Anterior Segment Cataract Table 2: Results of Cost-effectiveness Analysis of Antibiotic Prophylaxis20,38 Antibiotic Prophylaxis
Intracameral Cefuroxime Moxifloxacin
Subconjunctival Gentamicin Cefazolin
Topical Sulfacetamide
Polymyxin/trimethoprim Ciprofloxacin Ofloxacin
Moxifloxacin Gatifloxacin
Four antibiotic combination‡ 2.30
12.36 24.90 33.74 55.00 57.60 11.65
-0.71 0.30 1.55 2.44 4.56 4.82 0.40
Cost saving 1,211 6,288 9,867
18,474 19,527 1,976
0.81 (164) 4.36 (881)
8.79 (1,775) 11.90 (2,405) 19.40 (3,920) 20.32 (4,105) 4.11 (831)
* Net cost in a cohort of 100,000 eyes includes cost savings of prevented infections. † Includes cost saving from averted endophthalmitis. ‡ Intracameral cefuroxime, subconjunctival gentamicin, subconjunctival cefazolin, and topical sulfacetamide. NA = not applicable.
proven infectious cause (two cases of Staphylococcus. epidermis in the group receiving intracameral cefuroxime and one case of S. warneri in the group receiving intracameral cefuroxime and topical levofloxacin). The incidence of post-operative endophthalmitis was lower in patients receiving intracameral cefuroxime and peri-operative topical levofloxacin than in those receiving intracameral cefuroxime alone. The absence of prophylactic intracameral cefuroxime was associated with a statistically significant increase in the risk of presumed infectious post-operative endophthalmitis. The absence of topical levofloxacin was not associated with a statistically significant increase in risk of presumed infectious post-operative endophthalmitis. Data indicated intracameral injections of cefuroxime reduced the risk of infectious endophthalmitis after phacoemulsification cataract surgery.
Gupta et al.14
investigated whether intracameral cefuroxime increases the risk of macular edema. Patients were randomized to intracameral cefuroxime (1 mg of cefuroxime in 0.1 ml normal saline solution) or an equal volume of intracameral balanced salt solution. Macular edema was measured using ocular coherence tomography (OCT).14
The results showed
no statistically significant differences in macular edema between in the groups four to six weeks after surgery. The use of intracameral cefuroxime did not affect post-operative visual acuity. The data supports the safety of using intracameral cefuroxime in routine cataract surgery.14
Intracameral Moxifloxacin Lane and colleagues15
evaluated the safety of intracameral moxifloxacin.
Participants were randomized to receive intracameral moxifloxacin 0.5 % (250 μg/0.050 ml) or balanced salt solution. The parameters assessed included macular edema, visual acuity, intraocular pressure (IOP), effects on the cornea (endothelial cell density and thickness, corneal clarity, and edema), inflammation in the anterior chamber (aqueous cell count), and effects on the blood-–aqueous barrier (aqueous flare). The results showed that there were no statistically significant differences between the two groups in safety parameters pre-operatively or at follow- up visits at one day, two to four weeks, and three months post-operatively. The data
50
demonstrated that intracameral injection of moxifloxacin ophthalmic solution appears to be safe for the prophylaxis of endophthalmitis after cataract surgery.15
Intracameral Vancomycin and Gentamicin Ball and Barrett investigated whether the use of vancomycin and gentamicin increases the risk of macular edema after phacoemulsification cataract surgery.16
Cost Per Person ($) 2.83 13.81
2.95 3.57
Cohort Net Cost* ($ millions)
-0.48 0.44
-0.64 -0.58
Cost-effectiveness Ratio† Threshold Effectiveness Ratio Compared
with Intracameral Cefuroxime (Number of Prevented Cases)
Cost saving 1,800
Cost saving Cost saving
NA 4.87 (984)
1.04 (210) 1.26 (254)
Patients were randomized to
receive no antibiotics or vancomycin (20 μg/ml) and gentamicin (8 μg/ml) in the infusion fluid at the time of cataract surgery. The results did not yield statistically significant differences in macular edema or visual acuity between the groups. Data indicated the use of intracameral vancomycin and gentamicin did not increase visual rehabilitation or the risk of macular edema. One observational study showed a statistically significant reduction in the incidence of post-operative endophthalmitis when intracameral vancomycin plus topical fusidic acid was compared with topical fusidic acid alone.16,17
Intracameral Cefazolin
Two observational studies showed a statistically significant reduction in the rate of post-operative endophthalmitis with the use of intracameral cefazolin plus topical antibiotics compared with topical antibiotics alone. No toxic effects or anaphylactic reactions were reported in either study.18,19
Economic Considerations
Sharifi et al. determined the cost-effectiveness from a societal perspective in the US of different antibiotic regimens for the prevention of endophthalmitis after cataract surgery (see Table 2).20
The modes
of administration for the antibiotics were intracameral (cefuroxime or moxifloxacin), topical (sulfacetamide, polymyxin/trimethoprim, ciprofloxacin, ofloxacin, moxifloxacin, or gatifloxacin), and subconjunctival (gentamicin or cefazolin). A combination regimen of intracameral cefuroxime, subconjunctival gentamicin, subconjunctival cefazolin, and topical sulfacetamide was also assessed. The risk of endophthalmitis in the absence of any intervention was estimated to be 0.247 %.20
The risk US OPHTHALMIC REVIEW
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