Purpose Intracameral injection is an effective method for preventing infection, but no controlled study has been published in the United States. Design We conducted an observational, longitudinal cohort study to examine the effect of topical and injected antibiotics on risk of endophthalmitis. Participants We identified 315 246 eligible cataract procedures in 204 515 members of Kaiser Permanente, California, 2005–2012. Methods The study used information from the membership, medical, pharmacy, and surgical records from the electronic health record. Main Outcome Measures The adjusted odds ratio (OR) and 95% confidence interval (CI) for the association of antibiotic prophylaxis (route and agent) with risk of endophthalmitis was estimated using logistic regression analysis. Results We confirmed 215 cases of endophthalmitis (0.07% or 0.7/1000). Posterior capsular rupture was associated with a 3.68-fold increased risk of endophthalmitis (CI, 1.89–7.20). Intracameral antibiotic was more effective than topical agent alone (OR, 0.58; CI, 0.38–0.91). Combining topical gatifloxacin or ofloxacin with intracameral agent was not more effective than using an intracameral agent alone (compared with intracameral only: intracameral plus topical, OR, 1.63; CI, 0.48–5.47). Compared with topical gatifloxacin, prophylaxis using topical aminoglycoside was ineffective (OR, 1.97; CI, 1.17–3.31). Conclusions Surgical complication remains a key risk factor for endophthalmitis. Intracameral antibiotic was more effective for preventing post-cataract extraction endophthalmitis than topical antibiotic alone. Topical antibiotic was not shown to add to the effectiveness of an intracameral regimen.

The adoption of intracameral antibiotic injection coincided with a decline in the rate of postoperative endophthalmitis, and a low infection rate was observed with intracameral injection alone.

Purpose We conducted a retrospective comparative-effectiveness study of best-corrected visual acuity (BCVA) and refractive error (RE) following immediate sequential (ISBCS) and delayed sequential (DSBCS) bilateral cataract surgery. We tested two hypotheses: (1) among DSBCS patients, 2nd eye outcomes were no different than 1st eye outcomes; (2) averaged between each patient’s two eyes, outcomes did not differ between ISBCS and DSBCS patients. Design Retrospective comparative-effectiveness study. Subjects Kaiser Permanente Northern California members who underwent non-complex bilateral cataract surgery during 2013 through June 30, 2015. Methods We performed an intention-to-treat analysis comparing ISBCS to DSBCS using conditional logistic regression analysis, accounting for surgeon and patient-level factors. Main Outcome Measures BCVA, RE. Results The analysis of visual outcomes included both eyes of 13,711 DSBCS and 3,561 ISBCS patients. Because of the large sample size, some statistical differences lacked clinical significance. Ocular comorbidities were slightly more prevalent in DSBCS patients. Postoperative BCVA was 20/20 or better in 48% of DSBCS 1st eyes, 49% of DSBCS 2nd eyes, 53% of ISBCS right eyes, and 51% of ISBCS left eyes. The within-person difference in postoperative BCVA averaged zero (0.00) between the 1st and 2nd DSBCS eyes, and between the ISBCS right and left eyes. After adjustment, average postoperative BCVA was better in ISBCS patients, although the difference was not statistically significant. (compared with 20/20 or better: odds ratio for worse than 20/20 was 0.91, 95% confidence interval 0.83–1.01). Emmetropia (spherical equivalent −0.5 to 0 D) was achieved in 61% of 1st DSBCS eyes, 61% of 2nd DSBCS eyes, 63% of ISBCS right eyes, and 62% of ISBCS left eyes. After adjustment, average postoperative RE was no different in ISBCS compared with DSBCS patients (compared with emmetropia: odds ratio for ametropia was 1.02, confidence interval 0.92–1.12). We confirmed one case of postoperative endophthalmitis in 10,494 ISBCS eyes (1.0 per 10,000 eyes), two cases in 38,736 DSBCS eyes (0.5 per 10,000 eyes) (p=0.6), and no patient had bilateral endophthalmitis. Conclusion Compared with DSBCS cataract surgery, we found no evidence that ISBCS surgery was associated with worse postoperative BCVA or RE, or with an increased complication risk.

Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. These medications have been found to reduce pain, prevent intraoperative miosis, modulate postoperative inflammation, and reduce the incidence of cystoid macular edema (CME). Whether used alone, synergistically with steroids, or for specific high-risk eyes prone to the development of CME, the effectiveness of these medications is compelling. This review describes the potential preoperative, intraoperative, and postoperative uses of NSAIDs, including the potency, indications and treatment paradigms and adverse effects and contraindications. A thorough understanding of these issues will help surgeons maximize the therapeutic benefits of these agents and improve surgical outcomes.

