While we agree that intracameral cefuroxime may assist the eye, this benefit is defied by the statistics on endophthalmitis. We therefore thank Dr. Tan and coauthors for their observations and appreciate the opportunity to attempt to illuminate further the discussion regarding intracameral cefuroxime. We will address the key points raised in their letter.
No cataract surgeon denies that endophthalmitis is a devastating complication of his or her surgery. Endophthalmitis regularly results in poor visual outcomes and sometimes necessitates removal of the eye. However, anaphylaxis may have even worse consequences with its potential threat to life. Villada et al.1 reported a patient who developed anaphylaxis within 5 minutes of a 1.0 mg injection of intracameral cefuroxime. Stabilization of this patient was achieved only after prompt intervention by an anesthesiologist. The severity of this complication is not commensurate with the largely elective nature of phacoemulsification cataract surgery.
It is also understandable that few, if any, such cases with adverse systemic reactions have been reported. Indeed, underreporting of fatal anaphylactic reactions to appropriate regulatory agencies has been identified.2 Furthermore, as indicated by Dr. Tan and coauthors, careful selection of antibiotics minimizes but does not completely obviate the risk for anaphylaxis.
The authors have also highlighted the association of a reduction in the rate of endophthalmitis coincident with the introduction of prophylactic intracameral antibiotics. A recent paper by Behndig et al.3 explored and summarized available data relating to the use of intracameral cefuroxime in Europe for infective postoperative endophthalmitis prophylaxis following cataract surgery. Although findings in this study appear to support the use of intracameral cefuroxime for endophthalmitis prophylaxis, significant limitations to the process of data acquisition and analysis have been highlighted by our group4 and preclude definitive conclusions regarding the use of intracameral cefuroxime.
All of our cataract surgical colleagues are urged to evaluate critically and continually the available evidence in order to achieve the best possible outcome for each patient.
1. Villada JR, Vicente U, Javaloy J, Alió JL. Severe anaphylactic reaction after intracameral antibiotic administration during cataract surgery. J Cataract Refract Surg
2. Pumphrey RSH, Davis S., 1999. Under-reporting of antibiotic anaphylaxis may put patients at risk [letter], Lancet, 353, 1157-1158.
3. Behndig A, Cochener B, Güell JL, Kodjikian L, Mencucci R, Nuijts RMMA, Pleyer U, Rosen P, Szaflik JP, Tassignon M-J. Endophthalmitis prophylaxis in cataract surgery: overview of current practice patterns in 9 European countries. J Cataract Refract Surg
4. Williams SC, Aulia FA, Lim CHL, Yun STH, McPherson ZE, Wang SB, Agar A, Francis IC. Endophthalmitis in Europe: data collection conundrum. [letter] J Cataract Refract Surg 2014;40:688, reply by A Behndig, B Cochener, JL Güell, L Kodjikian, R Mencucci, RMMA Nuijts, U Pleyer, P Rosen, JP Szaflik, M-J Tasignon, 688–689.