Secondary Logo

Journal Logo

CATARACT SURGERY AND LENS IMPLANTATION: Edited by Natalie Afshari

Role of topical, subconjunctival, intracameral, and irrigative antibiotics in cataract surgery

Vazirani, Jayesh; Basu, Sayan

Author Information
Current Opinion in Ophthalmology: January 2013 - Volume 24 - Issue 1 - p 60-65
doi: 10.1097/ICU.0b013e32835a93be
  • Free

Abstract

INTRODUCTION

Cataract surgery is one of the most commonly performed surgical procedures across the world. Despite the advances in technology and technique that have transformed cataract surgery outcomes over the past few decades, postoperative endophthalmitis remains a significant concern. A meta-analysis of published literature estimated the worldwide incidence of endophthalmitis following cataract surgery to be 0.265% from 2000 to 2003 [1]. Alarmingly, this percentage was higher than reported rates in the 1980s (0.158%) and 1990s (0.087%) [1].

A variety of antiseptic and antibiotic agents have been tried in an effort to prevent postoperative endophthalmitis. Until recently, topical povidone–iodine was the only agent demonstrated in a prospective study to be effective in reducing the risk of endophthalmitis [2]. In the last decade, the European Society of Cataract and Refractive Surgeons (ESCRS) study provided high quality evidence for the utility of intracameral cefuroxime in reducing endophthalmitis rates [3]. Excellent review articles summarizing the factors implicated in causation of endophthalmitis postcataract surgery and the roles of antibiotic prophylaxis using different routes are available [4–7]. Here, we attempt to review recent literature on the topic, in particular the change in practice patterns around the world based on the ESCRS study results, and the subsequent impact on endophthalmitis rates.

POVIDONE–IODINE

Povidone–iodine is a nonselective antiseptic agent, with broad-spectrum microbicidal activity. In a nonrandomized prospective study, application of a 5% solution on the conjunctiva prior to surgery was found to reduce the rate of endophthalmitis by four-fold [2]. Other studies have also shown a reduction in concentration of conjunctival bacteria with povidone–iodine application [8–10]. A recent study determined that the preoperative use of topical fluoroquinolone antibiotics was more effective than povidone–iodine in conjunctival sterilization [11]. These conclusions need to be viewed in light of the small sample size in each of the groups and the difference in pretreatment cultures between groups. Preoperative use of topical povidone–iodine has become standard of care practice in cataract surgery, and has been mandated in the guidelines for infection prophylaxis from the American Academy of Ophthalmology [12]. No consensus exists regarding the concentration of povidone–iodine to be used, although a randomized prospective study demonstrated no difference in conjunctival cultures with use of either 5% or 10% solutions [13].

Box 1
Box 1:
no caption available

TOPICAL ANTIBIOTICS

Topical antibiotics are commonly used preoperatively, with the aim of sterilizing the ocular surface and achieving therapeutic concentrations in the anterior chamber of the eye. The most common strains from conjunctival isolates are found to be coagulase-negative staphylococci [14], which correlates well with the most commonly implicated organisms in endophthalmitis [15]. The antibiotic sensitivity profile of these organisms [14], coupled with the proven penetration into the anterior chamber [16] of topically administered fluoroquinolones, probably contributes to their popularity amongst surgeons. An overwhelming 91% of surgeons surveyed in the 2007 American Society of Cataract and Refractive Surgery (ASCRS) survey used topical antibiotic prophylaxis at the time of cataract surgery [17]. Of these, 81% preferred fourth generation fluoroquinolones (gatifloxacin or moxifloxacin). The preference for topical antibiotics continued in the 2011 ASCRS survey, wherein only 1% of surgeons reported not using them, and 77% preferred fourth generation fluoroquinolones [18]. This factor serves to highlight the chasm between evidence-based medicine and practice patterns, as the efficacy of topical antibiotics in preventing endophthalmitis has never been validated in a prospective trial. An argument advanced in favor of continuing prophylactic use of fluoroquinolones, rather than intracameral antibiotics as suggested by the strong evidence provided by the ESCRS study, is that the results of this trial are outdated [19]. Fourth generation fluoroquinolones such as moxifloxacin were not part of the ESCRS trial, and are now commercially available. It has been hypothesized that the results of the study might be different if the trial were to be repeated, substituting moxifloxacin for levofloxacin.

