Transcript Ophthalmic Findings in Graft Versus Host Disease

Preparing Intracameral
Cefuroxime for use in
Cataract Surgery
Frimley Park Hospital
NHS Foundation Trust
Surrey, UK
Dr William R Tucker BSc MBBS
The author has no financial interest in the subject matter of
this poster
Purpose
• Postoperative endophthalmitis is a rare but devastating
complication of cataract surgery. Preoperative antiseptic with
Povidone iodine combined with perioperative and
postoperative antibiotics is a UK standard of care. However
controversy exists over which antibiotics and route to use.
• A prospective randomised trial in 16,603 patients conducted
by the ESCRS found nearly a 5 fold reduction in risk of
postoperative endophthalmitis when using intracameral
cefuroxime compared to controls1. A smaller study found the
incidence of postoperative endophthalmitis was significantly
lower in a group given intracameral cefuroxime compared to
subconjunctival cefuroxime2.
1) Endophthalmitis study group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following
cataract surgery: results of the ESCRS multicentre study and identification of risk factors. J Cataract Refract Surg 2007: 33(6):978 – 988
2) Yu-Wai-Man et al. Efficacy of intracameral and subconjunctival cefuroxime in preventing endophthalmitis after cataract surgery. J Cataract
Refract Surg 2008; 34(3):447 – 451
Purpose
• Despite accumulating evidence that intracameral cefuroxime is
both effective and safe3 the uptake among cataract surgeons has
been poor. Chang et al surveyed 1312 surgeons of the ASCRS
and found only 6% used intracameral cefuroxime4. They also
found 82% would initiate use if a commercial preparation was
available. We believe this represents concerns about making up
`home-made` preparations in theatre.
• We therefore developed a visual, simple and step by step protocol
for preparing cefuroxime at 1mg/0.1ml before intracameral
injection at the end of the case.
• We present a method for preparing intracameral cefuroxime and provide
usage & complication data for cataract operations performed over an 18
month period at a UK hospital
3) Montan et al. Prophylactic intracameral cefuroxime. Evaluation of safety and kinetics in cataract surgery J Cataract Refract Surg
2002; 28(6):982 – 987
4) Chang DF et al. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey. J
Cataract Refract Surg 2007; 33:1801 – 5
Method
• We designed a flow-chart portfolio using the diagrams and
instructions shown on the following pages. This was placed
in theatre and used as a guide to preparing the intracameral
cefuroxime doses.
• Please note this is an OFF-LABEL use of the drug in the UK
• After 18 months of use we collected usage and complication
data for the local unit where it was utilised. A questionnaire
was sent around the nursing staff and surgeons asking about
any problems encountered with the technique.
Method
Zinacef ® 250 mg 2.5 ml Syringe
Saline 0.9%
1 ml Syringes
10 ml Syringe
Drawing up needles
Filter Needles
Double drape small trolley
Method
Inject this into the
Zinacef ®
Runner draws up 2.5 ml of saline into 2.5 ml syringe
Withdraw 1 ml into
1 ml syringe
Use a FILTER
NEEDLE
Shake THOROUGHLY until dissolved
Method
First Scrub Nurse takes 10 ml
Syringe
Fill 10ml syringe with Saline
Using a FILTER NEEDLE
Method
Express Saline to 9 ml mark
Withdraw plunger to make room
Assistant
fits
NEW
FILTER
NEEDLE to the 1 ml syringe of
Zinacef ® & injects into the 10 ml
syringe of Saline held by Scrub
Nurse
Method
Mix thoroughly
Withdraw 0.4 ml into 1 ml syringe
Method
Repeat step for number of cases
on list.
Cap 10 ml syringe & leave on
trolley as reserve
Place in instrument Tray.
LEAVE RED DRAWING UP NEEDLE
ON SYRINGE UNTIL END OF CASE
Surgeon will inject 0.1 ml into lens bag at
end of case
Result
• Over 18 months intracameral cefuroxime was prepared and
used in 3768 routine phacoemulsification cataract
operations.
• There were no cases of postoperative endophthalmitis over
the period of use.
• Nursing staff and the surgeons reported no other
complications and no difficulty in preparing the doses.
• However – please note we cannot accept
responsibility if another person uses this
method and suffers complications
Conclusion
• The use of intracameral cefuroxime is gaining credence as a
effective method for reducing postoperative endophthalmitis
rates.
• At present it seems to be held back by the lack of a
commercial preparation and concern over the safest way to
prepare it from available supplies.
• We have presented an easy to follow, step by step, visual
method allowing surgeons to have confidence that a
standard safe dose can be prepared by even the most
inexperienced theatre staff.
• This off-label method of preparing Intracameral cefuroxime
has proved to be a popular and safe method of administering
prophylaxis against postoperative endophthalmitis