up
• Specular microscope was used for the purpose of
  present study only. It is not a part of routine
  screening in outreach camps

6
Methods

• Preoperative prophylaxis-
• Topical Gatifloxacin 2 times one hour before
  surgery.
• Eye lash trimming and Povidone-Iodine paint after
  peribulbar anesthesia.
• Repeat Povidone-Iodine application in
  conjunctival sac immediately before draping the
  eye.
• Intraoperative measures
• Phacoemulsification in all cases stop and chop
  technique
• PMMA lens implantation with one 10-0 nylon suture
  in all cases.
• In the bag injection of antibiotic through side
  port at the end of surgery.
• Cefuroxime 1mg/ 0.1 ml.
• Moxifloxacin 0.5mg/0.1 ml.
• Fresh solution was prepared on each surgery day.
• 0.1 ml solution was used from a commercially
  available preservative free Moxifloxacin.

7
Methods

• Postoperative assessment
• Day 1
• Wound integrity, corneal clarity, AC
  reaction
• Day -7
• Visual acuity, AC reaction
• Day 30
• Best corrected visual acuity, endothelial
  cell counts, 90D fundus examination.
• Post-operatively all patients received
  topical Gatifloxacin and Prednisolone drops 5
  times/day for 7 days and topical Prednisolone eye
  drops for 21days in tapering doses.
• AC reaction- Hogan grading

8
Results

• Cefuroxime
  Moxifloxacin

Mean SD
Age 64.91 10
Nucleus 3.33 0.96
Vision pre-op 0.075 0.06
Endothelial cell pre-op 2035 122
Vision post-op 0.54 0.22
Endothelial cell post-op 1951 126
AC rxn day-1 1.67 0.7
AC rxn day-7 0.14 0.35
Mean SD
Age 67.26 11.59
Nucleus 3.63 1.01
Vision pre-op 0.084 0.01
Endothelial cell pre-op 2072 151.3
Vision post-op 0.6 0.27
Endothelial cell post-op 1999 160.8
AC rxn day-1 1.49 0.59
AC rxn day-7 0.12 0.33
9
Results
10
Discussion

• When do we need intracameral antibiotic?
• Final decision is left to the treating
  ophthalmologist.
• Cases where risk of infection is high
• Clinics with high volume surgery
• When wound construction is not satisfactory
• Traumatic cataract cases with associated open
  globe injury
• Associated surgical complications
• Older patients gt75 years Higher bacterial
  contamination of conjunctiva
• Which is better-Cefuroxime or Moxifloxacin ?
• Both have good safety profile and efficacy.
• Cefuroxime-
• - We have more experience with
  it.
• Moxifloxacin-
• - Broad spectrum
• - Easy availability

11
Conclusion

• Intracameral injection of Cefuroxime and
  Moxifloxacin both are equally safe and effective
  in prevention of post surgical endophthalmitis.
• Intracameral injection of antibiotics can be
  considered in specific surgical situations.
• Commercially available single dose units of
  antibiotics for intracameral injection can be a
  better alternative for time saving and
  maintaining sterility.
• Continuing studies are desired in this direction
  to determine optimal doses of different
  antibiotics and changing trends in bacterial
  resistance.

12
Reference

• ESCRS Endophthalmitis Study Group . Prophylaxis
  of postoperative endophthalmitis following
  cataract surgery results of the ESCRS
  multicenter study and identification of risk
  factors. J Cataract Refract Surg. 200733978988
  
• Chang DF, Braga-Mele R, Mamalis N,
  et al. Prophylaxis of postoperative
  endophthalmitis after cataract surgery results
  of the 2007 ASCRS member survey the ASCRS
  Cataract Clinical Committee. J Cataract Refract
  Surg. 20073318011805
• Prophylactic intracameral cefuroxime Evaluation
  of safety and kinetics in cataract surgery Per
  G. Montan, Gisela Wejde, Hans Setterquist,
  Margareta Rylander, Charlotta Zetterström
  Journal of Cataract Refractive Surgery June
  2002 (Vol. 28, Issue 6, Pages 982-987)
• Macular thickness after cataract surgery with
  intracameral cefuroxime Mamta S. Gupta, Hamish
  D.R. McKee, Manuel Saldaña, Owen G. Stewart
  Journal of Cataract Refractive Surgery June
  2005 (Vol. 31, Issue 6, Pages 1163-1166)
• Safety of prophylactic intracameral moxifloxacin
  0.5 ophthalmic solution in cataract surgery
  patients .Cesar Ramon G. Espiritu, Victor L.
  Caparas, Joanne G. Bolinao Journal of Cataract
  Refractive Surgery .January 2007 (Vol. 33, Issue
  1, Pages 63-68)
• Montan P, Lundström M, Stenevi U, Thorburn W.
  Endophthalmitis following cataract surgery in
  Sweden. The 1998 national prospective survey.
  Acta Ophthalmol Scand. 200280258261