Selecting topical regimens for cataract patients
An evidence-based approach to understanding the rationale for agents used during the perioperative period
Eyecare practitioners who deal with patients in the perioperative period are well aware of the need for topical therapy. In most cases, a combination of a steroid, a nonsteroidal anti-inflammatory drug (NSAID), and an antibiotic will be used for a few days before the day of surgery and then for a period afterward.
However, how these agents are used, in what combination, as well as which particular agents are selected is a matter of much debate. Understanding the role and rationale of each may provide a basis for making an informed decision about which agent may be most beneficial in a given scenario.
The role of an antibiotic during the perioperative period is relatively straightforward. Infection control and prevention are of critical importance, even if the risk of developing sight-threatening sequelae is low. Endophthalmitis following cataract surgery occurs in about 1 in every 1,000 surgeries.1-3 It is likely that only a fraction of these are truly infectious in nature with potential to affect vision; however, infectious endophthalmitis can have devastating consequences in terms of vision loss (Figures 1 and 2).
Most cataract surgeons use a preoperative preparation of povidone-iodine to achieve a sterile ocular surface.
The role of intracameral antibiotics is considered off-label and gaining in popularity in the United States, although it is routinely used in Europe.4 In addition, several studies have suggested a benefit for this practice.5-7
Selection of the agent used in intracameral preparations, should they be used, requires some forethought. The emergence of fluoroquinolone resistance patterns is concerning, and studies have indicated that prior systemic use of a fluoroquinolone may increase the risk.8 There is also recent evidence of hemorrhagic occlusive retinal vasculitis (HORV) associated with intracameral vancomycin use.9
More typically, patients undergoing cataract surgery are started on a topical antibiotic formulation a few days before surgery as prophylaxis, which is continued through the postoperative period. Again, resistance patterns become important because resistance to one or more antibiotics is prevalent in ocular isolates.10,11 Newer generation fluoroquinolones, such as moxifloxacin (Vigamox, Alcon) and gatifloxacin (Zymar, Allergan) are generally preferred for this reason. Another topical agent, besifloxacin (Besivance, Bausch + Lomb) is the only fluoroquinolone specifically developed for ocular use.