REVIEW ARTICLe
Endophthalmitis Prophylaxis for Cataract Surgery
Aravind Haripriya, MD,* Zervin R. Baam, MS,* and David F. Chang, MD†
Abstract: Endophthalmitis after cataract surgery is a rare but potential‑
ly devastating complication. There is great variability in endophthalmitis
prophylaxis practice patterns worldwide. Treatment varies globally and
is based on the microbiological profile and availability of formulations.
Periocular povidone-iodine antisepsis is universally adopted and consid‑
ered the standard of care in most practices. Perioperative topical antibiot‑
ics are also very popular despite the lack of level 1 evidence confirming
efficacy. Based on growing observational evidence, routine intracameral
antibiotic prophylaxis is increasing, especially where approved commer‑
cial intraocular preparations are available. This review updates recent
trends and evidence regarding endophthalmitis prophylaxis and the pre‑
ferred choice of intracameral antibiotics.
Key Words: endophthalmitis prophylaxis, povidone-iodine,
perioperative antibiotics, intracameral antibiotic prophylaxis
(Asia-Pac J Ophthalmol 2017;6:324–329)
E ndophthalmitis, although very rare, is one of the most seri‑
ous postoperative complications of ocular surgery. Infectious
postoperative endophthalmitis is caused by entry of microorgan‑
isms into the eye during or after the surgical procedure. Although
it can occur with any intraocular surgery, most cases are associ‑
ated with cataract surgery, as it is the most common eye operation
performed.1
The reported rate of endophthalmitis after cataract surgery
ranges from 0.03% to 0.70%.2,3 There has been wide variation in
the postoperative endophthalmitis rate over time, with the rate
reported to be 0.087% in 1990 and 0.265% in 2000.2 It has been
hypothesized that the increased rate observed during the 1990s
was related to the use of sutureless, clear corneal incisions (CCIs)
during phacoemulsification.2,4,5 There are also some studies that
seem to discredit this hypothesis and instead suggest that CCIs
may be associated with less endophthalmitis.6,7 Advanced age
(>85 years old), rural residence, male sex, and immunosuppres‑
sive states such as diabetes mellitus may be patient-associated
risk factors.8‒10 The European Society of Cataract and Refractive
Surgeons (ESCRS) multicenter prospective study11 identified 3
factors that significantly increased the risk of postoperative infec‑
tious endophthalmitis: a CCI, silicone intraocular lenses (IOLs),
and the occurrence of surgical complications.
From the *Aravind Eye Hospital, Madurai, India; and †Altos Eye Physicians, Los
Altos, California.
Received for publication May 31, 2017; accepted July 19, 2017.
The authors have no funding or conflicts of interest to declare.
Reprints: Aravind Haripriya, MD, Aravind Eye Hospital, 1 Anna Nagar, Madurai
625020 India. E‑mail: haripriya@aravind.org.
Copyright © 2017 by Asia Pacific Academy of Ophthalmology
ISSN: 2162-0989
DOI: 10.22608/APO.2017200
324 | www.apjo.org
Copyright © 2017 Asia-Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
According to the Endophthalmitis Vitrectomy Study (EVS),12
most affected individuals lose visual acuity permanently, and vi‑
sual outcomes are often are poor. One third of individuals do not
gain vision better than counting fingers, and 50% do not recover
vision better than 20/40.13 A more recent study reported that 34%
of affected patients achieved a final visual acuity of 20/200 or
worse.14 With the significant increase in cataract surgery due to
population aging worldwide, effective endophthalmitis prophy‑
laxis is a rising global imperative.
materials and methods
We reviewed the recent literature using the PubMed database
to identify original articles using the key words “endophthalmitis
prophylaxis,” “povidone iodine cataract surgery,” and “intracam‑
eral antibiotic prophylaxis.” Additional advanced search criteria
included the time period from January 1, 2008, to December 30,
2016, humans, and English language. Special consideration was fo‑
cused on all articles published on this topic in the past 18 months.
Results
In recent years, trends in endophthalmitis prophylaxis have
evolved considerably. Both surgical and nonsurgical preventive
strategies have been advocated.15 We highlight a number of op‑
tions and global practices below.
Povidone-Iodine Prophylaxis
The single most effective method of preoperative antisepsis
is the application of povidone-iodine (PVI) solution (5‒10%) to
the cornea, the conjunctival sac, and the periocular skin surface
for a minimum of 3 minutes before the commencement of sur‑
gery.16 This results in a significant decrease in the ocular surface
microbial flora and has been convincingly shown to reduce en‑
dophthalmitis rates.11,17‒22 The systematic implementation of PVI
prophylaxis was the single most important factor for endophthal‑
mitis reduction at an institution during a 20-year period of analy‑
sis.23 Shimada et al24 recently reported that the rate of anterior
chamber bacterial contamination was significantly lessened when
the operative field was irrigated every 20 seconds with balanced
salt solution (BSS) containing 0.025% or 0.0025% PVI (0% rate)
compared with irrigation with BSS alone (5% rate).24 There was
no difference in endothelial cell density or postoperative inflam‑
mation among the 3 groups. When PVI is contraindicated (true
allergy is rare and hyperthyroidism is a relative contraindica‑
tion),25 aqueous chlorhexidine 0.05% may be used.11 Preoperative
antisepsis of the periocular area with topical PVI is widely ad‑
opted and is considered the standard of care for endophthalmitis
prevention.26,27
Perioperative Topical Antibiotics
Antibiotic prophylaxis is another common preventive
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 4, July/August 2017
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 4, July/August 2017
measure. However, there is wide variation in the antibiotic agents
used (eg, fluoroquinolones, aminoglycosides, cephalosporins,
chloramphenicol), the administration routes (topical, intraocu‑
lar, subconjunctival, oral), and the timing (preoperative, intraop‑
erative, perioperative, postoperative).26, 28,32 The most common
causative bacteria are Gram-positive species, such as coagu‑
lase-negative Staphylococcus (CoNS), Streptococcus viridans,
or Staphylococcus aureus.33,34 Gram-negative organisms, such as
Pseudomonas or Haemophilus, are less common; fungi and No-
cardia are rare.3,15,35,36
There is wide variability in the use of topical antibiotic pro‑
phylaxis. In contrast to PVI prep, the evidence supporting topical
antibiotic prophylaxis is not as compelling, leading some surgeons
