The report is a product of the VA/HSR&D Evidence Synthesis Program.
Evidence Brief: Use of Intracameral Moxifloxacin after Cataract Surgery
Takeaway: Intracameral moxifloxacin use is associated with reduced odds of endophthalmitis compared to standard care. Intracameral moxifloxacin also appears to be safe at the dosages and preparations reported, with no studies reporting adverse events directly related to moxifloxacin use. Rigorous studies conducted in U.S. settings may increase support for broadening the use of intracameral moxifloxacin in place of or alongside topical antibiotics.
Endophthalmitis is a rare, serious infection of the eye that can lead to permanent loss of vision. Topical antibiotic eyedrops are often prescribed to prevent endophthalmitis after cataract surgery, but their efficacy is unclear. There also are concerns about patient adherence to the regular use of drops in the postsurgical period. Intracameral antibiotics, which are administered only once at the end of the surgical procedure, may be effective and provide advantages over topical drops.
Antibiotics such as moxifloxacin, and to a lesser extent, cefuroxime and vancomycin, are frequently delivered intracamerally after cataract surgery to prevent endophthalmitis. However, there are currently no antibiotics approved by the FDA for intracameral endophthalmitis prophylaxis.
In response to a request from the VA Ophthalmology Office, HSR&D’s Evidence Synthesis Program (ESP) Coordinating Center in Portland, OR reviewed evidence on the benefits and harms of intracameral moxifloxacin for preventing endophthalmitis after cataract surgery, with the aim of informing VA clinical practice. Investigators utilized existing systematic reviews to identify studies published prior to 2016 and searched Ovid MEDLINE, CINAHL, and other databases from 2016 through January 2022. From 169 potentially relevant articles, 21 were eligible for inclusion in the ESP Evidence Brief.
A meta-analysis of 14 comparative studies (3,566,022 eyes) found that intracameral moxifloxacin use is associated with a 73% reduction in the odds of endophthalmitis compared to standard care, corresponding to approximately seven fewer cases of endophthalmitis per 10,000 eyes. Standard care often included post-operative topical antibiotics and/or corticosteroids in both intervention and comparator groups. Intracameral moxifloxacin also appears to be safe at the dosages and preparations reported in the studies, with no studies reporting adverse events directly related to moxifloxacin use.
Despite the inclusion of an additional nine studies not included in previous systematic reviews, findings of the ESP Evidence Brief largely align with previous reviews’ conclusions. Overall, available studies are limited by study design and methodology, with a single randomized controlled trial (RCT) reporting endophthalmitis rates among the included studies. Also, no studies were conducted in VA, and only four studies were conducted within the U.S., potentially limiting the applicability of these results to intracameral moxifloxacin use in the U.S.
Implications for VA
Within VA, limited access to intracameral antibiotics has led to irregular and inconsistent usage across VA medical centers. In a 2016 survey of VA ophthalmology chiefs, 33% reported the use of intracameral antibiotics during cataract surgery (23% cefuroxime, 50% moxifloxacin, 18% vancomycin). Among those reporting no use of intracameral antibiotics, institutional and/or pharmacy difficulties was most often rated as the reason for non-use, followed by risk of dilution error, lack of evidence, risk of bacterial resistance, and risk of contamination. However, concerns remain about patient adherence to and the correct administration of topical eye drops, particularly among Veterans who may have barriers to compliance such as older age and higher rates of comorbidity and disability.
Available research showing the prophylactic benefit of intracameral moxifloxacin has largely been conducted outside the U.S. Moreover, most existing studies delivered topical antibiotics in both intervention and control groups, and only one identified study directly compared intracameral moxifloxacin to topical antibiotics. Thus, additional randomized controlled studies conducted in the U.S. – and directly comparing intracameral moxifloxacin alone to topical antibiotics – may increase support for the broader use of intracameral moxifloxacin in place of, or alongside topical antibiotics.
Anderson J, Young S, Cockerham G, Chomsky A, and Parr NJ. Evidence Brief: Intracameral Moxifloxacin for Prevention of Endophthalmitis After Cataract Surgery. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-199; 2022.
To view the full report, go to http://www.hsrd.research.va.gov/publications/esp/moxifloxacin-brief.cfm
ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
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