The use of perioperative antibiotics for prevention of infection and postoperative endophthalmitis remains a controversial issue. Postoperative endophthalmitis following pediatric cataract surgery is very uncommon, and the overall incidence has been reported to be 7 per 10,000 operations.¹ Due to the severity of the condition and the potential of visual loss, surgeons generally take preventive measures to reduce its incidence. Prophylaxis of endophthalmitis is discussed in Chapter 12. Povidone-iodine preparations are widely used for conjunctival antisepsis immediately before and at the conclusion of surgery.² The use of intracameral antibiotics is discussed in Chapter 12. Another preventive measure against endophthalmitis and wound infection is the use of perioperative topical antibiotics including gentamicin, neomycin, tobramycin, and polymyxin B.³,⁴,⁵ Many of these medications have been abandoned due to local and systemic side effects; instead fluoroquinolones are commonly used for this purpose. Fluoroquinolones were first introduced for the treatment of corneal and conjunctival infections, but ophthalmic surgeons currently use them before intraocular surgery to prevent bacterial endophthalmitis. These drugs have certain attractive characteristics for prophylactic use. They exhibit good activity against gram-negative and gram-positive organisms that are the main causative agents of postoperative endophthalmitis. These also have minimal epithelial toxicity and when used frequently can attain effective concentrations in the corneal stroma and the anterior chamber. Among topical fluoroquinolones, ofloxacin has the best transepithelial penetration. Ciprofloxacin is also effective against the major organisms producing endophthalmitis and also shows good coverage for gram-negative microorganisms. Perioperative use of both ciprofloxacin and ofloxacin has reduced bacterial colony counts of external ocular flora. Norfloxacin is less suitable for prophylactic use in ophthalmic practice since it is less effective against gram-positive organisms and penetrates the epithelium less readily.⁶

Fourth-generation fluoroquinolones such as gatifloxacin and moxifloxacin offer a broader spectrum of coverage than do previous generations of fluoroquinolones. These potent topical bactericidal agents promise to have greater antibacterial properties against gram-positive organisms and atypical mycobacteria. Recent studies showed that both of these fourth-generation fluoroquinolones achieved greater aqueous humor concentration after four times daily dosing relative to prior-generation fluoroquinolones. Moxifloxacin 0.5% ophthalmic solution achieved a significantly higher aqueous humor concentration than gatifloxacin 0.3% ophthalmic solution. The superior penetration of moxifloxacin into the aqueous humor may be attributed partially to its high degree of lipophilicity, greater solubility at neutral pH, and higher concentration in the commercial formulation.⁷,⁸,⁹ It has been suggested that moxifloxacin 0.5% used in a normal clinical setting is unlikely to cause any obvious adverse effects on the normal human cornea.¹⁰

Unlike intracameral antibiotics, topical antibiotics have not been shown to decrease the incidence of endophthalmitis in a randomized clinical trial. The best ocular penetration from eye drops still falls far below that achieved with intracameral use. The study by Espiritu et al.¹¹ showed that intracameral moxifloxacin 0.5 mg/mL appeared to be nontoxic in terms of visual rehabilitation, anterior chamber reaction, pachymetry, and corneal endothelial cell density. Another study showed no untoward effects after intracameral injection of moxifloxacin 0.5% ophthalmic solution diluted to a 0.1% concentration at the conclusion of routine cataract surgery.¹² There was also no increased risk associated with a 250 µg/0.050 mL intracameral injection of moxifloxacin for prophylaxis of endophthalmitis after cataract surgery.¹³

One regimen for prophylactic use of fluoroquinolones is preoperative frequent instillation, every 5 to 15 minutes, 1 to 1.5 hours before surgery and postoperative use every 6 hours for 5 to 7 days.⁶ However, a study by Ta et al.¹⁴ indicated that preoperative ofloxacin started 3 days prior to surgery was more effective than instillation 1 hour before the operation in reducing colony counts. All available fluoroquinolones are well tolerated by the corneal epithelium. Fluoroquinolones may cause damage to cartilage and result in arthropathy; therefore, systemic administration should be avoided in children. Topical use in children entails no risk of arthropathy.⁶