to forgo it entirely.37 The theoretical goal of topical antibiotic
prophylaxis is to reduce the conjunctival bacterial load, thereby
lowering the risk of intraocular contamination either intraopera‑
tively or postoperatively. Strong evidence to support its efficacy
is lacking, and there is the theoretical risk that prolonged and re‑
peated administration may induce bacterial antibiotic resistance.11
The vast majority of respondents in the 2014 American Society
of Cataract and Refractive Surgery (ASCRS) survey (90%) used
topical perioperative antibiotics and virtually all surgeons used
them postoperatively (97%). The American Academy of Oph‑
thalmology Cataract Preferred Practice Pattern cites that starting
topical antibiotics on the day of surgery seems to be preferable
to waiting until the next day to initiate them.38 Topical antibiot‑
ics are frequently used for up to 1‒2 weeks postoperatively until
the incision fully heals and should not be tapered, as this would
encourage emergence of resistant organisms.
Intracameral Antibiotics
Corneal incisions may permit influx of fluid during sur‑
gery and even after hydration of the main incision and side port.
Despite using preoperative antibiotics and povidone-iodine and
following careful sterilization and aseptic protocols, the rate of
intraocular bacterial contamination has been shown to be as high
as 31%.39 Similar rates of anterior chamber contamination have
been reported with both phacoemulsification and manual small-
incision cataract surgery (M-SICS).40 Injecting antibiotics in‑
tracamerally (IC) at the end of surgery is intended to kill bacterial
microbes that have been introduced during the procedure. This
practice is becoming more popular worldwide. The 2014 ASCRS
endophthalmitis prophylaxis survey found that 50% of the 1147
global respondents injected an IC antibiotic at the conclusion of
surgery.41 This is significantly more than in the comparable 2007
ASCRS endophthalmitis prophylaxis survey, where 30% of re‑
spondents were using intraocular antibiotic prophylaxis.42 Antibi‑
otics for intracameral use should have broad antimicrobial cover‑
age and have the least potential for toxicity. The most commonly
used antibiotics for intraocular prophylaxis are cephalosporins
(cefuroxime and cefazolin), vancomycin, and moxifloxacin.
Cefuroxime devastating complication associated with intracameral vancomy‑
Cefuroxime, a second-generation cephalosporin, was initial‑
ly studied for intracameral prophylaxis by Montan et al43,44 in the
early 1990s. In 2006, the prospective, multicenter ESCRS endo‑
phthalmitis prophylaxis study reported a significant reduction in
endophthalmitis rates with IC cefuroxime injection.9,45 This land‑
mark randomized controlled trial enrolled 16,603 total patients
and provides the strongest support for the efficacy of intracameral
© 2017 Asia-Pacific Academy of Ophthalmology
Copyright © 2017 Asia-Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Endophthalmitis Prophylaxis
antibiotic prophylaxis. The rates of culture-proven endophthalmi‑
tis in the 2 groups receiving intracameral cefuroxime prophylaxis
were 0.050% and 0.025% compared with 0.226% and 0.176% in
the 2 groups without intracameral antibiotic. Overall, direct in‑
tracameral cefuroxime injections resulted in a 5.86-fold decrease
in the rate of culture-positive endophthalmitis. A large number of
international retrospective studies5,44,46‒53 have also found a sig‑
nificant decrease in the postoperative endophthalmitis rate after
initiation of intracameral cefuroxime prophylaxis. One such long-
term study from France54 reported on 6,371,242 eyes over the 10-
year period from 2005 to 2014. During this period, a significant
decrease in endophthalmitis coincided with the commercial avail‑
ability of cefuroxime for intracameral injection. Two large studies
from Spain reported an approximately 10-fold reduction in endo‑
phthalmitis rates with IC cefazolin injections.55,56
The approval in multiple European countries of a commer‑
cial cefuroxime preparation for intracameral injection (Aprokam,
Thea) has led to a significant increase in intracameral antibiotic
prophylaxis in these countries.47 The 2013 ESCRS endophthalmi‑
tis prophylaxis guidelines support using a commercially approved
cefuroxime formulation based on the published evidence.11 A
2014 ESCRS survey showed that 74% of the respondents regular‑
ly employed intracameral antibiotic prophylaxis. However, Apro‑
kam is largely unavailable outside of the European region. This
may explain why the 2014 ASCRS survey found that, in addition
to cefuroxime, vancomycin and moxifloxacin are also commonly
used by those respondents injecting antibiotics intracamerally.
Recently, there have been several reports of endophthalmitis
caused by cefuroxime-resistant organisms. Data from the Swed‑
ish National Cataract Surgery Database suggests that the overall
postoperative endophthalmitis rates with intracameral cefurox‑
ime and moxifloxacin were similar.57 However, postoperative en‑
dophthalmitis after cefuroxime prophylaxis was associated with
worse visual outcomes, largely due to a higher proportion of cases
infected with resistant Enterobacter species. This raised a con‑
cern over increasing rates of cefuroxime-resistant Gram-negative
isolates in Sweden. At least 2 cases of anaphylaxis associated
with intracameral cefuroxime injection have been reported in the
literature.58,59
Vancomycin
Vancomycin is a broad-spectrum antibiotic that covers near‑
ly all staphylococcal and streptococcal species, the most frequent
causes of postoperative endophthalmitis after cataract surgery.
It has been a common choice for intraocular endophthalmitis
prophylaxis, but there is no preparation that is commercially ap‑
proved for intracameral use. Most commonly, 1 mg/0.1 mL of
the drug is injected intracamerally at the end of surgery. In the
2014 ASCRS survey this was the most commonly used antibiotic
among those respondents employing intracameral prophylaxis:
37% overall and 52% of American respondents. However in 2015,
Witkin et al60 reported on 6 patients that had an extremely rare but
cin: hemorrhagic occlusive retinal vasculitis (HORV). Findings
of a joint ASCRS-American Society of Retina Specialists (ASRS)
task force on HORV were subsequently published and included
36 eyes from 23 patients (13 bilateral cases).61 Every single case
occurred after uncomplicated cataract surgery in which intraocu‑
lar vancomycin was administered. Hemorrhagic occlusive retinal
vasculitis seems to be a type III hypersensitivity reaction because
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Haripriya et al Asia-Pacific Journal of Ophthalmology • Volume 6, Number 4, July/August 2017

