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Preoperative and intracameral antibiotic prophylaxis and intraocular contamination during cataract surgery
correspondence Preoperative and intracameral antibiotic prophylaxis and intraocular contamination during cataract surgery
surgery and 3 times at 2-hour intervals the evening before surgery. A drop of povidone–iodine 2.5% solution was placed in the eye in the preoperative area and was not irrigated. In the operating room, the patient was prepped using povidone–iodine 10% solution swabsticks. Vancomycin 5 mg, gentamicin 4 mg, and epinephrine 0.1 mg were added to a 500 mL bottle of balanced salt solution. Phacoemulsification was performed through a 3.0 mm, temporal, clear corneal incision. Five of the 100 incisions were sutured with a single 10-0 polyglactin (Vicryl威) suture; all others were no-stitch incisions. When phacoemulsification was completed, a silicone intraocular lens was inserted using an injector system without enlarging the incision. The ophthalmic viscoelastic device was removed and the anterior chamber reformed. The incision was hydrated and tested for patency, at which point 0.15 to 0.20 mL of aqueous was aspirated with a 27-gauge cannula attached to a tuberculin syringe. Within an hour, the samples were transported to the local hospital laboratory, where cultures were performed for aerobic and anaerobic bacteria. Only 1 had positive growth, growing a few colonies of coagulase-negative Staphylococcus. Most postoperative intraocular infections are caused by organisms introduced at the time of surgery, and several studies report a large percentage of eyes with bacterial contamination at the end of the procedure (Table 1).1–4 The contamination rate in these studies was
W
ith a comprehensive prophylaxis program, we have been successful in preventing endophthalmitis (R.E. Cole, MD, D.R. Acord, RN, “Demonstrated System for the Prevention of Endophthalmitis,” Administrative Eyecare, Spring 2003, pages 31–36). Between April 1996 and November 2003 at our center, 14 443 intraocular procedures were performed by 7 surgeons without a case of endophthalmitis. This excludes a patient who had a trabeculectomy in 1997 and in whom a blebitis in 2003 resulted in endophthalmitis. For most of these procedures, phacoemulsification was performed with a 3.0 mm, temporal, clear corneal nostitch incision. We conducted a study of aqueous contamination at the conclusion of cataract surgery for objective evidence of bacterial contamination and compared this with other reports. One hundred eyes of 100 consecutive phacoemulsification cases having routine cataract surgery were recruited for this prospective study. Surgeries were performed by the same surgeon (R.E.C.). Preoperative preparation included ofloxacin 0.3% drops (4th-generation fluoroquinolone) 4 times a day for 3 days. Patients with ocular or systemic infections were not treated in the ambulatory surgical center until the infection was addressed. The patient was instructed to wash his or her face with Acute-Kare威 antibacterial soap for 3 days before Table 1. Published results of anterior chamber contamination. Study*
Phacoemulsification (n)
ECCE (n)
50
50
110
100
110†
Manners1 2
Beigi
Beigi3 4
Srinivasan Current
10
Positive Cultures, ECCE Eyes, n (%)
(20)
12 (24)
22
(20)
29 (29)
—
22 3
(20) (2.7)‡
—
80
—
37 (46.25)
—
100
—
ECCE ⫽ extracapsular cataract extraction, n ⫽ number of eyes *First author given † Antibiotic in infusion ‡ Vancomycin and gentamicin in infusion
