Postsurgical Cataract Prophylaxis With Intravitreal “Triamcinolone-Moxifloxacin” May Not Be Optimal For Preventing Endophthalmitis (original) (raw)
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Archives of Ophthalmology, 2005
Recent reports of high endophthalmitis rates after intravitreal triamcinolone acetonide injection have raised concerns about the safety of this treatment. We sought to evaluate the effect of intravitreal triamcinolone injection on (1) the susceptibility to experimental bacterial endophthalmitis and (2) the subsequent therapeutic response to antibiotic treatment. For the susceptibility study, the right eye of 40 New Zealand white rabbits received an intravitreal injection of a known quantity of Staphylococcus epidermidis organisms. Half of the eyes received a simultaneous intravitreal injection of triamcinolone acetonide, 4 mg. All eyes were examined daily for signs of endophthalmitis (photophobia, conjunctival injection, and vitritis) using standardized grading protocols (scaled from 0 to 4 with increasing severity). On day 7, vitreous cultures were obtained. For the therapeutic response study, the right eye of 12 rabbits received an intravitreal injection of S epidermidis organisms sensitive to vancomycin. Half of the eyes received a simultaneous intravitreal injection of triamcinolone acetonide, 4 mg. All 12 eyes received an intravitreal injection of vancomycin hydrochloride, 1 mg, on development of the first signs of endophthalmitis. All eyes were examined daily for 7 additional days. On day 7 after treatment, vitreous cultures were obtained. In the susceptibility study, all 40 eyes developed signs of endophthalmitis. In eyes that received intravitreal bacteria plus triamcinolone, 17 (85%) of the 20 vitreous cultures were positive, whereas only 6 (30%) were positive in the 20 eyes receiving bacteria alone (P = .001). The vitritis was significantly increased in the bacteria plus triamcinolone group compared with the bacteria-only group (17 of 20 vs 7 of 20 with 4+ vitritis, respectively; P = .003). In the therapeutic response study, all 12 eyes developed clinical signs of endophthalmitis within 48 hours. All vitreous samples obtained 7 days after intravitreal vancomycin injection were culture negative. However, the severity of vitritis at the time of vitreous sampling was less in the eyes receiving triamcinolone plus bacteria compared with eyes receiving bacteria alone (0 of 6 vs 5 of 6 with 4+ vitritis, respectively; P = .02). In eyes with experimentally induced bacterial endophthalmitis, the presence of intravitreal triamcinolone results in a higher culture-positive rate and a higher degree of inflammation, suggesting an impaired ocular immune response and greater susceptibility to infection. However, in eyes with experimentally induced bacterial endophthalmitis receiving early treatment with intravitreal antibiotics, triamcinolone appears to suppress the ocular inflammatory response without impairing the therapeutic effect. These data suggest that caution must be exercised when combining intravitreal triamcinolone injection with intraocular surgery.
Journal of cataract and refractive surgery, 2016
To review current and past practices of intracameral antibiotic administration for infection prophylaxis in cataract surgery; to review the benefits and liabilities of available prophylactic drugs, dosage determination, and administration protocols; and to devise an optimum dose and administration protocol for intracameral moxifloxacin. Humber River Hospital and the University of Toronto, Toronto, Ontario, Canada. Retrospective evaluation of treatment modality. This study consisted of a detailed review of the history, drugs, and methods of intracameral prophylaxis and microbiological and pharmacodynamics analysis of options. A review of potential drug sources and doses was performed and 1 drug, dose, and administration protocol was selected. The current method's adoption reasons are described followed by the authors' experience. A single infection in 3430 cases occurred with a moxifloxacin-resistant strain of Staphylococcus epidermidis when moxifloxacin 100 mcg in 0.1 mL was...
American Journal of Ophthalmology, 2005
To determine whether Vigamox® (moxifloxacin 0.5% ophthalmic solution) can be safely injected intracamerally to prevent Staphylococcus aureus endophthalmitis in a rabbit model. • DESIGN: Animal study. • METHODS: The safety and bactericidal-effectiveness of Vigamox® were evaluated in three stages using 189 New Zealand White rabbits. (Stage 1) The toxicity of two intravitreal doses of Vigamox® (moxifloxacin 500, 250 g) was compared with vancomycin (1 mg) and saline. (Stage 2) A reproducible rabbit model of Staphylococcus aureus endophthalmitis was established. (Stage 3) The bactericidal effect of intracameral Vigamox® (moxifloxacin 500, 250, 125, 50 g) was compared with vancomycin (1 mg) and saline. Intracameral antibiotic therapy commenced immediately after Staphylococcus aureus intravitreal challenge (5000 cfu). Toxicity was evaluated by masked clinical examination using a slit-lamp, an indirect ophthalmoscope, and corneal-ultrasound pachymetry. The clinical examination included the exterior eye, cornea, anterior chamber, vitreous, and retina. The presentations were graded on a severity scale of 0, 0.5, 1, 2, and 3. The bactericidal efficacy was determined using intracameral colony counts. • RESULTS: In the toxicity studies without bacterial challenge, the clinical scores of rabbits injected intracamerally with Vigamox® were statistically equivalent to rabbits given intracameral vancomycin or saline. In the efficacy studies, eyes treated intravitreally with Vigamox®, at all doses, or vancomycin were negative for Staphylococcus aureus and nontreated controls remained culture-positive. • CONCLUSIONS: Vigamox® appears to be nontoxic for intracameral injection and effective in preventing experimental endophthalmitis in the rabbit model. Further studies will determine the clinical role of intracameral Vigamox® for surgical prophylaxis and postoperative therapy.