the onset is delayed (mean onset after 1 week) and exposure of the

50,177
5115
19,463
464,755
34,752
300,950
219,360
2,434,008
618,627
4,147,207
Total
second eye results in an earlier and more severe vasculitis. Out‑
comes are frequently poor because of rapid onset of neovascular
glaucoma. Although likely very rare, the true incidence of this
devastating complication is unknown, and many surgeons have
Duration

abandoned vancomycin for routine endophthalmitis prophylaxis.

11 years
5 years
14 years
6 years
4 years
8 years
9 years
5 years
2.5 years
Moxifloxacin
Moxifloxacin is a fourth generation fluoroquinolone that was
approved for systemic use in the United States in 1999 and for
United States
Singapore
Country

topical ophthalmic use in 2003. It has excellent ocular penetra‑

Sweden
France

France
Spain

Japan

India
Iran

tion after topical administration and reduced susceptibility to the

emergence of bacterial resistance, which is dose-dependent as op‑
posed to absolute.62‒64 There is a trend of increasing resistance
of CoNS to third and fourth generation fluoroquinolones.65 How‑
ever, intracameral moxifloxacin achieves bactericidal levels at
POE Rate (%)

least 10 times the minimum inhibitory concentration of the most

0.039
0.027
0.01
0.04

0.01
0.04

0.06
0.02
0.04

resistant bacteria for a limited time period but, because of its po‑
0

tent dose-dependent activity even at low injection concentrations,

With IC Antibiotic
Table 1. Most Recent Retrospective Studies Comparing Endophthalmitis Rates With and Without Intracameral Antibiotic (Published Since 2012)

