Publication Exclusive: Intraocular antibiotic prophylaxis in best interests of patients

During my residency and fellowship training in the 1970s, the two most dreaded complications of cataract surgery were expulsive choroidal hemorrhage and endophthalmitis. In advanced countries, expulsive choroidal hemorrhage has been nearly eliminated as a blinding complication by phacoemulsification with its small self-sealing incision. The incidence of infectious endophthalmitis has been reduced from as many as one per 400 during my training to about one per 1,000 through the use of povidone-iodine antiseptic prophylaxis, careful draping of lids and lashes, and surgeon care in assuring a well-sealed incision, but there is still room for improvement in preventing this serious sight-threatening complication.In the U.S., topical antibiotics are used nearly routinely, started a few hours to days before the surgery, given again in the operating room immediately after surgery and then continued for 1 or more weeks, depending on the surgeon. Unfortunately, data to support the use of topical antibiotics in an advanced country operating suite where povidone-iodine prep and good draping are utilized are lacking. Nonetheless, more than $500 million worth of off-label antibiotic drops (because the antibiotic drops utilized are only approved by the FDA for the treatment of bacterial conjunctivitis or keratitis) are prescribed each year in the U.S. and universally reimbursed by third-party payers, including CMS, for endophthalmitis prophylaxis.