PURPOSE To study the relationship of chemoprophylaxis and other factors on the occurrence of acute, clinical postoperative macular edema. DESIGN Retrospective cohort study. The drug regimens consisted of postoperative topical prednisolone acetate (PA) alone or with nonsteroidal anti-inflammatory drug (PA+NSAID) or intraoperative subconjunctival injection of 2 mg triamcinolone acetonide (TA) alone. PARTICIPANTS Patients undergoing phacoemulsification at Kaiser Permanente, Diablo Service Area, Northern California, 2007–2013. METHODS Incident macular edema diagnoses recorded 5–120 days after phacoemulsification, with visual acuity 20/40 or worse and evidence of macular thickening by optical coherence tomography were identified. Odds ratios (OR) and 95% confidence intervals (95% CI) were obtained from logistic regression analysis, conditioned on the surgeon and adjusted for year, patient age and race, diabetic retinopathy, other ocular comorbidities, systemic comorbidity and posterior capsular rupture. MAIN OUTCOME MEASURES Incident rates of acute, clinical, postoperative macular edema. RESULTS We confirmed 118 cases among 16,070 cataract surgeries (incidence, 0.73%). Compared with PA alone, the OR for the relationship of macular edema with PA+NSAID was 0.45 (95% CI, 0.21–0.95) and for TA injection was 1.21 (95% CI, 0.48–3.06). The frequency of intraocular pressure spikes ≥30 mm Hg between postoperative days 16 – 45 was 0.6% in the topical PA group, 0.3% for topical PA+NSAID (p=0.13) and 0.8% for TA (p=0.52). African-American race was associated with risk of macular edema (OR, 2.86; 95% CI, 1.41–5.79). CONCLUSIONS Adding prophylactic NSAID to PA was associated with a reduced risk of macular edema with visual acuity 20/40 or worse. Risk and safety of TA injection was similar to PA alone. Further research is needed on the prognostic significance of postoperative macular edema, the role of prophylaxis, risk in African-Americans, and the effectiveness of depot medications.

We thank our partners, the Cochrane Eyes and Vision US Satellite (CEV@US), for identifying reliable systematic reviews that we cite and discuss in support of the PPP recommendations.The Preferred Practice Patterns Committee members reviewed and discussed the document during a meeting in June 2021. The document was edited in response to the discussion and comments.

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efuroxime sodium (1 mg/0.1 mL) appears to be effective in preventing endophthalmitis. 1,2 Kaiser Permanente surgeons began injecting intracameral cefuroxime in 2007, with resulting declining rates of infection. 3,4 Cefuroxime is available in Europe as Aprokam, a manufactured product for intracameral injection. In the United States, no intracameral antibiotic preparation is approved to prevent endophthalmitis, thus creating a need for compounding for each surgical case. Reports have shown a long-term deleterious effect on the retina and cornea of injecting cefuroxime sodium at concentrations greater than 50 mg, 5,6 while no adverse effect has been observed at 3 mg. 7 We describe transient macular edema from injection of 9 mg of cefuroxime sodium. MethodsFollowing Kaiser Permanente Institutional Review Board approval, we reviewed medical records of 11 patients (13 eyes) who underwent cataract surgery by a single surgeon (D.C.W.) on a single day. In this article, exposed eye refers to an eye that underwent surgery and was injected with cefuroxime sodium at a dose of 9 mg/ 0.1 mL on that day. Reduced vision refers to Snellen visual acuity of 20/70 or worse on postoperative day 1 following uncomplicated clear-cornea cataract surgery. Data were collected and analyzed between June 2014 and January 2015. Informed consent was not required owing to the retrospective nature of the study.All patients were prescribed topical prednisolone acetate, 1%, diclofenac, 0.1%, and ofloxacin, 0.3%, 4 times daily in the eye undergoing surgery beginning 3 days prior to surgery. Two of the 11 patients underwent bilateral same-day surgery. Ordinarily, 750 mg of cefuroxime sodium injectable powder is reconstituted with 7.5 mL of preservative-free normal saline (sodium chloride, 0.9%). Three milliliters (300 mg) of the resulting solution is then injected into an empty 30-mL sterile interior vial. To this, 27 mL of preservative-free normal saline is added, resulting in a final cefuroxime sodium concentration of 1 mg/0.1 mL. 8 At each procedure's conclusion, 0.1 mL of compounded cefuroxime sodium solution was injected through the paracentesis. However, on this day, the final concentration was 9 mg/0.1 mL. Results Postoperative Day 1On the first postoperative day, 6 of 13 eyes (46%; 95% CI, 19%-75%) had reduced vision with uncorrected distance visual acu-IMPORTANCE Intracameral injection of cefuroxime sodium (1 mg/0.1 mL) has been reported to reduce the risk of endophthalmitis following cataract surgery. In the United States it must be compounded, which is subject to dilution error. We describe a series of 13 eyes that received intracameral injection of cefuroxime sodium, 9 mg/0.1 mL, intraoperatively.OBSERVATIONS On postoperative day 1, 6 of 13 eyes (46%; 95% CI, 19%-75%) had visual acuity of 20/70 or worse and macular edema. Spectral-domain optical coherence tomography of 2 eyes revealed central subfield thicknesses of 909 and 873 μm. On postoperative day 4, the mean (SD) central subfield thickness was 309 (78) μm in the 6 eyes with diagnosed...