cations like retinal ischemia and macular edema, and the possibility of
toxic anterior segment syndrome (TASS) or toxic posterior segment
syndrome (TPSS).
4. There are 3 intracameral antibiotics. There's cefuroxime,
vancomycin and moxifloxacin. Cefuroxime is widely used in Europe,
but its weaknesses have become apparent to some. "It has high resist-
ance and a lot of organisms aren't fazed by it," says Dr. Miller; the
most prominent of those, perhaps, is methicillin-resistant
Staphylococcus aureus (MRSA). In the U.S., cefuroxime is approved
and labeled only for intravenous and intramuscular use.
Compounding it is a complicated, laborious process. In Europe, those
concerns have been eliminated with the introduction of a premixed,
single-use formulation, Aprokam, made specifically for intracameral
application. The U.S. isn't so lucky.
Vancomycin is generally considered the most powerful of the 3 —
it's frequently referred to as "the antibiotic of last resort" — but also
possibly the most dangerous. "There's a lot of concern that it's our last
holdout, one of the few drugs that kills most everything," says Dr.
Miller. "You have MRSA, you want vancomycin to kill it. But van-
comycin resistance would be really bad."
Another big problem is vancomycin's recent association with hemor-
rhagic occlusive retinal vasculitis [HORV]. "It's a very rare problem,
but it's such a scary problem that almost everybody in the U.S. has
basically given up using intracameral vancomycin," says Dr. Miller. "If
someone loses their sight, that's a career-killer."
U.S. ophthalmologists are coalescing around moxifloxacin and its
good kill rate. But using it isn't as straightforward as doctors may
wish. Many facilities use Vigamox, the only preservative-free version
of topical moxifloxacin available, by "just drawing it up out of the
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