Studies have demonstrated a reduction in bacterial load of the conjunctival sac with preoperative application of topical fluoroquinolones [20–23]. A 3-day application of topical ofloxacin prior to surgery was found to be more effective than a 1-day or 1-h application [20,24]. With moxifloxacin, there appeared to be no difference between 3-day and 1-day applications [23]. The clinical relevance of these findings is open to debate, as the effect of reduced conjunctival bacterial load on endophthalmitis rates has not been explored. A randomized study found that topical application of moxifloxacin 1 day prior to surgery resulted in significant increase in fluoroquinolone-resistant bacteria [25]. The authors recommended that moxifloxacin, when used prophylactically, should be started 3 days prior to surgery, as such a regimen was not found to select for resistant organisms. This factor is particularly important in view of the increasing resistance of bacteria causing endophthalmitis to fluoroquinolones [26–28].

The newest fluoroquinolone developed solely for ophthalmic use is besifloxacin, with the objective of eliminating the contribution to resistance development due to systemic use [29–31]. Another purported advantage of this formulation is the use of DuraSite, a mucoadhesive polymer designed to prolong the adherence of the drug to the ocular surface [32]. Interestingly, though having broad spectrum antimicrobial activity, the aqueous humor concentrations achieved after topical application are less than that for moxifloxacin, and are deemed unlikely to be effective against drug-resistant bacteria frequently responsible for endophthalmitis [33]. Besifloxacin has been found to be well tolerated when used topically for infection prophylaxis prior to cataract surgery [34], though its efficacy has not been tested. As is usually the case with new drugs, the might of substantial marketing budgets is likely to ensure widespread adoption of this molecule by clinicians and relegation of ‘older generation’ antibiotics to the archives.

In summary, the preoperative use of topical antibiotics is widespread, particularly in the USA. A well entrenched practice pattern, it is unlikely to change in the near future, with newer fluoroquinolones being increasingly used. Postoperative topical antibiotic use is also near universal. Retrospective studies suggest that endophthalmitis rates are lower with the postoperative use of topical fourth generation fluoroquinolone use than those from historical controls [35,36]. The efficacy of this modality is unproven in a placebo-controlled prospective study.

SUBCONJUNCTIVAL AND IRRIGATIVE ANTIBIOTICS

Adequate aqueous humor concentrations of antibiotics have been demonstrated after subconjunctival injections [37,38]. Two large, retrospective studies have identified subconjunctival antibiotic use as highly effective in lowering the incidence of postoperative endophthalmitis [39,40]. A population-based study from Australia [39] found preoperative antiseptic preparation and use of subconjunctival antibiotics to be the only two factors independently associated with a decreased risk of endophthalmitis. Subconjunctival antibiotics were found to decrease the risk of endophthalmitis by half. Likewise, a hospital-based study [40] found a significant decrease in endophthalmitis rates with the use of subconjunctival antibiotics. With the increasing adoption of topical anesthesia for cataract surgery, the use of subconjunctival antibiotics is bound to wane.

Vancomycin added to the irrigating fluid during phacoemulsification has been found to achieve adequate concentrations in the aqueous humor [41]. A study found use of vancomycin in irrigating fluid to be more effective than preoperative topical antibiotic use in reducing anterior chamber microbial contamination [42]. Close to 15% of surgeons in the 2007 ASCRS survey and 21% in the 2011 survey reported use of irrigative antibiotics during cataract surgery [17,18]. High-quality evidence either supporting or refuting this practice is lacking.

INTRACAMERAL ANTIBIOTICS

The efficacy of prophylactic intracameral cefuroxime in preventing endophthalmitis after cataract surgery was suggested by retrospective data from Sweden [43], which showed a markedly lower rate of endophthalmitis with routine use of this modality. This finding was further substantiated by the ESCRS multicentre study of postoperative endophthalmitis. The ESCRS study remains, to date, the only prospective, randomized, placebo-controlled trial of prophylactic antibiotic use in cataract surgery [3]. The study initially aimed to enrol 35 000 patients across 24 ophthalmology units in Europe. A preliminary report [44] showed that incident rate of endophthalmitis in groups not receiving cefuroxime prophylaxis was nearly five-fold compared with groups receiving this treatment. It was deemed unethical to continue the trial and deny certain patients the benefits of cefuroxime prophylaxis. The robust evidence provided by the ESCRS study led to a change in practice patterns across Europe. For instance, 55% of surgeons surveyed in the United Kingdom in 2008 reported using intracameral cefuroxime, as compared with 10% in 2005 [45]. The major concerns cited by surgeons not using cefuroxime prophylaxis were lack of a preformulated preparation and risk of dilution errors, along with endothelial toxicity and possible bacterial contamination. Two-thirds of the surgeons not using cefuroxime would use it if a commercial preparation were available.

