Preparing Intracameral Cefuroxime for use in Cataract Surgery Frimley Park Hospital NHS Foundation Trust Surrey, UK Dr William R Tucker BSc MBBS The author has no financial interest in the subject matter of this poster

Purpose Postoperative endophthalmitis is a rare but devastating complication of cataract surgery. Preoperative antiseptic with Povidone iodine combined with perioperative and postoperative antibiotics is a UK standard of care. However controversy exists over which antibiotics and route to use. A prospective randomised trial in 16,603 patients conducted by the ESCRS found nearly a 5 fold reduction in risk of postoperative endophthalmitis when using intracameral cefuroxime compared to controls 1. A smaller study found the incidence of postoperative endophthalmitis was significantly lower in a group given intracameral cefuroxime compared to subconjunctival cefuroxime 2. 1) Endophthalmitis study group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicentre study and identification of risk factors. J Cataract Refract Surg 2007: 33(6):978 – 988 2) Yu-Wai-Man et al. Efficacy of intracameral and subconjunctival cefuroxime in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg 2008; 34(3):447 – 451

Purpose Despite accumulating evidence that intracameral cefuroxime is both effective and safe 3 the uptake among cataract surgeons has been poor. Chang et al surveyed 1312 surgeons of the ASCRS and found only 6% used intracameral cefuroxime 4. They also found 82% would initiate use if a commercial preparation was available. We believe this represents concerns about making up `home-made` preparations in theatre. We therefore developed a visual, simple and step by step protocol for preparing cefuroxime at 1mg/0.1ml before intracameral injection at the end of the case. We present a method for preparing intracameral cefuroxime and provide usage & complication data for cataract operations performed over an 18 month period at a UK hospital 3) Montan et al. Prophylactic intracameral cefuroxime. Evaluation of safety and kinetics in cataract surgery J Cataract Refract Surg 2002; 28(6):982 – 987 4) Chang DF et al. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey. J Cataract Refract Surg 2007; 33:1801 – 5

Method We designed a flow-chart portfolio using the diagrams and instructions shown on the following pages. This was placed in theatre and used as a guide to preparing the intracameral cefuroxime doses. Please note this is an OFF-LABEL use of the drug in the UK After 18 months of use we collected usage and complication data for the local unit where it was utilised. A questionnaire was sent around the nursing staff and surgeons asking about any problems encountered with the technique.

Method Zinacef ® 250 mg 2.5 ml Syringe Saline 0.9% 1 ml Syringes 10 ml SyringeDrawing up needles Filter Needles Double drape small trolley

Method Runner draws up 2.5 ml of saline into 2.5 ml syringe Inject this into the Zinacef ® Shake THOROUGHLY until dissolved Withdraw 1 ml into 1 ml syringe Use a FILTER NEEDLE

Method First Scrub Nurse takes 10 ml Syringe Fill 10ml syringe with Saline Using a FILTER NEEDLE

Method Express Saline to 9 ml mark Withdraw plunger to make room Assistant fits NEW FILTER NEEDLE to the 1 ml syringe of Zinacef ® & injects into the 10 ml syringe of Saline held by Scrub Nurse

Method Mix thoroughly Withdraw 0.4 ml into 1 ml syringe

Method Repeat step for number of cases on list. Cap 10 ml syringe & leave on trolley as reserve Place in instrument Tray. LEAVE RED DRAWING UP NEEDLE ON SYRINGE UNTIL END OF CASE Surgeon will inject 0.1 ml into lens bag at end of case

Result Over 18 months intracameral cefuroxime was prepared and used in 3768 routine phacoemulsification cataract operations. There were no cases of postoperative endophthalmitis over the period of use. Nursing staff and the surgeons reported no other complications and no difficulty in preparing the doses. However – please note we cannot accept responsibility if another person uses this method and suffers complications

Conclusion The use of intracameral cefuroxime is gaining credence as a effective method for reducing postoperative endophthalmitis rates. At present it seems to be held back by the lack of a commercial preparation and concern over the safest way to prepare it from available supplies. We have presented an easy to follow, step by step, visual method allowing surgeons to have confidence that a standard safe dose can be prepared by even the most inexperienced theatre staff. This off-label method of preparing Intracameral cefuroxime has proved to be a popular and safe method of administering prophylaxis against postoperative endophthalmitis