, Nidhi Relhan Batra1, Stephen G. Schwartz2 and Andrzej Grzybowski3, 4
(1)
Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
(2)
Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Naples, Florida, USA
(3)
Chair of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland
(4)
Institute for Research in Ophthalmology, Poznan, Poland
Antisepsis
This is the prevention of infection by inhibiting or arresting the growth and multiplication of germs (infectious agents) which is usually achieved by povidone-iodine, hydrogen peroxide, chlorhexidine, or polyhexanide application on the skin (Fig. 6.1).
Figure 6.1
Preoperative povidone-iodine antisepsis . (a) Skin antisepsis with povidone-iodine. (b) Conjunctival antisepsis with 5% povidone-iodine drops
Povidone-iodine antisepsis is the only clinical practice achieving class 1 evidence for effectiveness to prevent endophthalmitis in the setting of intraocular surgery. Povidone-iodine is a low-cost antiseptic agent with no antibiotic resistance and is rapidly bactericidal and used worldwide. In 2013, a prospective randomized study (Friedman et al.) of patients undergoing intravitreal injections reported that the use of 5% povidone-iodine leads to significant reduction in bacterial colonies, and exposure of 30 seconds appeared to be an adequate time to decrease conjunctival bacterial counts. Modjtahedi et al. (2016) retrospectively analyzed cases of endophthalmitis occurring in patients with self-reported iodine allergy who underwent intravitreal injections without povidone-iodine antisepsis. The study concluded that avoiding povidone-iodine owing to self-reported iodine “allergy” risks substantial ocular morbidity.
Chlorhexidine gluconate is a bisguanide germicide available for preoperative antisepsis. Concentrations of 0.1–4% to be highly active against a variety of gram-positive and gram-negative bacterial pathogens as noted in in vitro experiments. Chlorhexidine concentration of 2.0 and 4.0% in the external irrigating fluid has been shown to slow the corneal epithelial healing rate. Prolonged corneal contact with chlorhexidine may cause irreversible corneal endothelial damage.
References: Antisepsis
Ahmed Y, Scott IU, Pathengay A, Bawdekar A, Flynn HW, Jr. Povidone-iodine for endophthalmitis prophylaxis. Am J Ophthalmol. 2014;157(3):503–4.
Apt L, Isenberg SJ, Yoshimori R, Chang A, Lam GC, Wachler B, et al. The effect of povidone-iodine solution applied at the conclusion of ophthalmic surgery. Am J Ophthalmol. 1995;119(6):701–5.
Apt L, Isenberg SJ, Yoshimori R, Spierer A. Outpatient topical use of povidone-iodine in preparing the eye for surgery. ophthalmology. 1989;96(3):289–92.
Friedman DA, Mason JO, 3rd, Emond T, McGwin G, Jr. Povidone-iodine contact time and lid speculum use during intravitreal injection. Retina. 2013;33(5):975–81.
Hamill MB, Osato MS, Wilhelmus KR. Experimental evaluation of chlorhexidine gluconate for ocular antisepsis. Antimicrob Agents Chemother. 1984;26(6):793–6.
Mendivil Soto A, Mendivil MP. The effect of topical povidone–iodine, intraocular vancomycin, or both on aqueous humor cultures at the time of cataract surgery. Am J Ophthalmol. 2001;131(3):293–300.
Merani R, Hunyor AP. Endophthalmitis after intravitreal injections in patients with self-reported iodine allergy. Am J Ophthalmol. 2017;176:256–7.
Modjtahedi BS, van Zyl T, Pandya HK, Leonard RE, 2nd, Eliott D. Endophthalmitis after intravitreal injections in patients with self-reported iodine allergy. Am J Ophthalmol. 2016;170:68–74.
Nakashizuka H, Shimada H, Hattori T, Noguchi T, Kokubo N, Yuzawa M. Vitrectomy using 0.025% povidone-iodine in balanced salt solution plus for the treatment of postoperative endophthalmitis. Retina. 2015;35(6):1087–94.
Nentwich MM, Ta CN, Kreutzer TC, Li B, Schwarzbach F, Yactayo-Miranda YM, et al. Incidence of postoperative endophthalmitis from 1990 to 2009 using povidone-iodine but no intracameral antibiotics at a single academic institution. J Cataract Refract Surg. 2015;41(1):58–66.
Wan KH, Radke N, Lam DS. Endophthalmitis after intravitreal injections in patients with self-reported iodine allergy. Am J Ophthalmol. 2017;176:260.
Wykoff CC, Flynn HW, Jr., Han DP. Allergy to povidone-iodine and cephalosporins: the clinical dilemma in ophthalmic use. Am J Ophthalmol. 2011;151(1):4–6.
Topical Antibiotics
Topical antibiotics are utilized for endophthalmitis prophylaxis in two settings:
Preoperative topical antibiotics
Postoperative topical antibiotics
Preoperative topical antibiotics—A review by Packer et al. (2011) discussed the roles of surgical technique and topical antibiotic prophylaxis in prevention of endophthalmitis. The optimal timing and frequency of topical antibiotic prophylaxis as per this review has been the subject of debate. According to the European Society of Cataract & Refractive Surgeons (ESCRS) guidelines and several national European recommendations (Sweden, Denmark, France), the preoperative use of topical antibiotics is not justified when intracameral antibiotics are used. Generally, preoperative topical antibiotics are more commonly used for prophylaxis in the United States.
