The document discusses strategies to prevent post-operative endophthalmitis following cataract surgery. It finds that pre-operative povidone-iodine and topical antibiotics can significantly reduce conjunctival bacterial flora. Intracameral antibiotics during surgery, such as cefuroxime, also significantly lower the risk of endophthalmitis. Fourth generation fluoroquinolones like moxifloxacin and gatifloxacin are more potent than earlier generations against gram-positive bacteria. Subconjunctival antibiotics administered with surgery may halve the risk of post-operative endophthalmitis. Comprehensive pre, during and post-operative antibiotic protocols are important to minimize this potentially devastating

1. PERIOPERATIVE
ANTIBIOTICS IN
CATARACT SURGERY
ARE NEEDED
DR. AJAY DUDANI
DR. MEETU KHOLA

2. Post operative Endophthalmitis (POE) is
defined as a severe inflammation involving
both the anterior and posterior segments of
the eye secondary to an infectious agent.
Ophthalmol 2004; 49 (2): S55-S61

3. Postop. Endophthalmitis
 The incidence of endophthalmitis though has sharply
declined over the past 40 yrs., it is still one of the most
catastrophic complications of eye surgery.
 Incidence - 1900 - 10%
- 1950 - 1%
- 1990 - 0.3% or less
- 2008 – 0.09% *
* - J Cataract Refract Surg 2009; 35:629–636 Q 2009
ASCRS and ESCRS

4. Endophthalmitis - Prophylaxis
 Remains a challenge
still
 No firm guidelines
currently exist
 Surgeon should be
cognizant of risk factors
 Should assess their
patients carefully prior
to surgery

5.  Post operative endophthalmitits is a
devastating condition and every step
should be taken to reduce its occurrence.

6. 0.8
0.18 0.12 0.11
0
0.2
0.4
0.6
0.8
1
Cataract
Keratoplasty
Glaucoma
Cataract
+
Trabeculectomy
Incidence after various ocular surgeries (%)
Ophthalmology 1998; 105(6): 1004-1010

7. Day of presentation of infection
0
10
20
30
40
50
60
70
80
% infection
1-7 days 8-14 days >15 days >1 month
In most cases, infection occurs in immediate post-op period,
Suppl. Ophthal Times 2003; 28(5), 1-15

8. Most common organisms responsible for
endophthalmitis
Gram positive bacteria 75%-85% Gram negative bacteria 10%-15%
Staphylococcus epidemidis 43% Pseudomonas 8%
Streptococcus spp 20% Proteus 5%
Staphylococcus aureus 15% Haemophilus influenzae 0-1%
Propionibacterium acnes 30
reports
Klebsiella 0-1%
Bacillus cereus 1% Coliform spp 0-1%
Fungi (rare)
Candida parapsilosis
Aspergillus
Cephalosporium spp.
Br J Oph 1997, 81:1006-15

9. PRE OPERATIVE ANTIOBIOTIC
PROPHYLAXIS
Prophylactic methods in cataract surgery
include :
 Identification and adequate treatment of
ocular surface infections prior to surgery.
 Topical antibiotic prior to surgey.
 Povidone-iodine usage prior to surgery.
Can J Ophthalmol. 2007 Oct;42(5):681-8.

11. Pre-operative scrub
 Povidone-iodine (5%) has broad
antibacterial, as well as antifungal &
antiviral activity
 It decreases conjunctival flora growth to
91%
 Can destroy bacteria in 30 secs

12. Patient - Povidone Iodine 5%
 Best prophylactic agent
 In conj. sac for few min
before surgery
 Destroy bacteria in 30
sec.
 Low cost and minimal
toxicity
 Effect equivalent to 3
days course of topical
antibiotics

13. Use of Povidone – iodine largely reduces
the incidence of post – operative
endophthalmitis in any kind of
intraocular surgery.
 Hara J, Yasuda F, Higashitsutsumi M. Preoperative disinfection of the conjunctival sac in cataract
surgery. Ophthalmologica. 1997;211 (suppl 1):62-67.
 Rongrungruang Y, Tantaterdthum J, Tuntiwattanapibul Y, Sripalakij S, Danchaivijitr S. Bacterial
flora—A potential source of endophthalmitis after cataract surgery. J Med Assoc Thai. 2005;88
(suppl 10):S49-53.
 Barkana Y, Almer Z, Segal O, Lazarovitch Z, Avni I, Zadok D. Reduction of conjunctival bacterial
flora by povidone-iodine, ofloxacin and chlorhexidine in an outpatient setting. Acta Ophthalmol
Scand. 2005;83(3):360-363.