Subsequent to the results of the ESCRS study, multiple studies with large sample sizes from across Europe and Asia have reported decrease in endophthalmitis rates with the use of intracameral antibiotics (Table 1) [3,46–48,49▪▪,50,51]. Despite the inherent drawbacks of retrospective and observational study designs, lack of randomization or masking and possible selection bias, the statistical and clinical significance of the numbers from various centres is too consistent to be ignored. The antibiotics used have been cephalosporins (cefuroxime and cefazolin) as well as vancomycin. Interpreted in conjunction with the ESCRS trial outcomes, these studies constitute the largest cumulative body of evidence in favour of any single intervention for reducing the risk of postoperative endophthalmitis. From the public health perspective, routine use of intracameral antibiotics could possibly be one of the most cost effective measures to reduce endophthalmitis after cataract surgery. Sharifi et al.[52] in 2009 estimated the cost–effectiveness ratio for intracameral cefuroxime to be US$1403 per case of postoperative endophthalmitis prevented. According to them, fourth generation fluoroquinolones commonly used topically prior to surgery would have to be more than 19 times more effective than cefuroxime to achieve cost–effectiveness equivalence.

Table 1
Table 1:
A summary of recent studies on the efficacy of intracameral antibiotics in preventing postcataract surgery endophthalmitis

The impact of the ESCRS trial has been far less impressive on practice patterns across the Atlantic. In the 2007 ASCRS survey, 77% of respondent surgeons were not using any intracameral antibiotic [17]. However, 82% would do so if a reasonably priced commercial preparation were available. In the 2011 survey, the number of surgeons not using intracameral antibiotics went up to 81.7% [18]. This finding clearly indicates that surgeons in the USA have serious concerns regarding intracameral antibiotic use. These concerns include risks associated with preparing the solution, including dilution errors, bacterial contamination or toxic anterior segment syndrome. To overcome these, intracameral use of moxifloxacin has been suggested as an alternative [19]. A broad-spectrum antibiotic, it is available commercially as a nonpreserved formulation that can be diluted by the surgeon or administered directly with no further preparation. The safety profile of intracameral moxifloxacin has been established in a rabbit model [53] as well as in human controls [54]. Larger, well constructed studies that determine the efficacy of intracameral moxifloxacin in reducing postoperative endophthalmitis may lead to this modality assuming an important role in the future.

NEWER APPROACHES TO DRUG DELIVERY SYSTEMS

Collagen shields presoaked in antibiotic solutions have been explored as a method of drug delivery to the eye for well over a decade [55–57]. Although adequate penetration into the aqueous has been documented, the utility of this approach compared with the much simpler topical instillation is questionable. In a rabbit model, no statistical difference was found in endophthalmitis prophylaxis using fourth generation fluoroquinolones delivered either using collagen shields or by the topical route [58].

A fascinating approach to drug delivery is the potential use of polymeric devices to achieve sustained release of antibiotics postcataract surgery. This may have several potential advantages over traditional topical application of antibiotics, including cost, elimination of toxicity to the ocular surface and reliance on compliance by the patient. In a recently published study [59▪], a polymeric drug-delivery device incorporating norfloxacin was able to achieve therapeutic concentrations of the antibiotic in rabbit eyes. The device was attached to haptics of a commonly used intraocular lens, which was implanted subsequent to cataract surgery using a routine injection system. In an experimental endophthalmitis model, this approach was found to be superior to topical antibiotics for infection control. Such innovations may provide low-cost solutions for effective endophthalmitis prophylaxis in the future.

CONCLUSION

Preoperative antisepsis using povidone–iodine is essential for cataract surgery. Topical antibiotic prophylaxis, particularly the use of fourth generation fluoroquinolones continues to remain popular among surgeons, although convincing evidence regarding efficacy of the same is unavailable. In the light of convincing data published in the last decade from various centres across the world, we feel compelled to recommend the use of intracameral antibiotic prophylaxis as a routine measure in cataract surgery. There are legitimate concerns regarding lack of a commercially available, ready-to-inject formulation of cefuroxime. Further studies exploring the role of intracameral moxifloxacin may address these issues, and enhance greater adoption of this modality. Development of well tolerated, low-cost biocompatible devices for sustained antibiotic release is an exciting approach that merits further exploration.

