Study of Antibiotic Prophylaxis for Endophthalmitis Following Cataract Surgery

Condition(s) targeted: Endophthalmitis

Intervention: Cefuroxime (Drug); Levofloxacin (Drug)

Phase: N/A

Status: Completed

Sponsored by: City University, London

Official(s) and/or principal investigator(s):
Peter Barry, FRCS, Study Chair, Affiliation: ESCRS - European Society of Cataract and Refractive Surgeons
Mary D'Ardis, Principal Investigator, Affiliation: ESCRS

Cataract is the most important cause of visual impairment and decreased mobility in the elderly. While surgery is usually successful, it is also responsible for permanent loss of vision in up to 0. 1% of patients due to severe post-operative infection (endophthalmitis). Because of this risk, surgery is typically performed on one eye at a time leaving the patient with a monocular cataract causing considerable visual impairment with reduction in mobility and quality of life. A second operation is required which often takes place up to one year later.

It is not known at present whether the post-operative complication of endophthalmitis can be prevented by perioperative use of antibiotics. This randomised study (masked and placebo-controlled for topical levofloxacin and unmasked for intracameral injection of cefuroxime) sets out to test in 4 groups, each of 8,750 cataract surgery patients, if either topical antibiotic (levofloxacin) perioperatively or an intraocular (intracameral) injection of antibiotic (cefuroxime) at the end of phacoemulsification cataract surgery or the combination provides effective prophylaxis of post-operative infection (endophthalmitis) compared to controls in whom perioperative antibiotics are not used. The result will provide a scientific basis for prophylaxis of infection (endophthalmitis) following cataract surgery in Europe as well as an accurate figure for the incidence of endophthalmitis following phacoemulsification cataract surgery in Europe for the first time.

Official title: Antibiotic Prophylaxis for Cataract Surgery Version 7e January 22 2003

Study design: Prevention, Randomized, Double-Blind, Placebo Control, Factorial Assignment, Safety/Efficacy Study

Primary outcome:

Prevention of post-operative endophthalmitis following phacoemulsification cataract surgery in Europe due to use of perioperative antibiotics

Incidence of endophthalmitis in Europe following phacoemulsification cataract surgery

Secondary outcome: Effect of risk factors on the presentation of endophthalmitis in Europe following phacoemulsification cataract surgery

Detailed description: Cataract extraction with intra-ocular lens implantation is the most commonly performed surgical procedure in the elderly population in Europe. The frequency varies in different European Union (EU) countries involving 2 to 7 per 1000 population per annum. A population with an ever-increasing proportion of the elderly is advancing this figure with numbers requiring surgery expected to increase by 70% by 2006. While technical advances (phacoemulsification) have enhanced the efficacy of the procedure, the possibility of serious post-operative infection with loss of vision remains the most important unsolved problem.

In the absence of scientific evidence, the European Society of Cataract and Refractive Surgeons (ESCRS) wishes to determine whether one currently developed method of delivering antibiotics intraocularly in Sweden is of benefit compared to surgery without the use of perioperative antibiotics, as currently practised in many European centres, or to the use of frequent application of topical antibiotic drops perioperatively. The ESCRS also wishes to assess possible risk factors for later endophthalmitis.

This study requires four groups of 8,750 patients - 35,000 in all - to demonstrate reductions

of currently reported rates of endophthalmitis (approximately 0. 3%) in patients where no intraocular antibiotics are used, or where they are used by the subconjunctival route. Other studies using intraocular vancomycin have reported results as low as 0. 05%, but these studies were not standardised or controlled and the results were anecdotal. In addition, vancomycin should not be used for routine prophylaxis and should only be used as the antibiotic of 'last resort'.

