Intracameral Moxifloxacin for Endophthalmitis Prophylaxis following M-SICS- Findings from a Large-scale Indian Study

Table of Content

Background

Manual, sutureless, small incision cataract surgery (M-SICS) is used widely in several developing countries, including India.  Nevertheless, the surgical procedure is generally associated with higher rates of infectious post-operative endophthalmitis.

Aim

To compare the incidence of post-operative endophthalmitis before and after initiation of intracameral (IC) moxifloxacin administered for endophthalmitis prophylaxis in patients undergoing cataract surgery

Patient Profile

  • Patients (116714 eyes) undergoing cataract surgery between February 15, 2014, and April 15, 2015, at the Madurai Aravind Eye Hospital (AEH)
  • The study population was a mix of charity and private patients

Method

Study Design

  • Retrospective, clinical registry-based study

Treatment Strategy

  • Patients underwent one of the three surgical procedures; phacoemulsification, M-SICS, or manual large incision extracapsular cataract extraction
  • All patients received the standard post-operative therapy
  • Based on the use of IC moxifloxacin, the study population was categorized into three groups as follows:
    • Group 1: Charity patients who did not receive IC moxifloxacin (n=37777)
    • Group 2: Charity patients who received IC moxifloxacin prophylaxis (n=38160)
    • Group 3: Private Patients who did not receive IC moxifloxacin (n=40777)

Outcomes

  • Incidence of postoperative endophthalmitis before and after initiation of IC moxifloxacin within six weeks of cataract surgery
  • Endophthalmitis treatment cost

Results

  • Of the surgeries performed in the charity population during the 14-month period, 49.7% patients did not receive IC moxifloxacin (group 1) and 50.3% received IC moxifloxacin (group 2).
  • M-SICS accounted for nearly 97% of the total cataract surgeries in the charity group, as compared to only 21% in the private patient group.
  • Postoperative endophthalmitis was diagnosed in 30 eyes in group 1 (0.08%) and 6 eyes in group 2 (0.02%). The incidence of endophthalmitis in group 3 was significantly higher than that seen in group 2 (0.07%; 29 eyes; P for all < 0.0001) (figure 1).
Figure 1: Incidence of postoperative endophthalmitis in the study groups

  • Routine IC moxifloxacin prophylaxis significantly lowered the endophthalmitis rate in the charity population (group 2) compared with the private population (group 3).
  • Figure 2 depicts the reduction in incidence of the post-cataract endophthalmitis in the Madurai AEH charity population over time, including the 10 months immediately before and the 8 months immediately after routine initiation of direct IC moxifloxacin prophylaxis.
Figure 2: The incidence of endophthalmitis immediately before and after IC moxifloxacin treatment

  • No adverse events attributed to IC moxifloxacin were observed in group 2.
  • The total cost of treating the 30 patients with endophthalmitis in group 1 was virtually identical to the total combined cost of routine IC moxifloxacin prophylaxis and treatment of the 6 endophthalmitis cases in group 2.

Conclusions

  • Routine IC moxifloxacin prophylaxis was associated with a highly significant, four-fold reduction in postoperative endophthalmitis in patients undergoing M-SICS.
  • IC moxifloxacin was a cost-effective method for cutting down the incidence of infectious endophthalmitis in this higher-risk population of patients with cataract.
  • IC antibiotic prophylaxis is recommended for patients with M-SICS.

Ophthalmology 2016;123:302-308.