Pre-op Drops for Cataract surgery

[DrZeke]

I had a question about preop drops. In our residency for the standard patient with no other eye co morbidities we do not do preop drops. I have heard that in private practice people often do preop antibiotics and NSAID or steroid. In briefly searching the literature I have not found support for doing this.

Can any members comment on this? Is there data supporting this or is it just anecdotal evidence? What do you do in your own practice?

Thanks

---

Members don't see this ad.

 

[dos palomas]

Deleted.

 

[MstaKing10]

I think there is some evidence that pre op NSAIDs may limit intraop pupil construction.

 

[DrZeke]

What about preop antibiotics ?

 

[MstaKing10]

Only proven prophylaxis for infection prevention is povodone iodine prep. This goes for all surgical and in office procedures. There is no definitive evidence (to my knowledge) that preop, intraop, or even post op antibiotics actually decrease the risk of endophthalmitis to any significant degree.

 

[DrZeke]

This is what I had read.

Just wondering if there are still people out there doing preop antibiotics and why.

 

[Pinkertinkle]

Theres mixed evidence on preop antibiotics with some finding it may increase risk of resistant infections. Intracameral cefuroxime shown to reduce endophthalmitis in a convincingly large ESCRS study, and is used in europe as AproCam. No evidence to suggest necessity of drops preoperatively.

 

[Dusn]

"Just wondering if there are still people out there doing preop antibiotics and why."

I don't use them. But I could similarly ask you if you use post-op antibiotics any why. Why use any antibiotics at all?

I don't think there is good evidence for the use of post-op antibiotics either. There are unfortunately many things that we don't have large scale studies for due to a lack of resources and means. So the lack of a study isn't an argument for or against anything; you just have to make your best guess based on theoretically or anecdotal reasoning.

Intracameral antibiotics has stronger evidence for it and I'd like to see that being done more commonly

 

[LightBox]

There are not too many rigorous studies regarding pre-op antibiotics in the prevention of endophthalmitis because endophthalmitis is so rare...that it would take a huge and long (thus expensive) study to meet the endpoints. As a surrogate marker for infectious load, researchers test the conjunctival flora of patients who have or have not taken pre-operative antibiotics. There is evidence out there that using antibiotic eyedrops either 1 day or 1 hour before surgery, decreases the bacterial load on the conjunctiva. Povidone-iodine has the most effect on this infectious load.

Another thing you have to think about is liability. You don't want some trial lawyer questioning you why your endophthalmitis patient did not take pre-operative antibiotics, like he would have done if he was operated by the surgeon next-door. Once you have one endophthalmitis, you will try everything to make sure your ass is covered.

Personally, I do antibiotics starting one day pre-op; give intracameral Vigamox; and use 1 week or more of post-op antibiotics. I would use that "ReSure" sealant too if it actually got reimbursed the cost of it.

 

[OphthoApp]

Some places have stopped using all topical antibiotics. They only use intracameral cefuroxime. No study shows topical antibiotics do anything, but intracameral antibiotics do lower risk of endoph.

 

[OphthoApp]

And to the above comment you would never lose a lawsuit if a patient gets endophthalmitis and you didn't use pre-operative antibiotics. There is no evidence for it and it's not standard of care.

 

[backrow]

. There is no evidence for it and it's not standard of care.

If I understand correctly part of "standard of care" is based upon the community/geographic area in which one practices. So if the majority of the docs in one's particular location are doing something then it could be considered standard of care.

Maybe a lawyer is around and could clarify.

 

[Dusn]

"And to the above comment you would never lose a lawsuit if a patient gets endophthalmitis and you didn't use pre-operative antibiotics. There is no evidence for it and it's not standard of care."

You could lose a case for no good reason at all if a patient got endophthalmitis (or any other bad outcome). You'd almost definitely also get hit for damages from "loss of consortium" because clearly the endophthalmitis will prevent the couple from ever having sex again. It's all about the emotional appeal to the jury and nothing stirs up emotions like the argument that you didn't do something that you could have.

But I agree; even if you use the pre-op antibiotics the lawyer will bring up something else that's equally stupid.

 

[MstaKing10]

I understand practicing defensive medicine, but sometimes things get a bit out of hand and perhaps even counter productive.

Standard of care many years ago was pre and post injection antibiotics. Thanks to the work of many, like Dr. Flynn at BPEI, evidence overcame the senseless overuse of antibiotics to the point that we are today, where it is almost outside the standard of care to prescribe them for injections.

 

[LightBox]

I would love to be the trial lawyer who practices in an area where the eye surgeons don't use post-op antibiotics for their cataract surgeries 😉 Sure, there might not be Level 1 evidence for their use. But just try convincing the jury that is composed of the local butcher and garbage man why you did not prescribe antibiotics after an intraocular surgery. Do you really think they are going to understand what "Level 1" evidence means?!?

 

[DrZeke]

Thanks for all the responses!