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Intracameral moxifloxacin for
endophthalmitis prophylaxis?
Steve A Arshinoff
Roibeard O'hEineachain solution from a bottle of topical Vigamox, and then 8.0ml of BSS into a 10cc syringe. surgery is key in preventing the INTRACAMERAL injection of the fourth- He then rotates the syringe in his hand until complication, he generation fluoroquinolone moxifloxacin the solution is thoroughly mixed. He or his circulating nurse then place 0.5 cc of the ®, Alcon) at the end of cataract procedures provides a safe and effective solution into medicine cups, on e for prophylaxis against endophthalmitis, according to a series of presentations at the When injecting the solution into the with intracameral XXVI Congress of the ESCRS. eye, after assuring that the main incision is Steve A Arshinoff MD FRCSC said that sealed and the eye pressurised, he inserts he has been routinely using intracameral a syringe containing 0.3ml of the antibiotic moxifloxacin since 2004, and during preparation into a side port incision and that time, he has had no cases of places the tip of the needle under the distal endophthalmitis in over 3,000 cataract edge of the capsulorhexis. To prevent any Post-op OCT of the solution from being expel ed as he before and after He noted that although the ESCRS withdraws the needle, he injects a small steps of reconstitution and dilution of the surgery and intracamerally at the conclusion Endophthalmitis study has established that amount of remaining antibiotic just as the drug which is necessary when cefuroxime of surgery we can eliminate postoperative intracameral injection of the antibiotic needle's tip comes out through the incision. or vancomycin is used. No case of endophthalmitis. Fourth-generation cefuroxime at the end of cataract Dr Arshinoff noted that studies have endophthalmitis is recorded in more fluoroquinolones have a broader spectrum procedures can reduce the rate of shown that intracameral moxifloxacin than 2000 phaco cases done until now in of activity than cefuroxime so they are the postoperative endophthalmitis by 80 per is gentle to endothelial cells (Espiritu drug of choice these days," he added. cent, the study did not establish whether et al, JCRS, 2007; 33:63-68) and that its Moxifloxacin was used for The findings of another study supported cefuroxime was the best agent to use. use results in low endothelial cel loss endophthalmitis prophylaxis because it Dr Bansal's findings. The prospective Oliver Schein (Wilmer Institute postoperatively and has no detrimental is preservative free, self preserved. Its study involved 55 eyes of 55 cataract Baltimore, MD) stated (Ophthalmology effect on macular thickness as measured by osmolality of 290 mOsm/kg and ph 6.8 patients with no other ocular pathology Times 15 06 08) "The ideal agent OCT (Brothers Arbisser et al, JCRS, 2008; is compatible to the human aqueous. who underwent intracameral injection of for intracameral antibiotics would It has broad spectrum and its levels in 0.1ml of 0.5 per cent moxifloxacin at the have bactericidal activity and provide He also pointed out that he has not seen aqueous exceeding MICs (Mean Inhibitory conclusion of phacoemulsification surgery, adequate ocular concentrations at the any fibrin on the first postoperative day Concentration) for relevant species persists said Purendra Bhasin MD, Ratan Jyoti close of surgery and for 24 to 48 hours in the eyes of any of his cataract patients for minimum five hours and MPC, (Mutant Netralaya, Ophthalmic Institute & Research postoperatively. Cefuroxime, and other in whom he has injected moxifloxacin Prevention Concentration) which is 8-10 Centre, Gwalior, India. "In our series of current drugs, do not do that," said Dr intracameral y at the end of the cataract times of MIC is maintained for three patients, intracameral injection of 0.1ml of Arshinoff, University of Toronto, Toronto, procedures. He added that he has become hours after surgery. This is important 0.5 per cent moxifloxacin (Vigamox, Alcon) Ontario, Canada. However, cefuroxime convinced that, except in cases of TASS, the because it is observed that through clear was found to be safe in terms of visual works on a time-dependent mechanism, so presence of fibrin in the anterior chamber in corneal hydrated phaco incision there is rehabilitation, the corneal endothelium, its duration of activity is important. the first few days postoperatively generally influx of fluid into the aqueous in the early anterior chamber reaction, macular oedema He added that the fourth-generation indicates a subclinical infection rather than postoperative period. Therefore, presence and IOP," he said.
