cataract surgery postop eyedrops

[schistosomiasis]

To fellow third year residents out there:

Just out of curiosity, which antibiotic are you using for your postops? I had been using ocuflox at the VA; at our county hospital I had been using vigamox until, to my horror, I found that some patients were paying $60 for it or not filling it at all because of the price- now I have switched to ciloxan (but I don't know how much this costs). Most of my patients are medicare/ medicaid. Would it make any difference in what you prescribed if you broke the capsule, or had to enlarge the incision to extracap some fragments (this never happens to me, of course 😀 )

One of my overly anal attendings insists on giving PO cipro for a week if the capsule breaks during the case- anyone else practices this way?

What about acular/ NSAIDS? I gave them to all patients at the VA, but at the county hospital I haven't been giving them at all, and I've pretty much been getting good results- do you guys routinely give NSAIDS, or only in complicated cases, or only if you see CME?

Thanks for the responses.... any references to practice pattern surveys, or journal articles would be appereciated

 

[Andrew_Doan]

At the VAMC, I use TobraDex.

I also use Ocuflox + Pred-Forte too.

A professor at the U only uses a Pred-Forte taper without antibiotic. If your wound is good, then the endophthalmitis rate is very low.

Read this interesting Blog from one of my faculty: http://www.eyeorbit.org/bloggers.php?blogger=583

I give Acular to patients at high risk for CME, i.e., previous CME in the other eye after cataract surgery or severe diabetes. I also give Acular after complicated cataract cases.

I haven't seen PO antibiotics used after cataract surgery.

 

[schistosomiasis]

Andrew,
Thank you very much for your response; I think I'm going to stop using vigamox, and use ciloxan instead. Do you use only tobradex at the VA, or tobradex plus ocuflox plus pred forte?
I enjoyed reading the blog by your attending Dr. Oetting; I met him many years ago when I was interviewing at Iowa. (He is a big Duke basketball fan if I recall correctly.) I have lurked on this board periodically but this is my first post; thank you Dr. Doan for the wonderful job you have done moderating it. I actually met you at a interview in California when we were applying, you showed me picutres of your kids in the waiting room, there was a nice meal at a Chinese restauraunt afterwards....
Any other comments from third year residents' postop regimens would be welcome.

 

[Andrew_Doan]

Andrew,
Thank you very much for your response; I think I'm going to stop using vigamox, and use ciloxan instead. Do you use only tobradex at the VA, or tobradex plus ocuflox plus pred forte?
I enjoyed reading the blog by your attending Dr. Oetting; I met him many years ago when I was interviewing at Iowa. (He is a big Duke basketball fan if I recall correctly.) I have lurked on this board periodically but this is my first post; thank you Dr. Doan for the wonderful job you have done moderating it. I actually met you at a interview in California when we were applying, you showed me picutres of your kids in the waiting room, there was a nice meal at a Chinese restauraunt afterwards....
Any other comments from third year residents' postop regimens would be welcome.

Ahhh... ophthalmology is a small world! That was a nice dinner at USC. 😉

I use Tobradex alone: 4x/day for a week, 3x/day for a week, 2x/day for a week, once daily for a week, and then d/c Tobradex.

 

[mdkurt]

Ahhh... ophthalmology is a small world! That was a nice dinner at USC. 😉

I use Tobradex alone: 4x/day for a week, 3x/day for a week, 2x/day for a week, once daily for a week, and then d/c Tobradex.

I used Tobradex alone pretty much as above to simplify the regimen for my vets when I was a resident. Too many were screwing up which was the steroid. If cost is an issue, polytrim gives very good coverage. I agree with the statement about the wound being everything, but endophthalmitis eventually is a fact of life regardless of your surgical technique and I'd be hard pressed to try to defend giving up abx altogether.

 

[Phaco]

At the VAMC, I use TobraDex.

I also use Ocuflox + Pred-Forte too....

...I haven't seen PO antibiotics used after cataract surgery.

I agree. I wouldn't use PO abx after cataract surgery. The endoph vitrect study shows that ocular concentration of abx is very low with PO or IV meds.
I believe that if the patient is going to get endophthalmitis, he'll get it despite good ocular abx concentration. However, if the patient decides to contact a lawyer and he finds out there was PO meds, he can claim "standard of care" is not up to par

 

[Aaron_EyeMD]

This has raised two important questions:

1. Use of 4th generation fluoroquinolones vs. Ciprofloxicin.
There has not been conclusive evidence that the 4th generation meds have a lower incidince of endophthalmitis. However, studies have shown that they do have broader coverage and provide better coverage against gram-positive organisms (most common post-op organism in most cases). As such, I would recommend gatifloxacin or moxifloxacin for postop meds.

Refer to the following article:
Mather, et al. "Fourth generation fluoroquinolones: new weapons in the arsenal of ophthalmic antibiotics." Am J Ophthalmol. 2002 Apr;133(4):463-6.

The price is as follows (via Epocrates):
Ciloxan: $50.38 5ml bottle
Zymar: $54.93 5ml bottle
Vigamox: $60.19 3ml bottle
.... it is all pretty expensive!

2. Use of oral antibiotics for endophthalmitis prevention.
No evidence exists that there is a benefit of oral antibiotics in the prevention of endopthalmitis following cataract surgery. However, studies have shown that the 4th generation fluoroquinolones orally have better vitreous penetration compared to cipro orally. For me, in cases of trauma with open globe, I always get the patient on gatifloxacin IV or oral as soon as possible, especially if there is going to be a delay in getting the patient to the OR.

Refer to the following article:
Hariprasad, et al. "Vitreous and Aqueous Penetration of Orally Administered Gatifloxacin in Humans." Arch Ophthalmol. 2003;121:345-350.

Aaron M. Miller, MD

 

[Eyesore]

Some do not like to use TobraDex for post op gtts because when you taper it, you are tapering antibiotics.

I used Pred Forte and Ciloxan (or Ocuflox or Vigamox) qid x 1 week. Then I stopped the antibiotic and tapered PF tid x 1 week, bid x 1 week, and qd x 1 week.

 

[Aaron_EyeMD]

I used Pred Forte and Ciloxan (or Ocuflox or Vigamox) qid x 1 week. Then I stopped the antibiotic and tapered PF tid x 1 week, bid x 1 week, and qd x 1 week.

I do the same... I only use the antibiotic for about 10 days then stop it. If I did a clear cornea and used a suture, I take the suture out at 10 days and use the antibiotic for an additional 4 days.