This multi-centre randomised study involves 24 operating units in 8 EU countries (Austria, Belgium, England, Germany, Italy, Poland, Portugal and Spain) and Turkey. Results in 8,750 patients receiving an intracameral injection of antibiotic (cefuroxime) at the end of surgery will be compared to 8,750 patients receiving topical antibiotic (levofloxacin) prophylaxis before and at the end of surgery, 8,750 patients receiving the combination and 8,750 patients receiving neither regime; in addition, all patients will receive povidone iodine antiseptic prophylaxis prior to surgery and post-operative levofloxacin from days 1 to 6 to prevent wound infection.

This group size will be sufficiently large to ensure at least 80% statistical power to detect a reduction of incidence from 0. 25% to 0. 08% using 5% significance level tests.

Surgical data from all patients will be collected directly into computers based within each operating theatre and transmitted to a central server in Glasgow (University of Strathclyde). Follow-up data for the presence or absence of endophthalmitis will be collected from all patients at post-operative visits and similarly recorded on computers for transmission to the central server. Sophisticated techniques will be used to check all data as it is uploaded.

Minimum age: 18 Years. Maximum age: N/A. Gender(s): Both.

Criteria:

Inclusion Criteria:

- All patients, including diabetics, undergoing routine cataract surgery in each unit

taking part in the study

Exclusion Criteria:

- Patients who do not wish to take part in the trial

- Patients allergic to penicillins and cephalosporins.

- Long-term nursing home patients

- Patients with only one eye

- Pregnancy.

- Children less than 18 years old.

- All severely 'at-risk' groups for infection including:

- Severe atopic keratoconjunctivitis;

- Severe active blepharitis;

- Ocular cicatricial pemphigoid.

- Patients with complicated cataracts such as traumatic or subluxated

- Patients having combined operations with cataract surgery such as trabeculectomy or a

corneal graft.

- Patients known to be allergic to povidone iodine (very rare) or any other known

hypersensitivity to any components of the study medications.

- Patients who are incapacitated mentally and incapable of giving consent.

- Patients with severe thyroid disease

- Open infection anywhere, infection of lacrimal drainage channels or infection around

the eye

University Eye Clinic, Paracelsus Private Medical University, Salzburg, Austria

Jan Yperman Ziekenhuis, Ieper, Belgium

Oogheelkunde, Melveren, Belgium

Centre Hospitalier Universitaire, Liege, Belgium

University Hospital Antwerp, UZA Ophthalmology, Antwerp, Belgium

University of Gent, Universitaire Zeikenhuis, Gent, Belgium

Augenklinik Ahaus, Ahaus, Germany

Ospedale Borgo Trento, Verona, Italy

Azienda Ospedaliera di Desenzano del Garda, Desenzano, Italy

Kierownik Katedry i Kliniki, Warsaw, Poland

University Hospital, Coimbra, Portugal

Hospital Universitario de Canarias, La Laguna, Tenerife, Spain

La Candelaria University Hospital, La Candelaria, Tenerife, Spain

Instituto Oftalmologico VISSUM, Alicante, Spain

Hospital Oftalmologico Internacional, Madrid, Spain

Dokuz Eylul University, Izmir, Turkey

Sunderland Eye Infirmary, Sunderland, United Kingdom

Moorfields Eye Outreach Unit, Northwick Park Hospital, London, United Kingdom

Moorfields Eye Outreach Unit, St. George's Hospital, London, United Kingdom

West of England Eye Unit, Royal Devon & Exeter Hospital (Wonford), Exeter, United Kingdom

Axminster Hospital, Axminster, United Kingdom

Ipswich Hospital, Ipswich, United Kingdom

St. Thomas' Hospital, London, United Kingdom

Oxford Eye Hospital, Oxford, United Kingdom

Related publications:

Seal DV, Barry P, Gettinby G, Lees F, Peterson M, Revie CW, Wilhelmus KR; ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Case for a European multicenter study. J Cataract Refract Surg. 2006 Mar;32(3):396-406. Erratum in: J Cataract Refract Surg. 2006 May;32(5):709.

Starting date: September 2003
Ending date: May 2006
Last updated: June 7, 2007