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Original Investigation |

Effectiveness and Safety of an Intracameral Injection of Cefuroxime for the Prevention of Endophthalmitis After Cataract Surgery With or Without Perioperative Capsular Rupture

Vincent Daien, MD, PhD1,2,3; Laurence Papinaud, MD4; Mark C. Gillies, MBBS, PhD, FRANZCO5; Caroline Domerg, MS4; Nicolas Nagot, MD, PhD6; Sandy Lacombe, MS7; Jean Pierre Daures, MD, PhD7; Isabelle Carriere, PhD2,3; Max Villain, MD, PhD1,2
[+] Author Affiliations
1Department of Ophthalmology, Hôpital Gui de Chauliac, CHU de Montpellier, Montpellier, France
2Department of Ophthalmology, University of Montpellier, Montpellier, France
3Inserm, Montpellier, France
4Echelon Régional du Service Médical du Languedoc–Roussillon, Biostatistics Department, Montpellier, France
5The Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
6Department of Medical Information, Montpellier University Hospital, Montpellier, France
7Department of Biostatistics, Epidemiology, and Clinical Research, University of Montpellier, Montpellier, France
JAMA Ophthalmol. 2016;134(7):810-816. doi:10.1001/jamaophthalmol.2016.1351.
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Importance  Postoperative endophthalmitis (POE) often results in severe visual impairment. In clinical studies, an intracameral cefuroxime injection at the end of surgery was found to be effective at reducing the incidence of POE. Two important issues are the retinal safety of cefuroxime and its use for patients with perioperative capsular rupture where the risk of POE is dramatically increased.

Objective  To assess the effectiveness and retinal safety of an intracameral injection of cefuroxime sodium for the prevention of POE and its possible use in cases of a perioperative capsular rupture of the lens.

Design, Setting, and Participants  Population-based cohort study of patients 40 years of age or older who underwent cataract surgery at 1 of 1546 French health care facilities, public or private, and whose medical records were obtained from the national administrative database. Data analyses were performed between March and November 2015.

Main Outcomes and Measures  The effectiveness and safety of the prophylactic injection of cefuroxime as measured by the incidence of POE and cystoid macular edema.

Results  From January 2010 to October 2014, a total of 3 351 401 eyes of 2 434 008 patients 40 years of age or older (58.9% were women, and the mean [SD] age was 73.9 [9.5] years) underwent cataract surgery; 1941 patients (0.08%) developed POE during the 6 weeks after cataract surgery. The incidence of POE after cataract surgery decreased over the course of the study (0.11%, 0.09%, 0.08%, 0.06%, and 0.05% in 2010, 2011, 2012, 2013, and 2014, respectively [P = .001 for trend]) as the use of cefuroxime prophylactic injections increased (11.1%, 14.4%, 32.8%, 64.8%, and 79.1% in 2010, 2011, 2012, 2013, and 2014, respectively [P = .001 for trend]). After multivariate adjustment, the risk of POE was reduced with the use of cefuroxime (odds ratio, 0.61 [95% CI, 0.56-0.68]). The retinal safety of an injection of cefuroxime, which was assessed by multiadjusted odds of retinal cystoid macular edema, was not increased for patients receiving cefuroxime injections (odds ratio, 0.86 [95% CI, 0.71-1.05]). For patients with a perioperative capsular rupture of the lens (the major risk factor for POE), the incidence of POE was lower for those who received an injection of cefuroxime than for those who did not (0.37% vs 0.51%, respectively [P = .001]), whereas an increased risk of cystoid macular edema was not identified for those who received or did not receive an injection of cefuroxime (5.6% vs 7.3%, respectively [P = .12]).

Conclusions and Relevance  These data suggest that, in routine practice, the intracameral injection of cefuroxime at the conclusion of cataract surgery is associated with a lower risk of POE and is safe for patients with or without a perioperative capsular rupture. While these data might be used to support the consideration of its routine use to prevent POE, in the absence of a randomized clinical trial, they cannot prove a direct cause-and-effect relationship between the injection of cefuroxime and POE.

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Figure 1.
Incidence of Postoperative Endophthalmitis (POE) Among 2 434 008 Patients With or Without a Capsular Rupture and With or Without an Injection of Cefuroxime

For patients with a perioperative capsular rupture of the lens, the incidence of POE was lower for those who received an injection of cefuroxime than for those who did not (0.37% vs 0.51%, respectively [P = .001]). Comparisons were corrected for multiple testing using the Bonferroni method. Overall P < .001.

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Figure 2.
Incidence of Postoperative Cystoid Macular Edema (CME) Among 53 292 Patients With or Without a Capsular Rupture and With or Without an Injection of Cefuroxime

For eyes without a capsular rupture, the effect of the use or nonuse of cefuroxime on the incidence of CME was not identified (0.72% vs 0.84%, respectively [P = .80]), nor was an effect identified for eyes with a capsular rupture (5.6% vs 7.3%, respectively [P = .12]). Comparisons were corrected for multiple testing using the Bonferroni method. Overall P < .001.

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