A topical preparation of trimethoprim and polymyxin B has been widely used for the treatment of bacterial conjunctivitis and, more recently, as a possible agent for perioperative prophylaxis against infection during and after cataracts and refractive surgery. Sometimes, after surgery, blood vessels in the retina leak. As fluid builds up in the eye, vision becomes blurred. Here, surgeons share their experience and advice on how to do the best job possible to prevent postoperative inflammation and endophthalmitis, regardless of whether or not they have adopted any of the cutting-edge protocols.
To drop or not to drop? The biggest debate right now focuses on how to treat the patient at the end of surgery and in the postoperative period. Although the patient is given a battery of preoperative and postoperative periods. It is clear that, despite growing evidence that intracameral injection of antibiotics is effective, many American surgeons are hesitant to switch to this protocol. Mamalis points out that one of the reasons many surgeons haven't changed is because there is no FDA-approved medication for this purpose.
I think that stops many surgeons from changing. I'm lucky to be in a university, because we have our own pharmacy. They'll put a preservative-free antibiotic in a syringe for us under sterile conditions, so we can inject it directly. Without that advantage, surgeons have to find an outside source on their own.
Dr. . One method for placing drugs into the eye has consisted of placing a bolus of the drug in the vitreous, usually by inserting a cannula through the conules (as shown above). Given the potential for complications and, subsequently, patients often have to deal with hoverflies for a period of time, many surgeons have been reluctant to adopt this approach.
Matossian says he has been doing everything possible to avoid giving the patient postoperative drops for the past two years. Matossian points out that the downside of his current approach is that none of the versions of Dex-Moxi (one from Imprimis and the other from Ocular Sciences) are approved by the FDA. Matossian adds that he still has patients who use an NSAID once a day after surgery. In that situation, the patient also needs topical antibiotics, which I prescribe b, i, d.
In addition, if it is a complex case in which I went in and out of the eye more than usual, or I used a pupil dilation device or the case lasted for a few days, I could add a topical steroid for a few days, in addition to what I have placed intracamerally. Mamalis recognizes that a few or no postoperative drops would be good for both patients and offices. That means you have to go to a compound pharmacy to have the medication prepared for you. In addition, you cannot simply place it in the anterior chamber, but you must leave a reservoir of this medication in the eye, either by placing it through the conules or into the vitreous anterior.
Kershner points out that some ophthalmologists may be carried away by the illusion that contamination is inevitable and, if an infection occurs, an antibiotic will solve the problem. Surgeons should keep in mind that no amount of antibiotic will replace the strict adherence of preoperative and intraoperative care to the sterile technique. All ophthalmologists should consider this when deciding what to do to prevent endophthalmitis. One method for placing a drug, or drugs, into the eye has consisted of placing a bolus of drugs in the vitreous, usually by inserting a cannula through the conules.
Cynthia Matossian, MD, FACS, founder and medical director of Matossian Eye Associates, says she used to follow that protocol by placing a combination of antibiotics and steroids through the conules and into the vitreous. There is a learning curve for the injection technique, and not many ophthalmic surgeons are comfortable using it. He adds that there is also a possibility of skipping a drop of NSAIDs. Or, we could place the NSAID release cap on the upper points and place a Dexterza cap on the lower points.
In any case, the procedure would be completely indirect, after the operation. Kershner points out that ophthalmologists, like people in general, tend to resist trying new things. If surgeons have always done it a certain way and it seems to work, then they don't change. However, ophthalmologists need evidence-based studies to do what they do.
Kershner and Mamalis report that they have no financial ties to any product discussed. Rowen has advised Bausch+ Lomb, Kala, Sun Pharma and Eyepoint. Matossian is a consultant for Eyepoint, Ocular Therapeutics, Ocular Sciences and Imprimis. All units that perform intraocular cataract surgery have surgeons who know how to treat endophthalmitis and have clear ways to detect and treat this potentially devastating condition.
However, if this study shows that an intracameral antibiotic injection is effective, it will allow companies to obtain approval to manufacture a preservative-free antibiotic for single use after cataract surgery. Correcting or treating these risk factors prior to cataract surgery is desirable to reduce the risk of infection. On the other hand, the intracameral injection of the antibiotic cefuroxime (1 mg in 0.1 ml of normal saline solution) at the end of cataract surgery has led to a reduction in the number of cases of endophthalmitis. If you have had cataract surgery in your second eye and you don't have any pre-existing eye conditions that require monitoring or treatment, you will not receive any further appointments at the eye clinic (unless a problem is reported during the telephone consultation).
Infections after cataract surgery are rare, but if you have them, you'll get an injection of antibiotics in your eye. Cataract surgery rarely goes wrong or has postoperative complications, but it's possible, and you should be aware of the risks involved. Careful patient preparation for cataract surgery is arguably the most important factor in reducing the risk of endophthalmitis. .
