| BackgroundWith the continuous development of social economy,the global average life expectancy continues to extend,and the incidence of many elderly diseases is rising Cataract is one of them.It has become the biggest "killer" threatening the visual health of the elderly population worldwide,and has a great impact on the quality of life of people,especially the elderly population.For this disease,surgery or medication are currently available for treatment.But as we all know,drug therapy has only a certain effect on early patients.With the development of clinical science and technology,ophthalmic phacoemulsification is becoming more and more mature.At present,phacoemulsification+intraocular lens implantation is the main method to treat senile cataract.The operation time is short and the effect is good.It is praised by more and more clinical ophthalmologists However,the cumulative amount of operation also makes the complications of operation a problem that the majority of surgeons have to consider.Infectious endophthalmitis after cataract surgery is the most catastrophic complication,and its incidence is generally considered to be 0.04-0.27%.Statistics in China show that the incidence of infectious endophthalmitis after cataract surgery is 0.033-0.11%.Usually manifested as sudden eye pain with visual impairment,anterior chamber empyema and conjunctival congestion,serious damage to the eyeball tissue,damage to visual function.On the surface,the incidence of this complication is not high,but the phenomenon of missed diagnosis is very common in our country.Because of the lack of timely and effective treatment,vision loss and eye atrophy are catastrophic consequencesIt has been pointed out that most of the pathogenic bacteria of infective endophthalmitis after cataract surgery are Staphylococcus and streptococcus.Vancomycin,as a broad-spectrum antibiotic,can completely cover the above bacteria.At present,it has been widely used in the prevention of infective endophthalmitis after cataract surgery According to the American Society of Cataract and Refractive Surgery(ASCRS)survey in 2007 and 2014,anterior chamber injection of vancomycin is the most commonly used drug to prevent infective endophthalmitis after cataract surgery.37%of ophthalmologists worldwide use the drug at a dose of 1 mg/0.1 ml.With the routine use of vancomycin in preventing infective endophthalmitis after cataract surgery,adverse reactions of vancomycin in ophthalmology have also been reported.According to ASCRS and the American Society of Retina Specialists(ASRS),the most serious is hemorrhagic retinal vasculitis(HORV)after local use of vancomycin.HORV is considered to be delayed painless visual loss,mild anterior chamber and vitreous inflammation,and focal retinal hemorrhage.The complications are highly suspected to be related to vancomycin injection into the anterior chamber,and there is no direct evidenceThe effect of vancomycin on eyes after anterior chamber injection has not been reported in China.The concentration of vancomycin 1 mg/0.1 ml reported abroad is higher than that of clinical use in our hospital(0.01 mg/ml,0.1 ml).Therefore,it is necessary to retrospectively analyze the cases of clinical use of vancomycin in our hospital for many years in order to judge the local safety of vancomycin after anterior chamber injectionFor many years,cefuroxime and low concentration vancomycin(0.01 mg/ml,0.1 ml)were injected into the anterior chamber to prevent the occurrence of infectious endophthalmitis after cataract surgery.This concentration is 1/1000 of the concentration of vancomycin used in foreign reports,and the efficacy and safety of vancomycin in preventing postoperative infectious endophthalmitis have not been clinically reported.Combined with the clinical data of the center,the purpose of this study was to investigate the efficacy and safety of low-concentration vancomycin injection in the anterior chamber at the end of cataract surgeryPurpose1.Retrospective analysis of the clinical effect of low concentration vancomycin in the prevention of infective endophthalmitis after cataract surgery2.To observe the effect of low concentration vancomycin on the prevention of complications caused by infective endophthalmitis after cataract surgeryMethodsPart ?.The effect of low concentration vancomycin on the prevention of infective endophthalmitis after cataract surgeryIn this part of the study,13068 eyes with low concentration vancomycin injected into the anterior chamber at the end of cataract surgery in our hospital from January 1,2016 to December 31,2017 and 1577eyes with cefuroxime injected into the anterior chamber at the end of cataract surgery from January 1,2018 to December 1,2019 were collected.The incidence of infective endophthalmitis after cataract surgery in the above two groups was reviewed and compared.The preventive effect of the two groups on infective endophthalmitis after cataract surgery was analyzed by non inferior effect test.For the patients with decreased vision during follow-up,the cornea,anterior chamber and artificial crystal were examined under slit lamp,and the glass was examined by B-ultrasound Laboratory tests such as vitreous opacity and intraocular fluid culture were carried out to confirm the patients with infective