Acknowledgements

None.

Conflicts of interest

There are no conflicts of interest.

Financial Disclosures: None

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest

Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 83–84).

REFERENCES

1. Taban M, Behrens A, Newcomb RL, et al. Acute endophthalmitis following cataract surgery: a systematic review of the literature. Arch Ophthalmol 2005; 123:613–620.
2. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology 1991; 98:1769–1775.
3. Group EES. 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.
4. Ou JI, Ta CN. Endophthalmitis prophylaxis. Ophthalmol Clin North Am 2006; 19:449–456.
5. Kim JY, Ali R, Cremers SL, Henderson BA. Perioperative prophylaxis for postcataract extraction endophthalmitis. Int Ophthalmol Clin 2007; 47:1–14.
6. Yiu G, Young L, Gilmore M, Chodosh J. Prophylaxis against postoperative endophthalmitis in cataract surgery. Int Ophthalmol Clin 2011; 51:67–83.
7. Yu CQ, Ta CN. Prevention of postcataract endophthalmitis: evidence-based medicine. Curr Opin Ophthalmol 2012; 23:19–25.
8. Apt L, Isenberg SJ, Yoshimori R, et al. The effect of povidone-iodine solution applied at the conclusion of ophthalmic surgery. Am J Ophthalmol 1995; 119:701–705.
9. Mino de Kaspar H, Chang RT, Singh K, et al. Prospective randomized comparison of 2 different methods of 5% povidone-iodine applications for anterior segment intraocular surgery. Arch Ophthalmol 2005; 123:161–165.
10. Ferguson AW, Scott JA, McGavigan J, et al. Comparison of 5% povidone-iodine solution against 1% povidone-iodine solution in preoperative cataract surgery antisepsis: a prospective randomised double blind study. Br J Ophthalmol 2003; 87:163–167.
11. Coskun M, Altintas AG, Anayol MA, et al. Evaluation of efficacy of topical povidone-iodine and different types of fluoroquinolones in the sterilization of bacterial flora on the conjunctiva. J Ocul Pharmacol Ther 2011; 27:589–592.
12. American Academy of Ophthalmology Cataract and Anterior Segment Panel. Preferred Practice Pattern Guidelines. Cataract in the Adult Eye. San Francisco, CA: American Academy of Ophthalmology; 2011. http://www.aao.org/CE/PracticeGuidelines/PPP. Accessed 25 July 2012.
13. Ta CN, Singh K, Egbert PR, de Kaspar HM. Prospective comparative evaluation of povidone-iodine (10% for 5 min versus 5% for 1 min) as prophylaxis for ophthalmic surgery. J Cataract Refract Surg 2008; 34:171–172.
14. Ta CN, Chang RT, Singh K, et al. Antibiotic resistance patterns of ocular bacterial flora: a prospective study of patients undergoing anterior segment surgery. Ophthalmology 2003; 110:1946–1951.
15. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol 1995; 113:1479–1496.
16. Kim DH, Stark WJ, O’Brien TP, Dick JD. Aqueous penetration and biological activity of moxifloxacin 0.5% ophthalmic solution and gatifloxacin 0.3% solution in cataract surgery patients. Ophthalmology 2005; 112:1992–1996.
17. Chang DF, Braga-Mele R, Mamalis N, et al. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey. J Cataract Refract Surg 2007; 33:1801–1805.
18. Leaming D. 2011 Survey of US ASCRS Members. http://www.analeyz.com/AnaleyzASCRS2011.htm. Accessed 25 July 2012
19. O’Brien TP, Arshinoff SA, Mah FS. Perspectives on antibiotics for postoperative endophthalmitis prophylaxis: potential role of moxifloxacin. J Cataract Refract Surg 2007; 33:1790–1800.
20. Inoue Y, Usui M, Ohashi Y, et al. Preoperative disinfection of the conjunctival sac with antibiotics and iodine compounds: a prospective randomized multicenter study. Jpn J Ophthalmol 2008; 52:151–161.
21. Mino de Kaspar H, Kreutzer TC, Aguirre-Romo I, et al. A prospective randomized study to determine the efficacy of preoperative topical levofloxacin in reducing conjunctival bacterial flora. Am J Ophthalmol 2008; 145:136–142.
22. Isenberg SJ, Apt L, Yoshimori R, Khwarg S. Chemical preparation of the eye in ophthalmic surgery. IV. Comparison of povidone-iodine on the conjunctiva with a prophylactic antibiotic. Arch Ophthalmol 1985; 103:1340–1342.
23. He L, Ta CN, Hu N, et al. Prospective randomized comparison of 1-day and 3-day application of topical 0.5% moxifloxacin in eliminating preoperative conjunctival bacteria. J Ocul Pharmacol Ther 2009; 25:373–378.
24. Ta CN, Egbert PR, Singh K, et al. Prospective randomized comparison of 3-day versus 1-h preoperative ofloxacin prophylaxis for cataract surgery. Ophthalmology 2002; 109:2036–2040.
