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

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).

• 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.

• 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.