Cost-Effectiveness of Preoperative Topical
Antibiotic Prophylaxis for Endophthalmitis
Following Cataract Surgery
TINA FELFELI, RAFAEL N. MIRANDA, JEEVENTH KAUR, CLARA C. CHAN, AND DAVID M.J. NAIMARK
• PURPOSE: To determine the cost-effectiveness of pre-
operative topical antibiotic prophylaxis for the prevention
of endophthalmitis following cataract surgery.
• DESIGN: Cost-effectiveness analysis using a decision-
analytic microsimulation model.
• METHODS: Preoperative topical antibiotic prophylaxis
vs no-prophylaxis costs and effects were projected over a
life-time horizon for a simulated cohort of 500 000 adult
patients (≥18 years old) requiring cataract surgery in the-
oretical surgical centers in the United States. Efficacy and
cost (2021 US dollars) values were obtained from the lit-
erature and discounted at 3% per year.
• RESULTS: Based on inputted parameters, the mean
incidence of endophthalmitis following cataract surgery
for preoperative topical antibiotic prophylaxis vs no-
prophylaxis was 0.034% (95% CI 0%-0.2%) and
0.042% (95% CI 0%-0.3%), respectively—an absolute
risk reduction of 0.008%. The mean life-time costs for
cataract surgery with prophylaxis and no-prophylaxis
were $2486.67 (95% CI $2193.61-$2802.44) and
$2409.03 (95% CI $2129.94-$2706.69), respectively.
The quality-adjusted life-years (QALYs) associated with
prophylaxis and no-prophylaxis were 10.33495 (95% CI
7.81629-12.38158) and 10.33498 (95% CI 7.81284-
12.38316), respectively. Assuming a cost-effectiveness
criterion of ≤$50 000 per QALY gained, the thresh-
old analyses indicated that prophylaxis would be cost-
effective if the incidence of endophthalmitis after cataract
surgery was greater than 5.5% or if the price of the preop-
erative topical antibiotic prophylaxis was less than $0.75.
Supplemental Material available at AJO.com.
Meeting Presentation: The findings from this study were presented at
the Canadian Ophthalmological Society Meeting, in Halifax, Canada, on
June 10, 2022, and the Society for Medical Decision Making in Seattle,
United States on October 26, 2022.
Accepted for publication November 4, 2022.
From the Department of Ophthalmology and Vision Sciences, Uni-
versity of Toronto (T.F., C.C.C.); Institute of Health Policy, Manage-
ment and Evaluation, University of Toronto (T.F., R.N.M., D.M.J.N.);
Toronto Health Economics and Technology Assessment (THETA) Col-
laborative, University Health Network (T.F., R.N.M., D.M.J.N.); Faculty
of Medicine, University of Toronto (J.K.); Department of Ophthalmology,
Toronto Western Hospital, University Health Network (C.C.C.); and De-
partment of Medicine, Sunnybrook Health Sciences Centre (D.M.J.N.),
Ontario, Canada
Inquiries to Tina Felfeli, Department of Ophthalmology and Vision
Sciences, University of Toronto, Toronto, Ontario, Canada.; e-mail:
tina.felfeli@mail.utoronto.ca
152 © 2022 ELSEVIER INC. ALL RIGHTS RESERVED.
• CONCLUSIONS: General use of preoperative topical an-
tibiotic prophylaxis is not cost-effective compared with
no-prophylaxis for the prevention of endophthalmitis fol-
lowing cataract surgery. Preoperative topical antibiotic
prophylaxis, however, would be cost-effective at a higher
incidence of endophthalmitis and/or a substantially lower
price for prophylaxis. (Am J Ophthalmol 2023;247:
152–160. © 2022 Elsevier Inc. All rights reserved.)