25. He L, Ta CN, Miño de Kaspar H. One-day application of topical moxifloxacin 0.5% to select for fluoroquinolone-resistant coagulase-negative Staphylococcus. J Cataract Refract Surg 2009; 35:1715–1718.
26. Miller D, Flynn PM, Scott IU, et al. In vitro fluoroquinolone resistance in staphylococcal endophthalmitis isolates. Arch Ophthalmol 2006; 124:479–483.
27. Miller DM, Vedula AS, Flynn HW Jr, et al. Endophthalmitis caused by Staphylococcus epidermidis: in vitro antibiotic susceptibilities and clinical outcomes. Ophthalmic Surg Lasers Imaging 2007; 38:446–451.
28. Harper T, Miller D, Flynn HW Jr. In vitro efficacy and pharmacodynamic indices for antibiotics against coagulase-negative staphylococcus endophthalmitis isolates. Ophthalmology 2007; 114:871–875.
29. Haas W, Pillar CM, Zurenko GE, et al. Besifloxacin, a novel fluoroquinolone, has broad-spectrum in vitro activity against aerobic and anaerobic bacteria. Antimicrob Agents Chemother 2009; 53:3552–3560.
30. Carter NJ, Scott LJ. Besifloxacin ophthalmic suspension 0.6%. Drugs 2010; 70:83–97.
31. Haas W, Pillar CM, Hesje CK, et al. Bactericidal activity of besifloxacin against staphylococci, Streptococcus pneumoniae and Haemophilus influenzae. J Antimicrob Chemother 2010; 65:1441–1447.
32. Bowman LM, Si E, Pang J, et al. Development of a topical polymeric mucoadhesive ocular delivery system for azithromycin. J Ocul Pharmacol Ther 2009; 25:133–139.
33. Donnenfeld ED, Comstock TL, Proksch JW. Human aqueous humor concentrations of besifloxacin, moxifloxacin, and gatifloxacin after topical ocular application. J Cataract Refract Surg 2011; 37:1082–1089.
34. Malhotra R, Gira J, Berdy GJ, Brusatti R. Safety of besifloxacin ophthalmic suspension 0.6% as a prophylactic antibiotic following routine cataract surgery: results of a prospective, parallel-group, investigator-masked study. Clin Ophthalmol 2012; 6:855–863.
35. Moshirfar M, Feiz V, Vitale AT, et al. Endophthalmitis after uncomplicated cataract surgery with the use of fourth-generation fluoroquinolones: a retrospective observational case series. Ophthalmology 2007; 114:686–691.
36. Jensen MK, Fiscella RG, Moshirfar M, Mooney B. Third- and fourth-generation fluoroquinolones: retrospective comparison of endophthalmitis after cataract surgery performed over 10 years. J Cataract Refract Surg 2008; 34:1460–1467.
37. Souli M, Kopsinis G, Kavouklis E, et al. Vancomycin levels in human aqueous humour after intravenous and subconjunctival administration. Int J Antimicrob Agents 2001; 18:239–243.
38. Clements DB, Tailor V. A study of aqueous and serum levels of ceftazidime following subconjunctival administration. Br J Ophthalmol 1987; 71:433–435.
39. Ng JQ, Morlet N, Bulsara MK, Semmens JB. Reducing the risk for endophthalmitis after cataract surgery: population-based nested case–control study. J Cataract Refract Surg 2007; 33:269–280.
40. Colleaux KM, Hamilton WK. Effect of prophylactic antibiotics and incision type on the incidence of endophthalmitis after cataract surgery. Can J Ophthalmol 2000; 35:373–378.
41. Adenis JP, Robert PY, Mounier M, Denis F. Anterior chamber concentrations of vancomycin in the irrigating solution at the end of cataract surgery. J Cataract Refract Surg 1997; 23:111–114.
42. Srinivasan R, Gupta A, Kaliaperumal S, et al. Efficacy of intraoperative vancomycin in irrigating solutions on aqueous contamination during phacoemulsification. Indian J Ophthalmol 2008; 56:399–402.
43. Montan PG, Wejde G, Koranyi G, Rylander M. Prophylactic intracameral cefuroxime. Efficacy in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg 2002; 28:977–981.
44. Barry P, Seal DV, Gettinby G, et al. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery. J Cataract Refract Surg 2006; 32:407–410.
45. Gore DM, Angunawela RI, Little BC. United Kingdom survey of antibiotic prophylaxis practice after publication of the ESCRS Endophthalmitis Study. J Cataract Refract Surg 2009; 35:770–773.
46. Garat M, Moser CL, Martín-Baranera M, et al. Prophylactic intracameral cefazolin after cataract surgery. J Cataract Refract Surg 2009; 35:637–642.
47. García-Sáenz MC, Arias-Puente A, Rodríguez-Caravaca G, Bañuelos JB. Effectiveness of intracameral cefuroxime in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg 2010; 36:203–207.
48. Anijeet D. Intracameral vancomycin following cataract surgery: an eleven-year study. Clin Ophthalmol 2010; 4:321–326.
49▪▪. Romero-Aroca P, Méndez-Marin I, Salvat-Serra M, et al. Results at seven years after the use of intracamerular cefazolin as an endophthalmitis prophylaxis in cataract surgery. BMC Ophthalmol 2012; 12:2.