2004 ASCRS and ESCRS Published by Elsevier Inc.
Positive Cultures, Phaco Eyes n (%)
1
(1)
—
CORRESPONDENCE
between 20.00% and 46.25%, except for a study by Beigi et al.3 in which the contamination rate was 2.70% using vancomycin and gentamicin in the infusion. Many surgeons believe the increasing frequency of endophthalmitis is due in part to no-stitch clear corneal incisions. Nagaki et al.5 report the relative risk for endophthalmitis was 4.6 times higher with temporal clear corneal incisions than with sclerocorneal incisions. That study involved 10 different surgical locations and 8 surgeons. With those variables, it cannot be determined whether 1 or more surgeons, the incision site, or the surgery was the major risk factor. Preoperative antibiotic drops or antibiotics were not used in the infusion. Our study and experience show that a comprehensive prophylaxis program results in a low rate of anterior chamber contamination and a low rate of endophthalmitis and that a 3.0 mm, temporal, no-stitch clear corneal incision does not necessarily increase the risk for infection when such a program is used. RANDALL E. COLE, MD DONNA R. ACORD, RN Rogers, Arkansas, USA
References 1. Manners TD, Chitkara DK, Marsh PJ, Stoddart MG. Anterior chamber aspirate cultures in small incision cataract surgery. Br J Ophthalmol 1995; 79:878–880 2. Beigi B, Westlake W, Mangelschots E, et al. Preoperative microbial contamination of anterior chamber aspirates during extracapsular cataract extraction and phacoemulsification. Br J Ophthalmol 1997; 81:953–955 3. Beigi B, Westlake W, Chang B, et al. The effect of intracameral, per-operative antibiotics on microbial contamination of anterior chamber aspirates during phacoemulsification. Eye 1998; 12:390–394 4. Srinivasan R, Tiroumal S, Kanngo R, et al. Microbial contamination of the anterior chamber during phacoemulsification. J Cataract Refract Surg 2002; 28:2173– 2176 5. Nagaki Y, Hayasaka S, Kadoi C, et al. Bacterial endophthalmitis after small-incision cataract surgery: effect of incision placement and intraocular lens type. J Cataract Refract Surg 2003; 29:20–26
Iris-fixated phakic IOLs to correct postoperative anisometropia in unilateral cataract patients with bilateral high myopia
W 2240
e present 5 relatively young unilateral phakic cataract patients with bilateral high myopia who
had implantation of an Artisan myopia claw intraocular lens (IOL) (Ophtec). For subjective postoperative evaluation of pseudophakia in 1 eye and phakic IOL implantation in the other eye, a Dutch consensus translation of the refractive status and visual profile (RSVP), a vision-related quality-of-life questionnaire, was completed by patients for each eye.1
Case Reports Patient 1 was a 54-year-old man with bilateral high myopia and a nuclear cataract in the right eye. Two weeks after phacoemulsification and IOL implantation (SI-40, AMO), an Artisan phakic IOL was inserted in the left eye. Three months later, surgery was required for a local rhegmatogenous retinal detachment in the right eye. Twelve months postoperatively, the best spectacle-corrected visual acuity (BSCVA) was 1.00 and 1.25 in the pseudophakic eye and phakic eye, respectively. Patient 2 was a 51-year-old man with bilateral myopia, nuclear cataract in the left eye, and distinct astigmatism in the right eye. One week after phacoemulsification and SI40 IOL implantation, a toric Artisan phakic IOL was fitted in the right eye. After 2 months, the BSCVA was 1.25 in both eyes. Patient 3 was a 54-year-old man with bilateral myopic retinal degeneration. Two weeks after phacoemulsification of a corticonuclear cataract and IOL implantation (AcrySof,威 Alcon, 6.0 mm) in the right eye, the refraction in the phakic eye was corrected with an Artisan phakic IOL. At 18 months, the BSCVA was 0.40 in the pseudophakic eye and 0.50 in the phakic eye. Patient 4 was a 33-year-old myopic man diagnosed with nuclear cataract in the left eye. Phacoemulsification and IOL implantation (Flex 652, Domilens) were performed with implantation of an Artisan phakic IOL in the right eye 2 months later. Four months postoperatively, the