it remains bactericidal for a much longer duration than cefurox‑

ime.65 In many countries, such as the United States, moxifloxacin
POE (N)

can be compounded for intracameral prophylaxis by outsourcing

2
1
5
123
3
28
0
548
68
778

to compounding pharmacies. Intracameral injection of Vigamox

brand topical moxifloxacin, which is unpreserved, is a more pop‑
Surgeries (N)

ular option.30 Several studies have reported on the method and the
safety of using the topical brand Vigamox for intracameral pro‑
20,638
2289
12,868
461,951
18,794
63,241
25,920
954,850
315,383
1,875,934

phylaxis.66,67 Generic topical moxifloxacin contains preservatives

and other adjuvants that are not safe for intraocular use.
In India and several other countries outside Europe and the
United States, specific intracameral preparations of moxifloxacin
have been available since 2013, including Auromox 0.5% (Auro‑
POE Rate (%)

lab, Madurai, India) single-use 1 mL vials and 4-Quin PFS 0.5%

(Entod Pharmaceutical, India) single-use prefilled syringes. Injec‑
0.064
1.24
0.59
0.39
0.05
0.07
0.01
0.09
0.07
0.08

tion of 0.1 mL containing 500 μg of these ready-to-use commercial

Without IC Antibiotic

preparations achieves anterior chamber concentrations exceeding

1 mg/mL. Our early experience using intracameral moxifloxacin
POE (N)

(Auromox, Aurolab, India) for endophthalmitis prophylaxis on

19
35
39
11
8
187
28
1393
218
1938

charity patients of the Aravind Eye Hospital in Madurai showed

a significant 4-fold reduction in the endophthalmitis rate in eyes
that underwent M-SICS.68 Based on this positive experience, rou‑
Surgeries (N)

tine intracameral moxifloxacin prophylaxis became standard at

29,539
2826
6595
2804
15,958
237,709
193,440
1,479,158
303,244
2,271,273

all 10 surgical facilities of the Aravind Eye Care System. When

the endophthalmitis rate was analyzed in more than 600,000 con‑
secutive cataract surgeries performed over a 2.5-year period, we
saw a significant overall endophthalmitis reduction from 0.07%
to 0.02%. This was separately true for both phacoemulsification
IC Antibiotic Used

(7-fold) and M-SICS (3.5-fold) and at each of the large regional

Moxifloxacin

Moxifloxacin

centers individually.33 Table 1 summarizes recent large retrospec‑

Cefuroxime
Cefuroxime

Cefuroxime
Cefuroxime
Multiple *

POE indicates postoperative endophthalmitis.

Cefazolin

Cefazolin

*Cefuroxime (99%), Moxifloxacin (1%)

tive studies that support the efficacy of intracameral antibiotics

for endophthalmitis prophylaxis.
Although the debate regarding the safety and efficacy of us‑
ing intracameral antibiotic prophylaxis continues, a recent Co‑
chrane review69 analyzed studies that had been published through
December 2016 and concluded that the 2007 ESCRS study dem‑
Jabbarvand et al53 (2016)
Rodriguez et al70 (2013)

Herrinton et al73 (2016)

Haripriya et al33 (2017)

Matsuura et al72 (2013)

onstrated the efficacy of using intracameral antibiotics for reduc‑

Barreau et al50 (2012)

Friling et al71 (2013)

Daien et al74 (2016)

ing endophthalmitis. However, the antibiotic of choice may dif‑

Tan et al21 (2012)

fer based on the clinical setting. Although there may be concerns

regarding toxicity and contamination with cefuroxime, increas‑
ing resistance to endophthalmitis-causing organisms may be the
Study