fluoroquinolones moxifloxacin might simply an inflammatory response to surgery. of broad spectrum antibiotic maintained in None of the patients in the study represent a better choice. The agent In another study, 120 consecutive right concentration in the aqueous in early developed endophthalmitis in the six-month has several theoretical advantages over patients underwent intracameral injection postoperative period will decrease the fol ow-up period. The BCVA at one month cefuroxime, including a longer half-life, of 0.1ml of moxifloxacin in the anterior incidence of endophthalmitis. postoperatively was 20/30 or better in concentration dependent activity, making chamber at the end of uncomplicated Peter Barry FRCS, Dublin, Ireland noted al eyes and remained stable throughout it less dependent upon duration of activity, phacoemulsification and had completed that the spectre of resistance is casting a fol ow-up. In addition, mean endothelial and a broader spectrum of cidal efficacy, three months of follow-up, reported Rakesh shadow over the future of fourth-generation cel counts fel by only two per cent, from he noted. It is also wel tolerated in Bansal MD, Department of Ophthalmology, fluoroquinolones as a prophylaxis against a preoperative count of 2227cells/mm2 to Government Medical Col ege and Hospital, endophthalmitis. The agents are now 2191/mm2 at one month. Furthermore, Unlike cefuroxime, fourth-generation Chandigarh, India. entering the food chain due to their use in aqueous activity on the first postoperative fluoroquinolones are effective against As in previous studies, moxifloxacin animal husbandry, which may in turn lead day was similar to that seen in most series MRSA and Gram-positive enterococci and was wel tolerated within the eye, Dr to the generation of resistant strains of of cataract patients, and was grade 1 in 30 have only encountered resistance with Bansal noted. The mean preoperative eyes, grade 2 in 24 eyes, and grade 3 in one some ciprofloxacin-resistant species of and postoperative endothelial cel counts Dr Arshinoff concurred with Dr Barry eye. In addition, OCT examinations on day pseudomonas. In addition, studies have were 2495cells/cc2 and 2156 cells /cc2, and said that the overuse of systemic respectively, amounting to a mean cel loss one and day seven after surgery detected shown that cefuroxime at its concentration administration of the agents in the human of 13.5 per cent, he added. Furthermore, no signs of macular oedema.
at 45 minutes after intracameral injection population is another cause for concern.
OCT showed no changes in macular The mean IOP was 16.0 mmHg achieves less than one log unit kil of "Agriculture is a big problem for the thickness. Mild corneal oedema occurred preoperatively, 19.0 mmHg at day one, 17.0 fluoroquinolone sensitive staphylococcus. potential induction of bacterial antibiotic in six patients, but cleared up within the mmHg at day seven, and 15.0 mmHg at By comparison, moxifloxacin wil achieve resistance with al the antibiotics that we first postoperative week. Moreover, none one month postoperatively, Dr Bhasin said. more than a three log unit kil of resistant use. The other big culprit is the chronic use of the patients developed any sign of In seven cases with grade IV hard brown staphylococci at its concentration at 75 of Vancomycin oral y in cases of clostridium endophthalmitis. cataracts there was stromal oedema at minutes post intracameral injection. difficile, often for years, increasing the Dr Bansal noted that there are other day one, which disappeared at day seven Moxifloxacin is also easier to prepare for likelihood of developing resistant strains," factors that are important in preventing in al cases, he added. Moxifloxacin 0.5 per intracameral use than cefuroxime, because postoperative endophthalmitis. They include cent is taken directly from the vial into it doesn't require the use of a mil ipore a watertight wound architecture, and a 5ml syringe and then 0.1ml transferred filter and the process of dilution is much [email protected] good hydration of the wound at the end into a tuberculin syringe which is then simpler. Dr Arshinoff noted that to prepare [email protected] of surgery. However, use of intracameral injected intracamerally by 25G Cannula the antibiotic for intracameral injection he [email protected] moxifloxacin and a drop of five per cent under capsulorhexis margin. This avoids the first draws 2.0ml of moxifloxacin eye drop

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