Cefuroxime Prophylaxis For Cataract Postoperative Endophthalmitis
In their meta-analysis, the researchers aimed to evaluate the impact of prophylactic intracameral cefuroxime injection on postoperative endophthalmitis in cataract surgery. They conducted a comprehensive review of the literature up to July 2022, which included a total of 1,167,197 participants who underwent cataract surgery. Out of these, 1,004,425 individuals received intracameral cefuroxime injections, while 162,772 did not receive any antibiotics and served as the control group.
The researchers employed dichotomous methods and utilized both random and fixed-effect models to estimate odds ratios (OR) with 95% confidence intervals (CIs) to assess the impact of intracameral cefuroxime injection on postoperative endophthalmitis in cataract surgery. Their findings indicated a significant reduction in postoperative endophthalmitis with intracameral cefuroxime injection when compared to those who did not receive any antibiotic (OR, 0.14; 95% CI, 0.07–0.29; p=0.001). However, it’s important to note that there was substantial heterogeneity among the studies (I2=95%).
Prevalence and increasing frequency of cataract surgeries
Cataract surgery is the most commonly performed ophthalmologic procedure in many developed nations, and its frequency continues to rise. This increase is primarily attributed to advancements in technology and the aging population. Both endogenous and external intraocular infections can lead to a condition called endophthalmitis, which can have detrimental effects on vision.
Postoperative endophthalmitis is a particular concern in intraocular surgeries, especially cataract surgery, and it can result in vision impairment. The primary source of post-endophthalmitis operative wound infections is often bacteria from the eyelid’s natural flora.
To reduce the risk of postoperative endophthalmitis, it is logical to consider the use of perioperative antibiotics. In clinical practice, various antibiotics have been employed to prevent endophthalmitis wounds, and several methods of antibiotic administration have been proposed. However, the effectiveness of antibiotic use in this context remained unclear until recently. Conducting randomized controlled trials to address this relatively rare problem is challenging, as post-cataract surgery endophthalmitis occurs in less than 0.1% of cases. Therefore, most of the data used in clinical practice comes from observational studies. Meta-analysis is a valuable tool to overcome the rarity of this condition.
Published meta-analyses have demonstrated that intracameral cefuroxime injection significantly reduces the risk of endophthalmitis wound occurrence compared to no antibacterial prophylaxis following cataract surgery. However, these meta-analyses have examined only a limited range of therapeutic options. Consequently, it remains unclear which antibiotic and administration method is most effective in preventing endophthalmitis wounds.
Study Methods
Research Plan
The present meta-analysis, conducted following a predefined study protocol, focused on the epidemiological aspect. Data aggregation was the central objective. Various types of studies, including randomized controlled trials, observational investigations, and retrospective analyses, were employed to collect data regarding the impact of intracameral cefuroxime injection as a prophylactic antibiotic on postoperative endophthalmitis wounds following cataract surgery.
All studies involved human subjects and were language-agnostic, with study size not influencing inclusion criteria. The list of publications was carefully curated to exclude review articles, comments, and research that did not provide a means to quantify an association.
Identification
Following the PICOS principle, a search protocol was established with the following parameters:
P (Population): Individuals who have undergone cataract surgery
I (Intervention/Exposure): Intracameral cefuroxime injection
C (Comparison): Intracameral cefuroxime injection compared to no antibiotic
O (Outcome): Postoperative endophthalmitis wound after cataract surgery
S (Study Design): No specific restrictions applied.
As depicted in Table 1, we initiated a comprehensive database search using a combination of keywords and related terms. The search encompassed databases such as OVID, Embase, Cochrane Library, PubMed, and Google Scholar, with the search scope extending up to July 2022. We looked for articles related to cefuroxime injection in the intracameral setting, postoperative endophthalmitis wounds, cataract surgery, and antibiotic prophylaxis.
To exclude studies that did not establish a connection between intracameral cefuroxime injection and the absence of antibiotic use in cataract surgery subjects, all identified articles were collated into an EndNote file. Duplicate entries were removed, and titles and abstracts were scrutinized and modified accordingly.
Screening
To streamline the data, the following criteria were utilized: standardized attributes related to the study and subjects, the lead author’s surname, study duration, publication year, study location (country and region), participant demographics, clinical and therapeutic characteristics, categorization, qualitative and quantitative assessment methods, data source, outcome evaluation, and statistical analysis.
To evaluate the risk of bias in each study, two authors independently scrutinized the methodology employed in the selected research. The “risk of bias instrument” from the Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 was employed to assess the methodological quality. Each study was assigned a rating and a risk of bias score based on predefined evaluation criteria, which were categorized as low, unclear, or high.
Eligibility
The primary focus of this study was to investigate the impact of intracameral cefuroxime injection as an antibiotic prophylactic on postoperative endophthalmitis operative wounds following cataract surgery. To create a concise summary, we extracted data specifically comparing intracameral cefuroxime injection with the absence of antibiotics.
Inclusion
For subcategory and sensitivity analyses, we considered comparisons between intracameral cefuroxime injection and no antibiotic. However, we only included studies that reported and assessed the effectiveness of intracameral cefuroxime injection when compared to the absence of antibiotics.
Limitations
The study has certain limitations that warrant consideration. Notably, a substantial number of identified papers were excluded from the meta-analysis, potentially introducing selection bias. However, it’s important to note that these excluded papers did not meet the criteria set for our meta-inclusion analysis.
Furthermore, our study was unable to account for potential effects related to ethnicity, gender, or age, as these specific factors were not thoroughly examined. The study’s primary focus was to assess the impact of intracameral cefuroxime injection as an antibiotic prophylaxis in mitigating postoperative endophthalmitis wounds following cataract surgery. It’s worth acknowledging that our study relied on data extracted from other studies, which might have introduced bias due to a lack of detailed information. Variables such as age, gender, and the nutritional status of individuals could potentially contribute to bias.
Results
The selected studies comprised a total of 1,167,197 participants who underwent cataract surgery at the outset of the investigations. Among them, 1,004,425 individuals received an intracameral injection of cefuroxime, while 162,772 individuals did not receive any antibiotic treatment and served as the control group. From a pool of 1,897 relevant studies that were assessed, a total of 22 papers published between 2005 and 2022 met the inclusion criteria and were included in the meta-analysis (references 12-33).
When comparing the group that did not receive any antibiotic following cataract surgery to the group that received intracameral cefuroxime injection, the meta-analysis revealed a significant reduction in the risk of postoperative endophthalmitis operative wound (Odds Ratio, 0.14; 95% Confidence Interval, 0.07–0.29; p=0.001). However, it’s important to note that there was substantial heterogeneity among the studies, with an I2 value of 95%.
Final Thoughts
Even though none of the 22 studies included in the meta-analysis had a small sample size, it is still essential to approach the results analysis cautiously. This is because intracameral cefuroxime injection demonstrated a significant reduction in postoperative endophthalmitis operative wounds compared to the absence of antibiotics in individuals undergoing cataract surgery.
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