Total

concern with moxifloxacin. This review also cited the fact that

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Asia-Pacific Journal of Ophthalmology • Volume 6, Number 4, July/August 2017
clinical trials with rare outcomes require very large sample sizes
and are very costly to conduct. This explains why most published
evidence regarding postoperative endophthalmitis comes from
retrospective trials and that practitioners must consider differ‑
ent types of studies to make informed decisions regarding endo‑
phthalmitis prophylaxis.
Discussion
Javitt’s75 oft-cited editorial elegantly summarizes the multi‑
ple reasons that a prospective randomized placebo controlled trial
is so difficult, expensive, impractical, and potentially unethical to
now perform.
Although there is strong evidence supporting the efficacy
of intracameral antibiotic prophylaxis, the most important deter‑
rent seems to be the lack of a commercially approved preparation
in most countries, and this explains the wide global variation in
this practice.76 Mixing antibiotics in the operating room raises the
theoretical risk of dosing errors. Using pharmacies to compound
antibiotics raises the theoretical risk of introducing contaminants
or adjuvants that can cause toxic anterior segment syndrome.
Others have raised concerns that routine intraocular antibiotic
prophylaxis can lead to increasing bacterial drug resistance. The
recent editorial by Naseri et al77 effectively quiets this concern
because a 1-time, highly concentrated dose of antibiotic inject‑
ed into a physiologically isolated space is extremely unlikely to
promote bacterial resistance. In fact, the concern over promoting
antibiotic resistance should be directed more toward the common
use of topical antibiotic prophylaxis.78 Posterior capsular rupture
is one of the greatest risk factors for infectious endophthalmitis.
There is strong evidence that intracameral antibiotics reduce the
risk of endophthalmitis in eyes with this complication, and this is
true of both cefuroxime72 and moxifloxacin.33
In summary, there is much stronger evidence supporting
the efficacy of intracameral antibiotic injection than for topical
administration for endophthalmitis prophylaxis. Despite weaker
evidence for efficacy, topical antibiotic prophylaxis is ubiquitous
and the most common method in use. This is because it is consid‑
ered safe and readily available. In countries where an approved
antibiotic formulation for intraocular use is commercially avail‑
able, adoption is increasingly widespread. Where no such com‑
mercial source is available, the rare incidence of bacterial endo‑
phthalmitis must be weighed against the theoretical risks of using
compounded formulations or those mixed by the operating room
staff. In addition to theoretical compounding risks, vancomycin
poses the additional risk of HORV. Although rare, it can result
in bilateral blindness when used for close sequential surgery. If a
commercial formulation is not available, surgeons must individu‑
ally weigh the potential benefits and risks of using or not using an
intracameral injection.
References
1. Sandvig KU, Dannevig L. Postoperative endophthalmitis: establishment and
results of a national registry. J Cataract Refract Surg. 2003;29:1273‒1280.
2. Taban M, Beherens A, Newcomb RL, et al. Acute endophthalmitis following
cataract surgery: a systematic review of literature. Arch Ophthalmol. 2005;
123:613–620.
3. Kessel L, Flesner P, Andresen J, et al. Antibiotic prevention of postcataract
endophthalmitis: a systematic review and meta-analysis. Acta Ophthalmol.
© 2017 Asia-Pacific Academy of Ophthalmology
Copyright © 2017 Asia-Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Endophthalmitis Prophylaxis
2015;93:303‒317.
4. West ES, Behrens A, McDonnell PJ, et al. The incidence of endophthalmitis
after cataract surgery among the U.S. Medicare population increased
between 1994 and 2001. Ophthalmology. 2005;112:1388‒1394.
5. Lundstrom M, Wejde G, Stenevi U, et al. Endophthalmitis after cataract
surgery: a nationwide prospective study evaluating incidence in relation to
incision type and location. Ophthalmology. 2007;114:866‒870.
6. Colleaux KM, Hamilton WK. Effect of prophylactic antibiotics and incision
type on the incidence of endophthalmitis after cataract surgery. Can J
Ophthalmol. 2000;35:373‒378.
7. Fintelmann R, Naseri A. Prophylaxis of postoperative endophthalmitis
following cataract surgery. Drugs. 2010;70:1395‒1409.
8. Norregaard JC, Thoning H, Bernth-Petersen P, et al. Risk of
endophthalmitis after cataract extraction: results from the International