The inflammatory response following cataract surgery is more intense in children, which increases the risk of some postoperative complications such as fibrinous membrane formation, pupillary block, pigmentary and cellular deposits on the intraocular lens (IOL), posterior synechia, IOL capture, posterior capsule opacity, and cystoid macular edema (CME). Frequent administration of topical and sometimes regional and systemic steroids is needed to reduce the risk of these complications. Corticosteroids are relatively potent anti-inflammatory agents with multimodal mechanisms of action. Despite the efficacy of steroids in reducing postoperative inflammation, their long-term use is associated with multiple adverse systemic and ocular effects. Systemic complications of long-term steroid use in children include growth retardation, affective disorders, Cushing syndrome, skin atrophy, hirsutism, acne, osteoporosis, femoral head avascular necrosis, myopathy, water and electrolyte imbalance, hypertension, duodenal ulcer, immunosuppression, and delayed wound healing. Intracranial hypertension (pseudotumor cerebri) has also been associated with discontinuation of steroids.¹⁵
Ocular complications of long-term steroid use are ocular hypertension, glaucoma, predisposition to infections, and initiation or progression of cataract in the fellow eye.¹⁵ Ocular side effects are related to the potency of the steroid and individual susceptibility. Newer corticosteroids such as rimexolone and loteprednol have been shown to decrease the frequency of IOP elevation during long-term treatment (4 weeks or more) but have shown to be less effective in reducing inflammation.¹⁶ Difluprednate ophthalmic emulsion 0.05% (Durezol^®),¹⁷,¹⁸ which has been shown to be effective in the treatment of postoperative inflammation and pain, is being used more and more in children.

Following pediatric cataract surgery corticosteroids may be administered either regionally or systemically. Regional steroids may be used topically or locally in the form of eye drops, ointments, and subconjunctival or subtenon injections. Preservative-free triamcinolone acetonide (Triessence, Alcon Labs, and Fort Worth) improves visualization of the vitreous during pediatric cataract surgery, thereby ensuring a complete anterior vitrectomy without adverse postoperative effects.¹⁹ When used for this purpose, it is removed, at least in part, before the surgery is completed. It can also be added intracamerally and not removed (2-4 mg in children) in hopes that it will reduce the dependence on parental compliance with postoperative topical corticosteroids. In the anterior chamber, the triamcinolone is visible for 1 to 2 weeks but does not stay in the eye for a longer period of time like when it is injected into the vitreous cavity. This topic is explored in more detail in Chapter 22.

Common steroids for subconjunctival use include betamethasone and dexamethasone, 2 to 4 mg, injected into the inferior bulbar conjunctiva at the conclusion of surgery.⁵,²⁰,²¹,²²,²³,²⁴,²⁵ The authors usually inject betamethasone, 2 mg in patients under the age of 1 year and 4 mg in older patients. Steroids used for subtenon injection include methylprednisolone acetate and triamcinolone acetonide, 20 to 40 mg, depending on the age of the patient.²⁴,²⁶ This form of periocular steroid has been associated with precipitous elevations of IOP.²⁷ Some pediatric surgeons no longer use any subconjunctival steroid in routine cases, relying instead on topical or intracameral administration (M. Edward Wilson, e-mail communication).

Steroid eye drops are generally prescribed from the first postoperative day. Steroid drops are an easy, safe, effective, and inexpensive method of drug delivery and usually do not entail systemic effects. Children are usually defensive against eye drop instillation, so one must take time and be patient. Topical steroid eye drops used in the postoperative care of pediatric cataract surgery include prednisolone acetate, betamethasone, dexamethasone, and difluprednate. Most authors recommend 1% prednisolone acetate eye drops for routine use³,⁴,⁵,²⁰,²⁸,²⁹,³⁰,³¹; our experience has shown 0.1% betamethasone to be an acceptable alternative.²⁶ In uncomplicated cases with minimal postoperative inflammation, 1% prednisolone acetate administered every 4 to 6 hours should suffice. With more severe inflammation, sterile uveitis, or preexisting intraocular inflammation, more frequent dosage (e.g., every 1-2 hours) may be required. The duration of topical steroid therapy is 4 to 12 weeks, depending on the clinical course. Steroid ointments are limited to bedtime use and are not recommended during waking hours because of the possibility of blurred vision.

Systemic steroid use is uncommon in adult cataract surgery. However owing to the more severe inflammatory response, more extensive surgical manipulation (removal of the posterior capsule, anterior vitrectomy), and lack of adequate cooperation for eye drop instillation, systemic steroids may be needed for pediatric cataract surgery. The usual dose is 1 to 2 mg/kg oral Prednisolone for 1 week, which is tapered and discontinued by 1 to 2 weeks.³,²⁰,²⁴,²⁵

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