Postoperative topical antibiotics—A review by Kuklo et al. (2017) reported wide variations in the prophylaxis practices around the world. As per this review, there is no consensus on the use of prophylactic perioperative antibiotics to prevent endophthalmitis after cataract surgery. Another systematic review and meta-analysis of randomized controlled trials and observational studies performed by Huang et al. (2016) failed to show any evidence to support the use of postoperative topical antibiotics to prevent endophthalmitis after ocular surgery. However, postoperative topical antibioticsare a common standard in the United States to prevent endophthalmitis after ocular surgery.
Topical Antibiotics: Literature
Following are the few selected studies regarding the role of topical antibiotics in specific case scenarios:
Cataract Surgery
Allen HF and Mangiaracine AB (1974): In a series of 36,000 cataract operations, the low rate of infection (0.086% 31/36,000 cataract surgeries) was reported to be achieved by following three principles: (1) meticulous aseptic technique, (2) minimally traumatic surgery, and (3) preoperative antibiotic prophylaxis using a combination of chloramphenicol-polymyxin B sulfate drops and erythromycin ointment.
Jabbarvand et al. (2016): This retrospective, single-center, cross-sectional descriptive study evaluated patients who underwent cataract surgery in an eye hospital in Iran from 2006 through 2014. An incidence of endophthalmitis was reported to be 0.023% (112/480,104 operations). This series demonstrated 40–50% reduced odds of endophthalmitis with short-term treatment with topical or systemic preoperative antibiotics or postoperative subconjunctival injection compared with no prophylaxis.
Intravitreal Injections
Kim SJ et al. (2010): This prospective, observational study of 48 eyes (24 patients) demonstrated substantial levels of resistance to third- and fourth-generation fluoroquinolones and multidrug resistance among coagulase-negative Staphylococcus isolated from patients undergoing multiple intravitreal injections for choroidal neovascularization.
Kim SJ et al. (2011): In this prospective, randomized, controlled, clinical trial of 48 eyes (24 patients) undergoing unilateral intravitreal injections for choroidal neovascularization, it was concluded that repeated exposure of surface ocular flora to ophthalmic antibiotics selects for resistant strains.
Cheung CSY et al. (2012): Retrospective, comparativecase series reported the effect of different antibiotic prophylaxis strategies on the incidence of endophthalmitis after intravitreal injections of anti-vascular endothelial growth factors and triamcinolone acetonide. In this study, the rate of endophthalmitis after intravitreal injection was greater with the use of postoperative topical antibiotics (given for 5 days after injection) compared with no antibiotics.
Category | Rates of endophthalmitis, n/N (%) |
|---|---|
• No antibiotics | • 2/5266 (0.04%) |
• With antibiotics | • 7/10,629 (0.07%) |
Yannuzzi et al. (OSLI-Retina 2017): This is a retrospective case series (2006 and 2016) of 38 patients with endophthalmitis associated with intravitreal injection of anti-VEGF agents [27 (71%) referred and 11 (29%) in-house patients]. At the Bascom Palmer Eye Institute, topical antibiotics were not used before, during, or after intravitreal injections after 2008. The rates of post-injection endophthalmitis during the time period when no topical antibiotics were used (2015 to 2016) were approximately 1 in 20,000 compared to the time period when topical antibiotics were utilized (2006 to 2007) which were approximately 1 in 4,000 injections performed. This implies that topical antibiotics are not essential to prevent postintravitreal injection endophthalmitis.
References: Preoperative Topical Antibiotics
Allen HF. Aseptic technique in ophthalmology. Trans Am Ophthalmol Soc. 1959;57:377–472.
Allen HF. Recent advances in aseptic surgical technique. Trans Am Acad Ophthalmol Otolaryngol. 1960;64:493–9.
Allen HF, Mangiaracine AB. Bacterial endophthalmitis after cataract extraction. II. Incidence in 36,000 consecutive operations with special reference to preoperative topical antibiotics. Arch Ophthalmol. 1974;91(1):3–7.
Cheung CS, Wong AW, Lui A, Kertes PJ, Devenyi RG, Lam WC. Incidence of endophthalmitis and use of antibiotic prophylaxis after intravitreal injections. Ophthalmology. 2012;119(8):1609–14.
Huang J, Wang X, Chen X, Song Q, Liu W, Lu L. Perioperative antibiotics to prevent acute endophthalmitis after ophthalmic surgery: a systematic review and meta-analysis. PLoS One. 2016;11(11):e0166141.
Jabbarvand M, Hashemian H, Khodaparast M, Jouhari M, Tabatabaei A, Rezaei S. Endophthalmitis occurring after cataract surgery: outcomes of more than 480,000 cataract surgeries, epidemiologic features, and risk factors. Ophthalmology. 2016;123(2):295–301.
Kim SJ, Toma HS. Ophthalmic antibiotics and antimicrobial resistance a randomized, controlled study of patients undergoing intravitreal injections. Ophthalmology. 2011;118(7):1358–63.
Kim SJ, Toma HS, Midha NK, Cherney EF, Recchia FM, Doherty TJ. Antibiotic resistance of conjunctiva and nasopharynx evaluation study: a prospective study of patients undergoing intravitreal injections. Ophthalmology. 2010;117(12):2372–8.
Yannuzzi NA, Gregori NZ, Rosenfeld PJ, Relhan N, Patel NA, Si N, Miller D, Dubovy SR, Smiddy WE, Schwartz SG, Flynn HW Jr. Endophthalmitis associated with intravitreal injections of anti-vascular endothelial growth factor agents at a tertiary referral center (in-house and referred cases). (OSLI-Retina 2017).
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