Cataract Surgery Outcomes study. Br J Ophthalmol. 1997;81:102‒106.
9. ESCRS Endophthalmitis Study Group. Prophylaxis of postoperative
endophthalmitis following cataract surgery: results of the ESCRS
multicenter study and identification of risk factors. J Cataract Refract Surg.
2007;33:978‒988.
10. Keay L, Gower EW, Cassard SD, et al. Postcataract surgery endophthalmitis
in the United States: analysis of the complete 2003 to 2004 Medicare
database of cataract surgeries. Ophthalmology. 2012;119:914‒922.
11. Barry P, Cordovés L, Gardner S. ESCRS guidelines for prevention and
treatment of endophthalmitis following cataract surgery: data, dilemmas and
conclusions. http://www.escrs.org/downloads/endophthalmitis-guidelines.
pdf. 2013.
12. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis
Vitrectomy Study. A randomized trial of immediate vitrectomy and of
intravitreous antibiotics for the treatment of postoperative bacterial
endophthalmitis. Arch Ophthalmol. 1995;113:1479–1496.
13. Lalwani GA, Flynn HW Jr, Scott IU, et al. Acute-onset endophthalmitis
after clear corneal cataract surgery (1996-2005). Clinical features, causative
organisms, and visual acuity outcomes. Ophthalmology. 2008;115:473–476.
14. Gower EW, Keay LJ, Stare DE, et al. Characteristics of endophthalmitis after
cataract surgery in the United States Medicare population. Ophthalmology.
2015;122:1625–1632.
15. Behndig A, Cochener B, Güell JL, et al. Endophthalmitis prophylaxis
in cataract surgery: overview of current practice patterns in 9 European
countries. J Cataract Refract Surg. 2013;39:1421–1431.
16. Nguyen CL, Oh LJ, Wong E, et al. Povidone-iodine 3-minute exposure
time is viable in preparation for cataract surgery. Eur J Ophthalmol. April 7,
2017. [Epub ahead of print].
17. Sadaka A, Durand ML, Gilmore MS. Bacterial endophthalmitis in the age
of outpatient intravitreal therapies and cataract surgeries: host–microbe
interactions in intraocular infection. Prog Retin Eye Res. 2012;31:316–331.
18. Levison AL, Mendes TS, Bhisitkul R. Post procedural endophthalmitis: a
review. Expert Rev Ophthalmol. 2013;8:45–62.
19. Charles QY, Ta CN. Prevention of postcataract endophthalmitis: evidence-
based medicine. Curr Opin Ophthalmol. 2012;23:19–24.
20. Galor A, Goldhardt R, Wellik SR, et al. Management strategies to reduce
risk of postoperative infections. Curr Ophthalmol Rep. 2013;1:161–168.
21. Tan CS, Wong HK, Yang FP. Epidemiology of postoperative
endophthalmitis in an Asian population: 11-year incidence and effect of
intracameral antibiotic agents. J Cataract Refract Surg. 2012;38:425–430.
22. Keynan Y, Finkelman Y, Lagacé-Wiens P. The microbiology of
endophthalmitis: global trends and a local perspective. Eur J Clin Microbiol
Infect Dis. 2012;31:2879–2886.
23. Nentwich MM, Ta CN, Kreutzer TC, et al. Incidence of postoperative
endophthalmitis from 1990 to 2009 using povidone-iodine but no
intracameral antibiotics at a single academic institution. J Cataract Refract
www.apjo.org | 327
Haripriya et al
Surg. 2015;41:58–66.
24. Shimada H, Arai S, Nakashizuka H, et al. Reduced anterior chamber
contamination by frequent surface irrigation with diluted iodine solutions
during cataract surgery. Acta Ophthalmol. March 8, 2017. [Epub ahead of
print].
25. Hierholzer S, Hierholzer G. Polyvinylpyrrolidone iodine in accident
surgery. Unfallchirurgie. 1985;11:309–315.
26. Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for
cataract surgery; an evidence-based update. Ophthalmology. 2002;109:13–24.
27. Braga-Mele R, Chang DF, Henderson BA, et al. Intracameral antibiotics:
safety, efficacy, and preparation. J Cataract Refract Surg. 2014;40:
2134–2142.
28. Nanavaty MA, Wearne MJ. Perioperative antibiotic prophylaxis during
phaco-emulsification and intraocular lens implantation: national survey of
smaller eye units in England. Clin Exp Ophthalmol. 2010;38:462–466.
29. Yu-Wai-Man P, Morgan SJ, Hildreth AJ, et al. Efficacy of intracameral and
subconjunctival cefuroxime in preventing endophthalmitis after cataract
surgery. J Cataract Refract Surg. 2008;34:447–451.
30. Liesegang TJ. Perioperative antibiotic prophylaxis in cataract surgery
[erratum in Cornea. 2000;19:123]. Cornea. 1999;18:383–402.
31. Gordon-Bennett P, Karas A, Flanagan D, et al. A survey of measures used
for the prevention of postoperative endophthalmitis after cataract surgery in
the United Kingdom. Eye (Lond). 2008;22:620–627.
32. García-Sáenz MC, Arias-Puente A, Rodríguez-Caravaca G, et al.
Effectiveness of intracameral cefuroxime in preventing endophthalmitis
after cataract surgery; ten-year comparative study. J Cataract Refract Surg.
