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Antibiotics at the time of cataract surgery to prevent acute endophthalmitis after surgery

Gower EW, Lindsley K, Nanji AA, Leyngold I, McDonnell PJ
Published Online: 
15 July 2013

Endophthalmitis (inflammation of the inside of the eyeball due to infection or trauma) is a rare but potentially blinding complication of cataract surgery. It typically is caused by bacteria that enter the eye during surgery or in the first few days after surgery. Multiple preventive measures are used to try to prevent infection after surgery. Several studies have investigated different modes of prevention such as the types of antibiotics used, how the antibiotics are applied or taken, and when the antibiotics are given in the surgical process.

The authors searched the literature for randomized controlled trials of cataract surgery that evaluated giving antibiotics shortly prior to, during, or immediately after surgery to prevent acute endophthalmitis. Four trials with a total of 100,876 adults and 131 endophthalmitis cases met the inclusion criteria. Of these four trials, two reported reduced rates of endophthalmitis when comparing antibiotics injected into the eye versus antibiotics given in eye drops. In one study, penicillin injected into the eye resulted in a 67% reduction in endophthalmitis after surgery. In the more recent ESCRS study, cefuroxime injected into the eye reduced the risk of endophthalmitis by 80% to 90%, depending on whether antibiotic drops were also utilized. This study provides the best available current evidence for antibiotic prevention of endophthalmitis. Cefuroxime is used widely in Europe but on a limited basis in the United States, where some physicians have expressed concerns regarding risk of contamination or dilution errors during the compounding process (preparing drugs for ocular use) that could cause ocular toxicity (harms). 

Given that clinical trials with rare outcomes need to enroll a large number of participants and are costly to conduct, it is unlikely that additional clinical trials will be conducted to assess how well perioperative antibiotic prophylaxis works to prevent acute endophthalmitis after cataract surgery. Practitioners should consider the evidence shown by the ESCRS study, that antibiotics injected into the eye are likely to reduce the risk of endophthalmitis after cataract surgery when they can be sterilely obtained and delivered.