BSCVA was 1.60 and 1.25 in the left eye and right eye, respectively. Patient 5 was a 40-year-old woman who developed posteriocapsular cataract and keratoconjunctivitis sicca in the right eye from radiotherapy. Four months after phacoemulsification and SI-40 IOL implantation, an Artisan phakic IOL was implanted in the left eye. After a 6-month follow-up, the BSCVA was 1.00 in the pseudophakic eye and 1.25 in the phakic eye. The BSCVA in all the pseudophakic eyes improved postoperatively, and the BSCVA in the phakic eyes remained the same or improved after Artisan phakic IOL implantation. No significant differences were found between the total RSVP scores of the phakic and pseudophakic patients, the subscales (Table 1), or, with the exception of 1 question, responses between eyes. When asked to rate their satisfaction with
J CATARACT REFRACT SURG—VOL 30, OCTOBER 2004
surgery and 3 times at 2-hour intervals the evening before surgery. A drop of povidone–iodine 2.5% solution was placed in the eye in the preoperative area and was not irrigated. In the operating room, the patient was prepped using povidone–iodine 10% solution swabsticks. Vancomycin 5 mg, gentamicin 4 mg, and epinephrine 0.1 mg were added to a 500 mL bottle of balanced salt solution. Phacoemulsification was performed through a 3.0 mm, temporal, clear corneal incision. Five of the 100 incisions were sutured with a single 10-0 polyglactin (Vicryl威) suture; all others were no-stitch incisions. When phacoemulsification was completed, a silicone intraocular lens was inserted using an injector system without enlarging the incision. The ophthalmic viscoelastic device was removed and the anterior chamber reformed. The incision was hydrated and tested for patency, at which point 0.15 to 0.20 mL of aqueous was aspirated with a 27-gauge cannula attached to a tuberculin syringe. Within an hour, the samples were transported to the local hospital laboratory, where cultures were performed for aerobic and anaerobic bacteria. Only 1 had positive growth, growing a few colonies of coagulase-negative Staphylococcus. Most postoperative intraocular infections are caused by organisms introduced at the time of surgery, and several studies report a large percentage of eyes with bacterial contamination at the end of the procedure (Table 1).1–4 The contamination rate in these studies was
W
ith a comprehensive prophylaxis program, we have been successful in preventing endophthalmitis (R.E. Cole, MD, D.R. Acord, RN, “Demonstrated System for the Prevention of Endophthalmitis,” Administrative Eyecare, Spring 2003, pages 31–36). Between April 1996 and November 2003 at our center, 14 443 intraocular procedures were performed by 7 surgeons without a case of endophthalmitis. This excludes a patient who had a trabeculectomy in 1997 and in whom a blebitis in 2003 resulted in endophthalmitis. For most of these procedures, phacoemulsification was performed with a 3.0 mm, temporal, clear corneal nostitch incision. We conducted a study of aqueous contamination at the conclusion of cataract surgery for objective evidence of bacterial contamination and compared this with other reports. One hundred eyes of 100 consecutive phacoemulsification cases having routine cataract surgery were recruited for this prospective study. Surgeries were performed by the same surgeon (R.E.C.). Preoperative preparation included ofloxacin 0.3% drops (4th-generation fluoroquinolone) 4 times a day for 3 days. Patients with ocular or systemic infections were not treated in the ambulatory surgical center until the infection was addressed. The patient was instructed to wash his or her face with Acute-Kare威 antibacterial soap for 3 days before Table 1. Published results of anterior chamber contamination. Study*
Phacoemulsification (n)
ECCE (n)
50
50
110
100
110†
Manners1 2
Beigi
Beigi3 4
Srinivasan Current
10
Positive Cultures, ECCE Eyes, n (%)
(20)
12 (24)
22
(20)
29 (29)
—
22 3
(20) (2.7)‡
—
80
—
37 (46.25)
—
100
—
ECCE ⫽ extracapsular cataract extraction, n ⫽ number of eyes *First author given † Antibiotic in infusion ‡ Vancomycin and gentamicin in infusion