2010;36:203–207.
33. Haripriya A, Chang DF, Ravindran RD. Endophthalmitis reduction with
intracameral moxifloxacin prophylaxis: analysis of 600,000 surgeries.
Ophthalmology. 2017;124:768–775.
34. Gentile RC, Shukla S, Shah M, et al. Microbiological spectrum and
antibiotic sensitivity in endophthalmitis: a 25-year review. Ophthalmology.
2014;121:1634–1642.
35. Haripriya A, Lalitha P, Mathen M, et al. Nocardia endophthalmitis after
cataract surgery: clinicomicrobiological study. Am J Ophthalmol. 2005;
139:837–846.
36. Moloney TP, Park J. Microbiological isolates and antibiotic sensitivities in
culture-proven endophthalmitis: a 15-year review. Br J Ophthalmol. 2014;
98:1492–1497.
37. Grzybowski A, Kuklo P, Pieczynski J, et al. A review of preoperative
manoeuvres for prophylaxis of endophthalmitis in intraocular surgery: topical
application of antibiotics, disinfectants, or both? Curr Opin Ophthalmol.
2016;27:9–23.
38. Olson RJ, Braga-Mele R, Chen SH, et al; American Academy of
Ophthalmology Preferred Practice Pattern Cataract and Anterior Segment
Panel. Cataract in the adult eye preferred practice pattern. Ophthalmology.
October 13, 2016. [Epub ahead of print].
39. Balestrazzi A, Malandrini A, Montagnani F, et al. Phacoemulsificator and
sterile drapes contamination during cataract surgery: a microbiological
study. Eur J Ophthalmol. 2012;22:188–194.
40. Kumar MA, Kurien SS, Selvaraj S, et al. Comparison of different techniques
of cataract surgery in bacterial contamination of the anterior chamber in
diabetic and non-diabetic population. Indian J Ophthalmol. 2012;60:41–44.
41. Chang DF, Braga-Mele R, Henderson BA, et al. Antibiotic prophylaxis of
postoperative endophthalmitis after cataract surgery: results of the 2014
ASCRS member survey. J Cataract Refract Surg. 2015;41:1300–1305.
42. Chang DF, Braga-Mele R, Mamalis N, et al. Prophylaxis of postoperative
endophthalmitis after cataract surgery: results of the 2007 ASCRS member
survey. J Cataract Refract Surg. 2007;33:1801–1805.
43. Montan PG, Wejde G, Koranyi G, et al. Prophylactic intracameral
328 | www.apjo.org
Copyright © 2017 Asia-Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 4, July/August 2017
cefuroxime; efficacy in preventing endophthalmitis after cataract surgery. J
Cataract Refract Surg. 2002;28:977–981.
44. Montan PG, Wejde G, Setterquist H, et al. Prophylactic intracameral
cefuroxime; evaluation of safety and kinetics in cataract surgery. J Cataract
Refract Surg. 2002;28:982–987.
45. Barry P, Seal DV, Gettinby G, et al. ESCRS study of prophylaxis of
postoperative endophthalmitis after cataract surgery: preliminary report of
principal results from a European multicenter study. J Cataract Refract
Surg. 2006;32:407–410.
46. Wejde G, Montan P, Lundstrom M, et al. Endophthalmitis following cataract
surgery in Sweden: national prospective survey 1999-2001. Acta Ophthalmol
Scand. 2005;83:7‒10.
47. Barry P. Adoption of intracameral antibiotic prophylaxis of endophthalmitis
following cataract surgery; update on the ESCRS Endophthalmitis Study. J
Cataract Refract Surg. 2014;40:138–142.
48. García-Sáenz MC, Arias-Puente A, Rodríguez-Caravaca G, et al.
Effectiveness of intracameral cefuroxime in preventing endophthalmitis
after cataract surgery; ten-year comparative study. J Cataract Refract Surg.
2010;36:203–207.
49. van der Merwe J, Mustak H, Cook C. Endophthalmitis prophylaxis with
intracameral cefuroxime in South Africa. J Cataract Refract Surg. 2012;
38:2054.
50. Barreau G, Mounier M, Marin B, et al. Intracameral cefuroxime injection
at the end of cataract surgery to reduce the incidence of endophthalmitis:
French study. J Cataract Refract Surg. 2012;38:1370–1375.
51. Shorstein NH, Winthrop KL, Herrinton LJ. Decreased postoperative
endophthalmitis rate after institution of intracameral antibiotics in a Northern
California eye department. J Cataract Refract Surg. 2013;39:8–14.
52. Arshinoff SA, Bastianelli PA. Incidence of postoperative endophthalmitis
after immediate sequential bilateral cataract surgery. J Cataract Refract Surg.
2011;37:2105–2114.
53. Jabbarvand M, Hashemian H, Khodaparast M, et al. Endophthalmitis
occurring after cataract surgery; outcomes of more than 480,000 cataract
surgeries, epidemiologic features, and risk factors. Ophthalmology. 2016;
123:295–301.
54. Creuzot-Garcher C, Benzenine E, Mariet AS, et al. Incidence of acute
postoperative endophthalmitis after cataract surgery: a nationwide study in
France from 2005 to 2014. Ophthalmology. 2016;123:1414–1422.
55. Garat M, Moser CL, Alonso-Tarres C, et al. Intracameral cefazolin to prevent