Journal of Ocular Pharmacology and Therapeutics, 2012
Purpose: Topical antibacterial agents, used as an off-label indication, are frequently administered pre-and postoperatively to prevent endophthalmitis. We compared topical treatment with fluoroquinolone (FQ) antiinfectives to non-FQ antibacterial agents to prevent Staphylococcus aureus endophthalmitis. We hypothesize that FQ anti-infectives are more effective than non-FQ antibacterial agents for preventing endophthalmitis. Methods: Moxifloxacin 0.5%, ofloxacin 0.3%, gentamicin 0.3%, chloramphenicol 0.5%, polymyxin B/trimethoprim (10,000 units/mL/0.1%), povidone-iodine 5%, and saline were tested for topical treatment to prevent endophthalmitis. Topical treatment was applied every 15 min for 1 h (5 drops) to the left eye of 14 rabbits for each antibacterial agent and saline. After appropriate anesthesia, the anterior chambers were injected with 1 · 10 5 colony-forming units of a clinical endophthalmitis isolate of a S. aureus that was susceptible to all tested antibacterials. One drop was administered immediately and another 4 drops of topical treatment were applied over 24 h after injection. At 24 h postinjection, the eyes were graded for clinical signs of endophthalmitis (ocular discharge, conjunctivitis/scleral injection, limbal injection, hypopyon*, iritis*, anterior chamber cells*, anterior chamber flare*, corneal infiltration, and fibrin production*) using a severity scale (0-3). The indication of clinical endophthalmitis was a total score of > 3.0 for the presentations marked with an asterisk. The data were analyzed using Fisher's Exact Randomization or Mann-Whitney nonparametric testing. Results: Topical ofloxacin (14/14, 100% without endophthalmitis) and moxifloxacin (13/14, 93%) prevented the clinical presentation of endophthalmitis significantly more frequently (P = 0.03, Fisher's Exact Test (FE)) than topical gentamicin (7/14, 50%), povidone iodine (4/14, 29%), chloramphenicol (0/14, 0%), polymyxin B/trimethoprim (0/14, 0%), and saline (0/14, 0%). The median total clinical scores for the ofloxacin (0.5) and moxifloxacin (0.8) groups were significantly (P = 0.008, Mann-Whitney Test (MW)) lower than gentamicin (5.7), chloramphenicol (17.5), polymyxin B/trimethoprim (21.2), povidone-iodine (15.5), and saline (18.7). Conclusions: The FQs, ofloxacin and moxifloxacin, were more effective in preventing endophthalmitis than the non-FQ antibacterial agents in a rabbit S. aureus endophthalmitis model. The observed results are consistent with the hypothesis that FQs penetrate into the anterior chamber at more effective levels than many of the common non-FQ antibacterial agents.
Intravitreal Triamcinolone Acetonide in the Management of Exogenous Bacterial Endophthalmitis
American Journal of Ophthalmology, 2006
PURPOSE: To determine the effectiveness of intravitreal triamcinolone acetonide in the management of bacterial endophthalmitis. DESIGN: Interventional case series. METHODS: This pilot case series included five patients (three patients after trauma and two patients after cataract surgery) with culture proven bacterial endophthalmitis. After 48 to 72 hours of the initial surgical procedure, 4 mg/0.1 ml of intravitreal triamcinolone acetonide was injected, after confirmation that the vitreous isolate was sensitive to the initially administered intravitreal antibiotics. All patients received oral ciprofloxacin 750 mg twice each day for seven days. The course of inflammation and the clinical outcome were noted. RESULTS: In all the five cases, there was complete resolution of inflammation with favorable clinical outcome at the end of one month that was maintained at the end of three months. CONCLUSION: Intravitreal triamcinolone acetonide could be a treatment option in the selected cases of bacterial endophthalmitis.
2011
Material and Methods: This prospective study was conducted in the department of Ophthalmology Fauji Foundation Hospital, Rawalpindi, from December 2006 to November 2007 and comprised of 200 patients. The patients were divided into two groups. Group 1 received 0.1 ml of intracameral moxifloxacin 0.5 % ophthalmic solution at the conclusion of the surgery and the patients in the group 2 were not given the intracameral antibiotic. None of the patients was given postoperative sub conjunctival antibiotic and steroid injection. All patients were examined for AC reaction and pachymetry was done preoperatively and postoperatively (first day, first week and 4 weeks postoperatively). Anterior chamber reaction and pachymetry values between the two groups were compared .Statistical analysis was done by using paired sample t test. P value of less than 0.05 was taken as significant.