endophthalmitis,and the change of treatment plan and prognosis of these patients were followed upPart ?.Clinical observation of low concentration vancomycin to prevent complications related to infective endophthalmitis after cataract surgeryFrom January 2014 to November 2017,24916 eyes of cataract patients underwent cataract surgery in our hospital,all of whom received 0.1 ml(0.01 mg/ml)low concentration vancomycin injection into the anterior chamber at the end of the surgery After the operation,the patients with decreased vision were followed up.Slit lamp examination and B-ultrasonic examination were performed.The patients with inflammation in the eyes were screened out.The pathogenic microorganism in the room water was examined.The infective endophthalmitis after cataract operation was eliminated.The remaining patients were screened out.The optical coherence tomography(OCT)and fundus fluorescein angiography were performed FFA,IL-6,VEGF,transforming growth factor(TGF-?1),VCAM,21 Detection of nucleic acid of pathogenic microorganism,broad-spectrum bacteria and broad-spectrum fungi.Follow up the change of treatment plan and the prognosis.All data are processed using Microsoft Excel and SPSS software.In this study,the effectiveness and counting data of vancomycin at low concentration were described in percentage,and the non-inferiority test of the two groups was used for statistical analysis.Inspection level=0.025.P<0.025 indicates statistical significance.The one-side z test was used for the noninferiority test of the rate,and the statistic z was subject to the standard normal distribution.The calculation formula was as follows:Z=?-(Pc-PT)/SPC-PTSpc-pt is the standard error of the difference between two groups of rates.The calculation method is the combination(average)method of two groups of rates.The calculation formula is:SPC-PT=(?)ResultsPart ?.The effect of low concentration vancomycin on the prevention of infective endophthalmitis after cataract surgeryA total of 5 eyes(5 eyes)were selected for cataract surgery.Among them,3 cases(3 eyes)were found in vancomycin group,the incidence rate was 0.0229%,and 2 cases in Cefuroxime group were 2 eyes,the incidence rate was 0.0127%.In the low concentration vancomycin group,the results of pathogenic bacteria culture were 1 Pseudomonas aeruginosa and 2 Staphylococcus epidermidis,and in the cefuroxime group,1 fungus and 1 Streptococcus mitis.The two groups had a non inferiority test on the incidence rate of postoperative infectious endophthalmitis(P<0.025),that is,low concentration vancomycin had no difference in the prevention of infective endophthalmitis after cataract surgery.There was no significant difference between cefuroxime group and low concentration vancomycin group in the clinical manifestations of patients with postoperative infectious endophthalmitis,all of which showed decreased vision,different degrees of corneal edema under slit lamp,positive of floating cells and Tyn in the anterior chamber,some patients with hyphema in the anterior chamber,flocculent exudation in the anterior chamber,adhesion of exudative membrane on the surface of intraocular lens,moderate and severe vitreous turbidity.Part ?.Clinical observation of low concentration vancomycin to prevent complications related to infective endophthalmitis after cataract surgeryIn addition to infectious endophthalmitis,21 patients with intraocular inflammation were found in 25 eyes,17 in one eye and 4 in both eyes.The mean time of intraocular inflammation was 22.26±12.58 days after cataract surgery.VEGF was 96.95±58.49pg/ml(reference interval 0-40.0),TGF-was 175.05±33.55pg/ml(reference interval<1.0),il-629123.83±16066.97pg/ml(reference interval 1.0-50.0),il-10 5.85±1.15pg/ml(reference interval 0-50.0),and VCAM 14650±10144.62pg/ml(reference interval 200-1000).No 21 common pathogenic microorganisms were detected in the eyes,and no fungal or bacterial growth was detected by culture microscopy.Corneal edema was mild under slit-lamp,and the anterior chamber was positive for planktonic cells and Tyn,and the intraocular lens was transparent.Ocular ultrasound suggested vitreous opacity.The treatment with vancomycin was not well controlled or even aggravated,and the condition was significantly alleviated after stopping the treatment with vancomycin.Conclusions1.The effect of vancomycin injection in the anterior chamber at the end of cataract operation is not inferior to that of cefuroxime.It provides an alternative for a few cataract patients who are allergic to cephalosporins to prevent postoperative infectious endophthalmitisIn terms of the prevention of infectious endophthalmitis complications after cataract surgery with low concentration of vancomycin,according to the clinical observation of our center,although the rare late non infectious inflammatory reaction may occur,there is no catastrophic Horv case,which is considered to be related to the low concentration of vancomycin in our hospital.Because of the rare and late complications,we should pay attention to follow-up in clinical application,especially for the suspected cases such as the aggravation of vancomycin treatment and the slow symptoms after discontinuation of treatment,hormone therapy is recommended. |
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