endophthalmitis in cataract surgery: 3-year retrospective study. J Cataract
Refract Surg. 2005;31:2230–2234.
56. Romero P, Mendez I, Salvat M, et al. Intracameral cefazolin as prophylaxis
against endophthalmitis in cataract surgery. J Cataract Refract Surg. 2006;
32:438–441.
57. Behndig A. What the Swedish National Cataract Database can tell us. Paper
presented at: 20th Congress of the European Ophthalmological Society;
June 7, 2015; Vienna, Austria.
58. Villada JR, Vicente U, Javaloy J, et al. Severe anaphylactic reaction after
intracameral antibiotic administration during cataract surgery. J Cataract
Refract Surg. 2005;31:620–621.
59. Moisseiev E, Levinger E. Anaphylactic reaction following intracameral
cefuroxime injection during cataract surgery. J Cataract Refract Surg. 2013;
39:1432–1434.
60. Witkin AJ, Shah AR, Engstrom RE, et al. Postoperative hemorrhagic
occlusive retinal vasculitis; expanding the clinical spectrum and possible
association with vancomycin. Ophthalmology. 2015;122:1438–1451.
61. Witkin AJ, Chang DF, Jumper JM, et al. Vancomycin-associated
hemorrhagic occlusive retinal vasculitis, clinical characteristics of 36 eyes.
Ophthalmology. 2017;124:583–595.
62. Wagner RS, Abelson MB, Shapiro A, et al. Evaluation of moxifloxacin,
© 2017 Asia-Pacific Academy of Ophthalmology
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 4, July/August 2017
ciprofloxacin, gatifloxacin, ofloxacin, and levofloxacin concentrations in
human conjunctival tissue [letter]. Arch Ophthalmol. 2005;123:1282–1283.
63. Hwang DG. Fluoroquinolone resistance in ophthalmology and the potential
role for newer ophthalmic fluoroquinolones. Surv Ophthalmol. 2004;49:
S79–S83.
64. Kim DH, Stark WJ, O’Brien TP, et al. Aqueous penetration and biological
activity of moxifloxacin 0.5% ophthalmic solution and gatifloxacin 0.3%
solution in cataract surgery patients. Ophthalmology. 2005;112:1992–1996.
65. Holland EJ, McDonald MB, Parekh JG, et al. Antibiotic resistance in acute
postoperative endophthalmitis. Ophthalmology. 2014;121:S1–S12.
66. Arshinoff SA, Modabber M. Dose and administration of intracameral
moxifloxacin for prophylaxis of postoperative endophthalmitis. J Cataract
Refract Surg. 2016;42:1730–1741.
67. Arbisser LB. Safety of intracameral moxifloxacin for prophylaxis of
endophthalmitis after cataract surgery. J Cataract Refract Surg. 2008;34:
1114–1120.
68. Haripriya A, Chang DF, Namburar S, et al. Efficacy of intracameral
moxifloxacin endophthalmitis prophylaxis at Aravind Eye Hospital.
Ophthalmology. 2016;123:302–308.
69. Gower EW, Lindsley K, Tulenko SE, et al. Perioperative antibiotics for
prevention of acute endophthalmitis after cataract surgery. Cochrane
Database Syst Rev. 2017;2:CD006364.
70. Rodriguez-Caravaca G, García-Sáenz MC, Villar-Del-Campo MC, et al.
Incidence of endophthalmitis and impact of prophylaxis with cefuroxime on
© 2017 Asia-Pacific Academy of Ophthalmology
Copyright © 2017 Asia-Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Endophthalmitis Prophylaxis
cataract surgery. J Cataract Refract Surg. 2013;39:1399–1403.
71. Friling E, Lundström M, Stenevi U, et al. Six-year incidence of
endophthalmitis after cataract surgery: Swedish national study. J Cataract
Refract Surg. 2013;39:15–21.
72. Matsuura K, Miyoshi T, Suto C, et al. Efficacy and safety of prophylactic
intracameral moxifloxacin injection in Japan. J Cataract Refract Surg.
2013;39:1702–1706.
73. Herrinton LJ, Shorstein NH, Paschal JF, et al. Comparative effectiveness of
antibiotic prophylaxis in cataract surgery. Ophthalmology. 2016;123:287–294.
74. Daien V, Papinaud L, Gillies MC, et al. Effectiveness and safety of an
intracameral injection of cefuroxime for the prevention of endophthalmitis
after cataract surgery with or without perioperative capsular rupture. JAMA
Ophthalmol. 2016;134:810–816.
75. Javitt JC. Intracameral antibiotics reduce the risk of endophthalmitis after
cataract surgery: does the preponderance of the evidence mandate a global
change in practice? Ophthalmology. 2016;123:226–231.
76. Grzybowski A, Schwartz SG, Matsuura K, et al. Endophthalmitis prophylaxis
in cataract surgery: overview of current practice patterns around the world.
Curr Pharm Des. 2017;23:565–573.
77. Naseri A, Melles RB, Shorstein NH. Intracameral antibiotics in the shadow of
hemorrhagic occlusive retinal vasculitis. Ophthalmology. 2017;124:580–582.
78. Kim SJ, Toma HS. Ophthalmic antibiotics and antimicrobial resistance a
randomized, controlled study of patients undergoing intravitreal injections.
Ophthalmology. 2011;118:1358–1363.
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