14. Antibiotics
 Adding antibiotics to irrigation
solution , show a reduction of incidence
of endophthalmitis.

15.  Addition of vancomycin in the
concentration of 20 micrograms/ml in the
irrigating solution led to a statiscally
significant amount of reduction in the
number of bacterial colonies from aqueous
samples obtained 2 hours after surgery.
 Am J Ophthalmol : 2001 March;131 (3):293-300.

16.  Intraoperative usage of vancomycin
20microgm/ml and gentamicin
0.8microgm/ml reduces the culture
positivity of aqueous samples obtained at
end of surgey to < 6.8%.
 Eur J Ophthalmol. 2003 Nov-Dec;13(9-10):773-8.

17. REDUCTION OF PREOPERATIVE CONJUNCTIVAL
BACTERIAL FLORA WITH THE USE OF MUPIROCIN
NASAL OINTMENT
 Prospective, double-arm, blinded clinical trial of
37 eyes of 37 patients undergoing intraocular
surgery (cataract extraction or pars plana
vitrectomy) randomized to either control or
mupirocin treatment groups. Treated patients
received mupirocin nasal ointment twice daily for
5 days prior to surgery. Nasal cultures were
obtained in all patients. All patients received a
standard 5% povidone-iodine preparation before
the surgical procedure, and conjunctival cultures
were obtained in all patients before and after
the povidone-iodine preparation.

18.  All of 37 patients nasal swabs were positive for bacterial
growth (cultures were obtained prior to the use of
mupirocin ointment in the treatment group). One of 15
eyes (6.7%) in the treatment group had positive
conjunctival cultures prior to povidone-iodine
preparation, compared with nine of 22 eyes (41%) in the
control group (P < .05). Even after povidone-iodine
preparation, eight of 22 eyes (36%) in the control group
demonstrated persistent positive cultures, whereas one
(6.7%) of the treatment eyes exhibited growth (P <
.05).

Trans Am Ophthalmol Soc. 2006 December; 104: 196–201.

19.  Prophylactic use of mupirocin nasal
ointment resulted in significant reduction
of conjunctival flora with or without
preoperative topical 5% povidone-iodine
preparation. The use of mupirocin nasal
ointment prior to intraocular surgery or
intravitreal injections is a novel method for
reducing conjunctival contamination rates,
which theoretically should reduce the
incidence of endophthalmitis.

20. Role of prophylactic antibiotics
Studies have shown that prophylactic antibiotic
reduces the number of conjunctival bacteria at
the time of surgery
 Optimal choice of pre-operative topical antibiotic
depends on spectrum of bacteria covered
 Rapidity of killing
 Duration of action
 Penetration and toxicity of antibiotic
 Antibiotic susceptibility pattern
 Cost

21. INCREASING FLUOROQUINOLONE RESISTANCE
 A number of recent studies have reported
emerging resistance to FQ’s among ocular
isolates particularly among gram positive
organisms
 In recent years, up to 30% or more of S.
aureus strains are found to be
fluoroquinolone resistant
Surv Ophth 2004; 49(2): 579-583

22. A new generation
to treat infection
 The fourth generation fluoroquinolones like
gatifloxacin, moxifloxacin have enhanced activity
against gram positive pathogens.
 Organisms resistant to earlier gen FQs are
susceptible to fourth gen FQs
 Secondly they are less prone to encourage
development of resistant strains
Surv Oph 2004,49 (2),S55-61
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23. Potential role of 4th generation FQs
 In terms of forestalling the development
of resistance, primary use of 4th gen FQs
may actually be a better strategy than
initial use of older FQs
 Conventional strategy of reserving the use
of newer anti-microbial only when older
anti-microbial fails may not be a wise
strategy if applied to FQs

