To review current and past practices of intracameral antibiotic administration for infection prophylaxis in cataract surgery; to review the benefits and liabilities of available prophylactic drugs, dosage determination, and administration protocols; and to devise an optimum dose and administration protocol for intracameral moxifloxacin. Humber River Hospital and the University of Toronto, Toronto, Ontario, Canada. Retrospective evaluation of treatment modality. This study consisted of a detailed review of the history, drugs, and methods of intracameral prophylaxis and microbiological and pharmacodynamics analysis of options. A review of potential drug sources and doses was performed and 1 drug, dose, and administration protocol was selected. The current method's adoption reasons are described followed by the authors' experience. A single infection in 3430 cases occurred with a moxifloxacin-resistant strain of Staphylococcus epidermidis when moxifloxacin 100 mcg in 0.1 mL was used. Increasing the dose and changing the administration technique resulted in no infections in 4601 cases and no detrimental side effects or complications. Intracameral moxifloxacin prepared by dilution of 3 cc moxifloxacin 0.5% (Vigamox) with 7 cc balanced salt solution and with the administration of 0.3 to 0.4 cc (450 to 600 mcg.) as the final step in cataract surgery via the side port after the main incision has been sealed and hydrated showed advantages over alternative intracameral antibiotic prophylactic methods, with minimum risk. Neither author has a financial or proprietary interest in any material or method mentioned.

To evaluate HsS (elastoviscous hylan surgical shield, 0.45%) as an alternative to repeated corneal irrigation with a balanced salt solution during cataract surgery. York Finch General Hospital, Toronto, Ontario (Center A), and Centre Hospitalier de St. Laurent, St. Laurent, Quebec (Center B), Canada. This dual-center, randomized, prospective clinical trial comprised 60 patients (40 at Center A; 20 at Center B) who had routine small incision cataract surgery (Center A, endolenticular phacoemulsification; Center B, Khoury manual phacofragmentation) with in-the-bag implantation of a posterior chamber intraocular lens. The corneal irrigating fluid was randomly assigned to be HsS or a balanced salt solution. The frequency of required applications, duration of efficacy of each application, and assessment of corneal moisture, clarity, transparency, and reflection in the HsS and balanced salt solution groups were recorded and compared. Mean frequency of applications was 13.9 per procedure in the balanced salt solution group and 1.3 per procedure in the HsS group (P = .0001). Mean duration of effectiveness per application was 23.4 minutes for HsS and 2.0 minutes for balanced salt solution (P = .0001). No significant differences in safety or effect on corneal health were observed between the two solutions. The HsS was significantly more effective than a balanced salt solution in maintaining corneal moisture, clarity, and transparency. The use of HsS may be a safer, more effective option in ophthalmic surgery because it minimizes the obstructed visualization of the surgical field caused by frequent corneal irrigation and loss of surgeon concentration.

To create a model of the abatement profiles of the three most commonly employed endophthalmitis prophylaxis intracameral (IC) antibiotics-cefuroxime, vancomycin, and moxifloxacin-to enable comparison of their durations of efficacy against common endophthalmitis pathogens. Humber River Hospital and The Eye Foundation of Canada, Toronto, Ontario, the University of Toronto, Ontario, and McGill University, Montreal, Quebec, Canada. Literature review, as well as review of our clinical experience with 4797 consecutive cases with IC vancomycin, followed by 9185 consecutive cases with IC moxifloxacin. A detailed review of the prophylactic antibiotic literature was performed. Exponential decay models of the selected IC antibiotics were updated from previous work by the study authors with decay constants adjusted to agree with the available published objective data. The graphs generated by the study data demonstrate the relative duration of IC bactericidal activity of moxifloxacin, cefuroxime, and vancomycin. They suggest that at present, IC moxifloxacin, when administered in appropriate doses, is the most effective agent in preventing postoperative endophthalmitis. Unlike vancomycin and cefuroxime, bacterial resistance to moxifloxacin is dose-dependent, and it is overcome in the vast majority of cases with doses that can safely be achieved intracamerally. The graphs can serve as a useful tool to assess the expected efficacy of each antibiotic in reference to local pathogen resistances. The model shows IC moxifloxacin, cefuroxime, and vancomycin durations of bactericidal efficacy post-cataract surgery, which correlate well with the published objective data.

A detailed retrospective analysis and literature review were conducted for all previously published reports of bilateral simultaneous postoperative endophthalmitis (BSPOE) since 1970. There have been 7 (9, with 2 currently being reported elsewhere) cases of BSPOE after immediately sequential bilateral cataract surgery (ISBCS) reported over 50 years. Generally, in these cases, the surgical protocol recommended by the International Society of Bilateral Cataract Surgeons (iSBCS) was breached or uncertain. Bacterial causes were Pseudomonas aeruginosa (3), Staphylococcus epidermidis (3), and Burkholderia cepacia complex (1). One case showed negative results for bacterial infection and 1 was not determined. Visual recovery was light perception, or worse, for Pseudomonas cases, generally good for Staphylococcus and Burkholderia cases, and mixed in cases of unknown etiology. Therefore, BSPOE is rare and causes vary. Strict adherence to the iSBCS General Principles of Excellence in ISBCS 2009 surgical protocol and care with operating room construction seem to considerably lessen the risk.