Opinions of the Fourth-Generation Fluroroquinolones in the Management of Bacterial Keratitis: A Survey of Ophthalmologists from Four States This study was supported in part by Research to Prevent Blindness (RPB), Inc. Financial Disclosures: Hugo Y. HsuNone Heidi A. IsraelNone Randall NackeNone Jonathan C. SongNone Sonia H. YooAlcon, AMO, Carl Zeiss Meditect Eduardo C. AlfonsoNone

Background Over the past 20 years, empiric therapy with commercially-available antibiotics has come to replace fortified antibiotics as the drugs of choice in the treatment of the majority of bacterial keratitis. The 1990’s saw the introduction of the fluoroquinolones for ophthalmic use with studies suggesting equal efficacy when compared to fortified antibiotics. The newest “generation” of fluoroquinolones– moxifloxacine & gatifloxacine–were introduced in 2003 for ophthalmic use. While officially approved for the treatment of bacterial keratitis, the newer fluoroquinolones have become popular replacements for their older cousins in the treatment of bacterial keratitis.

Purpose To evaluate ophthalmologists’ opinions of the newer fluoroquinolone antibiotics in the management of bacterial keratitis anonymous practice-pattern questionnaires were sent to ophthalmologists in California, Florida, Illinois, & Missouri The questionnaires were grouped and filtered by the type and setting of the respondents’ practices Descriptive statistics, chi-square, & non- parametric analysis techniques were employed. Methods

Methods: Questions asked

Results 629 surveys were returned (10.3%) Comprehensive475 (75.5%) Cornea100 (15.9%) Retina45 (7.2%) Refractive58 (9.2%) Glaucoma52 (8.3%) Peds/Strabismus40 (6.4%) Others31 (4.9%) Total629* * Respondents were allowed to indicate more than one choice to describe the nature of their practice

“Overall, has the introduction of the 4th generation fluoroquinoones (Vigamox ® & Zymar ® ) impacted your practice and your usage of antibiotics?” Comprehensive practices Cornea practices P- value “not really”35 (8.5%)9 (9.2%) “a little bit”107 (25.8%)30 (30.6%) “definitely”272 (65.7%)59 (60.2%) Total41498

“4th generation fluoroquinolones make me to culture a patient with a corneal ulcer.” Comprehensive practices Cornea practices P-value “more likely”9 (2.2%)3 (3.0%) < “no change”195 (47.3%)67 (67.7%) “less likely”208 (50.5%)29 (29.3%) Total41299

“4th generation fluoroquinolones make me to refer a patient with a corneal ulcer.” Comprehensive practices Cornea practices P-value “more likely”3 (0.7%)0 < “no change”219 (53.0%)78 (79.6%) “less likely”191 (46.2%)20 (20.4%) Total41398

“4th generation fluoroquinolones represent a significant improvement over prior fluoroquinolons in the treatment of corneal ulcers.” Comprehensive practices Cornea practices P-value “don’t agree”35 (8.5%)13 (13.1%) “somewhat agree” 138 (33.3%)37 (37.4%) “mostly agree”141 (34.1%)28 (28.3%) “strongly agree”100 (24.2%)21 (21.2%) Total41499

Is there a difference between cornea specialists in private vs. academic practices? P-value “…has the 4th generation fluoroquinolones impacted your practice and usage of antibiotics?” 0.55 “4th generation…make me culture a patient” 0.08 “4th generation…make me refer a patient”0.22 “4th generation…represent a significant improvement…” (degrees of agreement) 0.90

Conclusion The newer fluoroquinolones have impacted the practices of and the usage of antibiotics among ophthalmologists. Slightly over half of ophthalmologists surveyed indicate that the newer fluoroquinolones are an improvement over their older cousins in the management of corneal ulcers. These impacts and impression are more strongly felt by comprehensive ophthalmologists than cornea specialists.

Conclusion Specifically, while having similar opinions, fewer cornea specialists have changed their management of corneal ulcers compared to their comprehensive colleagues due to the newer fluoroquinolones. No difference(s) were found in the answers between private cornea specialists and academic cornea specialists.