18

Update

caTaracT & rEfracTivE

New challenge of anti-VEGF cases

by Priscilla Lynch in Southport

ENDOPHTHALMITIS
that too is a risk factor, Dr Barry noted. he cited the esCRs study results showing a five-times greater risk if there were surgical complications. however, overall, the most important risk factor is the failure to use perioperative antibiotics, Dr Barry stressed. The esCRs endophthalmitis study showed the range of endophthalmitis was between 0.05 per cent in those patients who were randomly allocated to receive intracameral cefuroxime 1.0mg in 0.1ml of normal saline into the anterior chamber at the end of the case versus an incidence of 0.35 per cent developing endophthalmitis in that group that did not receive any perioperative antibiotic, either topically or intracamerally. They all received povidone iodine because at the time of the study that was the only evidence-based, recognised prophylaxis, he explained. The endophthalmitis range of 0.35 per cent surprised the study organisers and was widely criticised, particularly in the us, as extraordinarily high. But if you compare that figure with the swedish prospective study of 225,000 patients from Mats Lndstrom and the range of endophthalmitis in sweden, it is

Dr Barry reported that following glaucoma surgery the risk of endophthalmitis is higher
Peter Barry FRCS

hile endophthalmitis following cataract surgery is on the decline thanks to the growing use of intracameral antibiotics, infection associated with repeated anti-VeGF injections appears to be a growing problem, according to Peter Barry FRCs, st Vincents university hospital and Royal Victoria eye and ear hospital, Dublin, ireland. Dr Barry outlined the latest research on the risk factors for developing endophthalmitis following cataract surgery, trauma, glaucoma surgery, sutureless vitrectomy and antiVeGF injections, to delegates at the united Kingdom & ireland society of Cataract & Refractive surgeons (uKisCRs) XXXV Congress in southport, uK. he revealed a surprising risk factor identified by the esCRs endophthalmitis study was the use of silicone iOLs, which led to a three-times greater risk of developing endophthalmitis as opposed to other iOLs, the vast majority being acrylic. A large controlled study carried out in sweden showed silicone iOLs had a greater risk than heparin surface-modified PMMA. if the cataract surgery is complicated

between 0.048 per cent in patients receiving cefuroxime which is the norm. But if you subtract that small group of patients from the swedish register who did not receive intracameral cefuroxime for whatever reason, then the endophthalmitis rate was 0.35 per cent in that group which coincides precisely to the non-antibiotic group in the [esCRs] endophthalmitis study. he added that the standard regime in the us, which is topical 4th generation fluoroquinolones commenced on the day of surgery, has been demonstrated in a large cohort study to have an endophthalmitis rate of 0.05 per cent, similar to the intracameral group of the esCRs study. Dr Barry reported that following glaucoma surgery the risk of endophthalmitis is higher with studies showing a 0.1 per cent rate for early onset and up to 0.7 per cent for late onset, increasingly quite dramatically with the utilisation of 5-fluorouracil. he noted that after standard vitrectomy the incidence of vitrectomy is traditionally low. however, after the introduction of 23-gauge vitrectomy there was a scare in the earlier years. in Japan, Kunimoto [Ophthalmology 2007] demonstrated a 12-times odds ratio with 25-gauge vitrectomy

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EUROTIMES | Volume 17 | Issue 4

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Peter Barry peterbarryfrcs@eircom.net

for endophthalmitis. hu [Ophthalmology 2009] demonstrated no difference, and Baharani [Ophthalmology 2010] showed no difference between 20-, 23- and 25-gauge vitrectomy; 0.02 per cent, 0.03 per cent and 0.02 per cent, out of a series of 35,000 eyes in a multicentre study, he reported. Dr Barry believes that this earlier high risk related probably to technique, and that nowadays surgeons do not think that sutureless vitrectomy has a meaningfully higher risk.

Anti-VEGF Nowadays probably the most important challenge, he said, is the risk of endophthalmitis from anti-VeGF injections, which have seen huge growth in recent years. The risk of endophthalmitis has been reported as between 0.022 per cent and 0.16 per cent, but there are particular issues with the injections in that there is a cumulative risk if the patients are receiving six or more injections in a given year, and are using an off-licensed product. Particular attention should be given by retinal surgeons and physicians to the routine use of topical antibiotic drops for several weeks after the anti-VeGF injection as there is a risk. i think this will facilitate the development of resistant organisms in that patients conjunctival sac and expose them to a higher risk of endophthalmitis a couple of weeks later when they are faced with their next injection, Dr Barry contended. summarising, Dr Barry said endophthalmitis following cataract surgery has been dramatically reduced by the adoption of intracameral antibiotics. in the us he believes intracameral injections are moving forward all the time though it is still an un-licensed procedure there.