Reply : Povidone–iodine for endophthalmitis prophylaxis

Abstract

Recently, Hosseini et al. 1 addressed the use of povidone-iodine for endophthalmitis prophylaxis. In their article, the authors concluded that using povidone-iodine 5% solution for 15 minutes was the most effective approach to prevent the growth of postcataract-surgery endophthalmitis bacterial isolates. The study was limited by its in vitro nature, and it would be worthwhile to know how it works in real clinical conditions. Coincidently, our routine consists of topical administration of povidone-iodine 5% solution 3 times (every 5 minutes) in the 15 minutes immediately before the beginning of surgery. We also use a fourthgeneration fluoroquinolone (moxifloxacin 0.5% or gatifloxacin 0.3%) 4 times a day starting 1 day before surgery. After surgery, the fourth-generation fluoroquinolone is administered 6 times a day for 8 postoperative days. To provide more data for this discussion, we present the statistics from our clinical practice, as we have used this same routine for endophthalmitis prevention in our cataract surgeries over the past 7 years.A review of medical records provided all consecutive cataract surgeries (phacoemulsification) performed during the previous 7 years (January 2005 through December 2011) in our clinical practice. Traumatic cases with perforated eyes were excluded from this analysis. All surgeries were performed by the same surgeon (L.P.B.) using a clear corneal incision (2.75 mm) and foldable intraocular lens implantation. An incision suture was used if judged necessary by the surgeon at the end of surgery.A total of 5952 surgeries were performed in 3078 patients (mean age 74.21 years G 10.34 [SD]). Topical anesthesia with mild sedation was used in 5860 (98.45%) cases and peribulbar anesthesia in the remaining 92 (1.55%). A main incision suture was used in 28 (0.47%) eyes; 5924 (99.53%) eyes did not need sutures.We observed that 5943 (99.85%) surgeries were uneventful. Eight (0.13%) cases of posterior capsule rupture occurred in patients with very hard nuclei. One case (0.02%) of anterior capsule rupture occurred in a white cataract without posterior capsule rupture or other complications. Toxic anterior segment syndrome was present the first postoperative day in 7 (0.12%) eyes and resolved in 4 days with topical administration of prednisolone 1%.Fortunately, no cases of endophthalmitis occurred. While the fourth-generation fluoroquinolones may have contributed to this, we do not think this success can be attributed to fluoroquinolones alone since povidone-iodine was also administered. Evidence suggests that preoperative antibiotic use in combination with povidone-iodine confers no additional benefit to use of povidone-iodine alone. 2,3 Despite evidence suggesting benefits of intracameral antibiotics, we have not changed our routine. We still use topical fourth-generation fluoroquinolones in association with povidone-iodine in our cataract surgeries.In summary, we think that our results together with those shown by Hosseini et al. 1 reinforce each other, supporting the use of povidone-iodin...