A prospective study of surgeries carried out at 38 different hospitals in Spain with or without use of intracameral cefazolin found more than 11-fold decrease in endophthalmitis incidence after introduction of intracameral cefuroxime use. With data on over 25 000 surgeries, this study corroborates the evidence provided by the ESCRS study in favor of intracameral antibiotic use.

50. Barreau G, Mounier M, Marin B, et al. Intracameral cefuroxime injection at the end of cataract surgery to reduce the incidence of endophthalmitis: French study. J Cataract Refract Surg 2012; 38:1370–1375.
51. Tan CS, Wong HK, Yang FP. Epidemiology of postoperative endophthalmitis in an Asian population: 11-year incidence and effect of intracameral antibiotic agents. J Cataract Refract Surg 2012; 38:425–430.
52. Sharifi E, Porco TC, Naseri A. Cost–effectiveness analysis of intracameral cefuroxime use for prophylaxis of endophthalmitis after cataract surgery. Ophthalmology 2009; 116:1887–1896.
53. Kowalski RP, Romanowski EG, Mah FS, et al. Intracameral Vigamox (moxifloxacin 0.5%) is nontoxic and effective in preventing endophthalmitis in a rabbit model. Am J Ophthalmol 2005; 140:497–504.
54. Lane SS, Osher RH, Masket S, Belani S. Evaluation of the safety of prophylactic intracameral moxifloxacin in cataract surgery. J Cataract Refract Surg 2008; 34:1451–1459.
55. Taravella M, Stepp P, Young D. Collagen shield delivery of tobramycin to the human eye. CLAO J 1998; 24:166–168.
56. Taravella MJ, Balentine J, Young DA, Stepp P. Collagen shield delivery of ofloxacin to the human eye. J Cataract Refract Surg 1999; 25:562–565.
57. Hariprasad SM, Shah GK, Chi J, Prince RA. Determination of aqueous and vitreous concentration of moxifloxacin 0.5% after delivery via a dissolvable corneal collagen shield device. J Cataract Refract Surg 2005; 31:2142–2146.
58. Haugen B, Werner L, Romaniv N, et al. Prevention of endophthalmitis by collagen shields presoaked in fourth-generation fluoroquinolones versus by topical prophylaxis. J Cataract Refract Surg 2008; 34:853–858.
59▪. Garty S, Shirakawa R, Warsen A, et al. Sustained Antibiotic Release from an Intraocular Lens-Hydrogel Assembly for Cataract Surgery. Investig Ophthalmol Visual Sci 2011; 52:6109–6116.

This experimental study provides useful pointers towards the future of drug delivery systems into the eye, raising the possibility of well tolerated, effective and low-cost biocompatible devices for sustained antibiotic release.

Keywords:

antibiotic prophylaxis; cataract surgery; endophthalmitis; intracameral; topical

Copyright © 2013 Wolters Kluwer Health, Inc. All rights reserved.