24. Aim : To study in vitro potency of 2nd, 3rd, 4th generation fq’s
for: bacterial endophthalmitis isolates
Results ( % of
significant colony
count)
CIP OFX GAT MOX Potency by
Rank
(p=.05)
2nd Gen FQ-Res SA 6.4 6.4 3.5 1.75 mox>gat>ci
p=ofx
2nd Gen FQ-Sen SA .32 .63 .11 .06 mox>gat>ci
p>ofx
CoagNeg Staph FQ 6.4 6.4 2.0 2.5 mox=gat>ci
p=ofx
CoagNeg. Staph FQ .13 .38 .09 .05 mox>gat=ci
p> ofx
Strep. pneumoniae .75 2.0 .22 .09 Mox>gat=ci
p>ofx
Gram-negatives .06 .19 .06 .08 Cip=gat=mo
x> ofx

25. Conclusion
In vitro study suggests that the 4th generation FQ are
more potent than the 2nd and 3rd generation FQ for
gram-positives and equally as potent for gram-negatives.
The 4th gen FQ appear to cover 2nd and 3rd generation
FQ resistance.

26. Comparison of 2 moxifloxacin regimens for preoperative prophylaxis:
prospective randomized triple-masked trial.
 PURPOSE: To evaluate the aqueous concentration of moxifloxacin
following 2 dosing regimens of topically administered moxifloxacin
hydrochloride ophthalmic solution 0.5% (Vigamox).
 In Group A (n = 76), Vigamox was instilled 4 times a day
1 day before surgery plus 1 drop 2 hours before surgery
(total of 5 drops). In Group B (n = 76), Vigamox was
first instilled 2 hours before surgery and then every 15
minutes for 1 hour (total of 5 drops). In both groups,
aqueous samples (0.1 mL) were collected within 2 hours
of the first instillation on the day of surgery

27. J Cataract Refract Surg (2008) 34: 1379-82.
A.R.Vasavada, D.Gajjar, S M Raj, V Vasavada
 RESULTS: The mean aqueous humor concentration of
moxifloxacin was 1.58 microg/mL +/- 0.80 (SD) in Group
A and 2.05 +/- 0.72 microg/mL in Group B (P<.0001;
95% CI, -0.72 to -0.22).
 CONCLUSIONS: Both dosing regimens produced
substantially higher aqueous concentrations than the
known minimum inhibitory concentration for
Staphylococcus epidermidis. Topical moxifloxacin
administered 2 hours before surgery achieved
significantly higher aqueous concentrations than topical
moxifloxacin administered 1 day before surgery with 1
drop given on the day of surgery.

28. Post-op Antibiotics
Injection of intracameral 1mg/0.1ml
of cefuroxime (3000ug/ml @ a/c ) at
the end of surgery:
 It has been shown that the risk of
Endoph. with this regimen reduced by
almost 5 folds (ESCRS ) study.

29. ESCRS STUDY
 A randomized prospective partially masked
cataract surgery study with 16603 patients
based on a 2×2 factorial design with
intracameral cefuroxmine 1mg in 0.1ml
normal saline or peri - operative topical
Levofloxacin drops.

30.  RESULTS: 20 were proven to have infective endophthalmitis. The
absence of an intracameral cefuroxime prophylactic regimen at 1
mg in 0.1 mL normal saline was associated with a 4.92-fold
increase (95% confidence interval [CI], 1.87-12.9) in the risk for
total postoperative endophthalmitis.
 In addition, the use of clear corneal incisions (CCIs) compared to
scleral tunnels was associated with a 5.88-fold increase (95% CI,
1.34-25.9) in risk.
 The use of silicone intraocular lens (IOL) optic material compared
to acrylic with a 3.13-fold increase (95% CI, 1.47-6.67).
 The presence of surgical complications increased the risk for total
endophthalmitis 4.95-fold (95% CI, 1.68-14.6), and more
experienced surgeons were more likely to be associated with
endophthalmitis cases.
 When considering only proven infective endophthalmitis cases, the
absence of cefuroxime and the use of silicone IOL optic material
were significantly associated with an increased risk, and there was
evidence that men were more predisposed to infection (OR, 2.70;
95% CI, 1.07-6.8).

