Methodological quality of the review: Low confidence

Author: Al-Abduljabbar KA, and Stone DU

Region: Worldwide

Sector: Endophthalmitis after cataract surgery

Sub-sector: Risk, practice pattern, cefuroxime

Type of cataract: Age-related cataract

Equity focus: None specified

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable

Background:

Endophthalmitis after cataract surgery is a rare but vision-threatening complication. Intracameral cefuroxime (ICC) has been reported to be effective at reducing the risk, but concerns regarding the risks associated with this intervention remain.

Research objectives:

The purpose of this review is to provide an evidence-based review and synthesis of the literature regarding the risks of ICC when administered for the prevention of post-cataract surgery endophthalmitis, thereby informing decisions regarding best practices for cataract surgery.

Main findings:

Findings from studies identified suggest that ICC injection during cataract surgery was well tolerated in a prospective study of 40 penicillin-allergic patients with a negative preoperative cefuroxime skin test. After a critical review of a case-control study (where the control group was the cohort of patients undergoing cataract surgery under a hospital policy of excluding patients with self-reported penicillin allergy) this policy altered and all patients without history of cephalosporin anaphylactic reaction were administered ICC. Out of 13,592 subsequent cataract surgeries, authors stated that there no reported cases of anaphylaxis or allergic reactions.

Authors found a prospective study noting that ICC at the standard dose of 1mg did not have a statistically significant effect on postoperative macular thickness compare with non-administrations of intracameral antibiotic. When looking at studies which administered high doses of cefuroxime, authors acknowledged that studies identified are limited when assessing the risk based on these, as these had major limitations in order to draw conclusions.

Authors noted that toxic anterior segment syndrome after cataract surgery has been associated with intracameral use of cefuroxime. However, evidence is very weak.

Based on evidence identified, authors concluded that cefuroxime can be administered safely to penicillin-allergic patients, and steps should be taken to reduce the risk of compounding to avoid the benefits of this intervention. Authors recommend practice patterns for endophthalmitis prophylaxis should consider the risks and benefits of ICC.

Methodology:

Authors conducted a search on PubMed and Google Scholar for published articles. They used key words such as “cefuroxime,” “endophthalmitis” and “cataract surgeries.” No date or language restrictions were applied. All included articles were read by two authors with the exception of two that were available as abstracts only. Authors noted that the highest level of evidence for each aspect of intervention was assigned utilizing the Oxford Centre for Evidence-based Medicine Guidelines.

Applicability/external validity:

The reviewers propose that an acceptable practice pattern would be to consider ICC in all cataract surgery patients, including those with a history of penicillin allergy. Authors also suggest administration to those patients with cephalosporin allergy may be considered, but skin testing may be indicated to identify those patients that are at increased risk of anaphylaxis and should not receive ICC.

Geographic focus:

Authors did not focus on a specific income setting, in addition authors did not report findings from low- and middle-income countries.

Quality assessment:

Low confidence was attributed for this systematic review, as important limitations were identified. The authors did not conduct a thorough search of the literature to ensure the inclusion of grey literature and other potentially relevant studies by searching references of included studies. Therefore, this review is prone to publication bias which may have an impact on the overall conclusions of the review. In addition, methods used screen studies and extract data of included studies were not clear enough or not reported to understand if authors avoided biases.