2004 ASCRS and ESCRS Published by Elsevier Inc.
Positive Cultures, Phaco Eyes n (%)
1
(1)
—
CORRESPONDENCE
between 20.00% and 46.25%, except for a study by Beigi et al.3 in which the contamination rate was 2.70% using vancomycin and gentamicin in the infusion. Many surgeons believe the increasing frequency of endophthalmitis is due in part to no-stitch clear corneal incisions. Nagaki et al.5 report the relative risk for endophthalmitis was 4.6 times higher with temporal clear corneal incisions than with sclerocorneal incisions. That study involved 10 different surgical locations and 8 surgeons. With those variables, it cannot be determined whether 1 or more surgeons, the incision site, or the surgery was the major risk factor. Preoperative antibiotic drops or antibiotics were not used in the infusion. Our study and experience show that a comprehensive prophylaxis program results in a low rate of anterior chamber contamination and a low rate of endophthalmitis and that a 3.0 mm, temporal, no-stitch clear corneal incision does not necessarily increase the risk for infection when such a program is used. RANDALL E. COLE, MD DONNA R. ACORD, RN Rogers, Arkansas, USA
References 1. Manners TD, Chitkara DK, Marsh PJ, Stoddart MG. Anterior chamber aspirate cultures in small incision cataract surgery. Br J Ophthalmol 1995; 79:878–880 2. Beigi B, Westlake W, Mangelschots E, et al. Preoperative microbial contamination of anterior chamber aspirates during extracapsular cataract extraction and phacoemulsification. Br J Ophthalmol 1997; 81:953–955 3. Beigi B, Westlake W, Chang B, et al. The effect of intracameral, per-operative antibiotics on microbial contamination of anterior chamber aspirates during phacoemulsification. Eye 1998; 12:390–394 4. Srinivasan R, Tiroumal S, Kanngo R, et al. Microbial contamination of the anterior chamber during phacoemulsification. J Cataract Refract Surg 2002; 28:2173– 2176 5. Nagaki Y, Hayasaka S, Kadoi C, et al. Bacterial endophthalmitis after small-incision cataract surgery: effect of incision placement and intraocular lens type. J Cataract Refract Surg 2003; 29:20–26
Iris-fixated phakic IOLs to correct postoperative anisometropia in unilateral cataract patients with bilateral high myopia
W 2240
e present 5 relatively young unilateral phakic cataract patients with bilateral high myopia who
had implantation of an Artisan myopia claw intraocular lens (IOL) (Ophtec). For subjective postoperative evaluation of pseudophakia in 1 eye and phakic IOL implantation in the other eye, a Dutch consensus translation of the refractive status and visual profile (RSVP), a vision-related quality-of-life questionnaire, was completed by patients for each eye.1
Case Reports Patient 1 was a 54-year-old man with bilateral high myopia and a nuclear cataract in the right eye. Two weeks after phacoemulsification and IOL implantation (SI-40, AMO), an Artisan phakic IOL was inserted in the left eye. Three months later, surgery was required for a local rhegmatogenous retinal detachment in the right eye. Twelve months postoperatively, the best spectacle-corrected visual acuity (BSCVA) was 1.00 and 1.25 in the pseudophakic eye and phakic eye, respectively. Patient 2 was a 51-year-old man with bilateral myopia, nuclear cataract in the left eye, and distinct astigmatism in the right eye. One week after phacoemulsification and SI40 IOL implantation, a toric Artisan phakic IOL was fitted in the right eye. After 2 months, the BSCVA was 1.25 in both eyes. Patient 3 was a 54-year-old man with bilateral myopic retinal degeneration. Two weeks after phacoemulsification of a corticonuclear cataract and IOL implantation (AcrySof,威 Alcon, 6.0 mm) in the right eye, the refraction in the phakic eye was corrected with an Artisan phakic IOL. At 18 months, the BSCVA was 0.40 in the pseudophakic eye and 0.50 in the phakic eye. Patient 4 was a 33-year-old myopic man diagnosed with nuclear cataract in the left eye. Phacoemulsification and IOL implantation (Flex 652, Domilens) were performed with implantation of an Artisan phakic IOL in the right eye 2 months later. Four months postoperatively, the BSCVA was 1.60 and 1.25 in the left eye and right eye, respectively. Patient 5 was a 40-year-old woman who developed posteriocapsular cataract and keratoconjunctivitis sicca in the right eye from radiotherapy. Four months after phacoemulsification and SI-40 IOL implantation, an Artisan phakic IOL was implanted in the left eye. After a 6-month follow-up, the BSCVA was 1.00 in the pseudophakic eye and 1.25 in the phakic eye. The BSCVA in all the pseudophakic eyes improved postoperatively, and the BSCVA in the phakic eyes remained the same or improved after Artisan phakic IOL implantation. No significant differences were found between the total RSVP scores of the phakic and pseudophakic patients, the subscales (Table 1), or, with the exception of 1 question, responses between eyes. When asked to rate their satisfaction with
J CATARACT REFRACT SURG—VOL 30, OCTOBER 2004