31.  When considering only proven infective
endophthalmitis cases, the absence of
cefuroxime and the use of silicone IOL
optic material were significantly
associated with an increased risk, and
there was evidence that men were more
predisposed to infection (OR, 2.70; 95%
CI, 1.07-6.8).
 J Catarac Refract Surg: 2007 June; 33(6) :978-88.

32.  Nine eligible studies published between 2002 and
2008 were identified, eight of which are
presented.
 The five in-vitro studies demonstrated that
moxifloxacin 0.5% and gatifloxacin 0.3% ( fourth
generation fluoroquinolones ) are statistically
more potent than levofloxacin 0.5% ( third
generation fluoroquinolone ) against Gram-
positive organisms and similar in potency in most
cases of Gram-negative bacteria.
 Adv Ther 2008: Oct 25(10):975-99.

33. SUBCONJUNCTIVAL
ANTIBIOTICS
 Subconjunctival antibiotics reduced the risk for
postoperative endophthalmitis by half.
 44% of Australian and New Zealand ophthalmologists
routinely used perioperative subconjunctival antibiotic for
prophylaxis.
 Rosha DS, Ng JQ, Morlet N, et al. Cataract surgery practice and endophthalmitis prevention by Australian and New
Zealand ophthalmologists. Clin Exp Ophthalmol 2006; 34:535–544.
 Lertsumitkul S, Myers PC, O’Rourke MT, Chandra J. Endophthalmitis in the western Sydney region: a case-control
study. Clin Exp Ophthalmol 2001; 29:400–405.
 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; discussion by RA Morgan, 378.
 Lehmann OJ, Roberts CJ, Ikram K, et al. Association between nonadministration of subconjunctival cefuroxime
and postoperative endophthalmitis. J Cataract Refract Surg 1997; 23: 889–893.

35.  Prophylactic antibiotics reduced
infection risk after cataract surgery
 Subconjunctival antibiotic injections
significantly decreased the incidence
of endophthalmitis in a study.
 OCULAR SURGERY NEWS EUROPE/ASIA-PACIFIC EDITION October 1,
2001

37.  Patients undergoing clear-corneal surgery without
preoperative antibiotic drops or subconjunctival antibiotic
injections had the highest incidence of endophthalmitis
(0.417%). The postop infection rate was significantly
lower with subconjunctival antibiotic injections than
without (0.011% versus 0.179%; P=.009). While results
showed that use of antibiotic drops lowered the infection
rate, the difference was not statistically significant
(P=.48). However, the subgroup analysis revealed
patients who underwent clear-corneal surgery fared
better with the drops than without (0% versus 0.417%).

38. PERIOPERATIVE TOPICAL
ANTIBIOTICS
 Aqueous penetration and biological activity of
moxifloxacin 0.5% ophthalmic solution and
gatifloxacin 0.3% solution in cataract surgery
patients.
 Ophthalmology (2005) 112: 1992-6. DH Kim, WJ Stark, TP O'Brien, JD Dick

39.  This study demonstrated that after topically
administered perioperative antibiotics with
cataract surgery, moxifloxacin 0.5% ophthalmic
solution achieved a statistically significantly
higher concentration in aqueous humor
compared with gatifloxacin (P = 0.00003).
Results from the broth dilution analysis showed
that moxifloxacin 0.5% was biologically more
active against S. epidermidis than gatifloxacin
0.3% in aqueous humor after topical application.
There were no adverse events reported, and
incision wounds healed quickly and as expected.