Dr Harminder P. Singh MD

Dr Priyanka Galhotra MD

India Authors have no financial interest of any kind in the present study

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.

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.

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 groupsGroup 1 – Cefuroxime group {done in 2006} Group 2 – Moxifloxacin group { done in 2007}

Day care surgery Preoperative assessment – General physical examination Ocular examination- - Visual acuity - Nucleus grading { LOCS - 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

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.

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

Cefuroxime Moxifloxacin MeanMean SDSD

AgeAge 64.9164.91 1010

NucleusNucleus 3.333.33 0.960.96

Vision pre-opVision pre-op 0.0750.075 0.060.06

Endothelial cell pre-Endothelial cell pre-opop 20352035 122122

Vision post-opVision post-op 0.540.54 0.220.22

Endothelial cell post-Endothelial cell post-opop 19511951 126126

AC rxn day-1AC rxn day-1 1.671.67 0.70.7

AC rxn day-7AC rxn day-7 0.140.14 0.350.35

MeanMean SDSD

AgeAge 67.2667.26 11.5911.59

NucleusNucleus 3.633.63 1.011.01

Vision pre-opVision pre-op 0.0840.084 0.010.01

Endothelial cell Endothelial cell pre-oppre-op 20722072 151.3151.3

Vision post-opVision post-op 0.60.6 0.270.27

Endothelial cell Endothelial cell post-oppost-op 19991999 160.8160.8

AC rxn day-1AC rxn day-1 1.491.49 0.590.59

AC rxn day-7AC rxn day-7 0.120.12 0.330.33

00.20.40.60.8

Pre-opvision

Post-opvision

Cefuroxime

Moxifloxacin

1900

2000

2100

2200

Endotheliumpre-op

Endotheliumpost-op

Cefuroxime

Moxifloxacin

00.5

11.5

2

AC rxnday 1

AC rxnday 7

Cefuroxime

Moxifloxacin

64.9167.26

50

60

70

80

Mean age

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 >75 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

- Preservative free

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.

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. 2007;33:978–988

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. 2007;33:1801–1805

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. 2002;80:258–261