C
ataract surgery remains one of the most
cost-effective and commonly performed procedures
in several countries worldwide.1 Although rela-
tively rare, endophthalmitis following cataract surgery is
a devastating and sight-limiting complication of great sig-
nificance for patients and their surgeons and has an as-
sociated substantial cost.2 , 3 Postoperative endophthalmitis
rates have been reported to vary between 0.02% and 0.2%
derived from health care databases or registries.4-17 With
improvements in surgical techniques and use of intraoper-
ative prophylaxis measures, there has been a steady decline
in the rates of postoperative endophthalmitis over the past
decades.14 , 18 , 19
The use of preoperative topical antibiotic prophylaxis ad-
ministered 2-7 days prior to surgery for prevention of en-
dophthalmitis following cataract surgery remains contro-
versial. A systematic review evaluating the use of periopera-
tive antibiotics for endophthalmitis prevention found that
the use of antibiotic ophthalmic drops with antibiotic in-
jections (periocular or intracameral) reduces infection risk
relative to either measure used alone.20 Other studies, how-
ever, have reported no significant infection risk reduction
with preoperative antibiotics.21-23
The European Society of Cataract & Refractive Sur-
geons (ESCRS) guidelines note that use of topical preop-
erative drops are controversial, with some clinicians opting
to use them whereas others do not.18 None among the ES-
CRS,18 United Kingdom Royal College of Ophthalmolo-
gists (RCOphth),24 or American Academy of Ophthalmol-
ogy (AAO)25 specifically recommends preoperative topical
prophylactic antibiotics. Nonetheless, previous studies of
ophthalmologists’ practice patterns conducted across differ-
ent countries indicate the use of topical antibiotic prophy-
laxis.26-28
0002-9394/$36.00
https://doi.org/10.1016/j.ajo.2022.11.008
FIGURE 1. Model state schematic of patients undergoing cataract surgery and transitions following assignment to prophylaxis vs
no prophylaxis for endophthalmitis following cataract surgery, through postoperative complications and vision loss states. Note: At
all states, individuals have a risk from natural cause of death. All utilities were calculated based on vision outcomes in each of the
health states.

This study aims to determine the cost-effectiveness of
preoperative topical antibiotic prophylaxis for the preven-
tion of endophthalmitis following cataract surgery.
METHODS
We constructed an individual-level, discrete-time, Monte
Carlo simulation29 and then subjected the simulated data
to a cost-utility analysis. We compared 2 strategies: (1) pre-
operative topical antibiotic prophylaxis and (2) no topical
antibiotic prophylaxis (no-prophylaxis) in theoretical sur-
gical centers in the United States. Preoperative topical an-
tibiotic prophylaxis costs and effects were projected over
the first year after cataract surgery as a discrete time step
(to account for potential postoperative outcomes) followed
by a continuous extrapolation to a lifetime horizon (rest of
life beyond the 1-year postoperative period) for a simulated
cohort of 500 000 adult patients (≥18 years old) requiring
cataract surgery.
Ethics approval was not required for this study because no
patient information or medical records were accessed. All
modeling procedures and analyses adhered with the Con-
solidated Health Economic Evaluation Reporting Stan-
dards (CHEERS) statement.30 The model was constructed
on TreeAge Pro Healthcare 2021 (TreeAge Software Inc).
We modeled a reduced risk of developing endophthalmi-
tis among patients receiving prophylaxis relative to no-
prophylaxis (Figure 1). Multiple possible combinations of
events were modeled in the first year, as patients post
cataract surgery transitioned to possibility of developing en-
dophthalmitis followed by various vision outcomes. The
model employed estimates of event probabilities based on
efficacy-adjusted visual acuity change. Efficacy results were
derived from a Cochrane systematic review on perioper-
ative antibiotics (evaluated separately from postoperative
antibiotics) for prevention of acute endophthalmitis after
cataract surgery.20
Patients could die in the first year after cataract surgery
from natural causes of death based on age-adjusted mortal-
ity rates31 and exit the model. For survivors past 1 year, time
to death from natural causes was sampled from age- and sex-
specific Gompertz distribution.32 Disease stages included
“alive short-term” (1 year after the initial cataract surgery),
“alive long-term” (for time accrued beyond 1 year following
cataract surgery), and “dead” (the absorbing state).
• UTILITY AND COST VALUES: Health state utility values
were used as a preference-based value expressing the rela-
tive value associated with health states ranging from 0 (ie,
health state equivalent to death) to one (ie, perfect health).
For the 5 vision states, “excellent,” “good,” “poor,” “uni-
lateral blind,” and “bilateral blind” utilities were derived
from the literature.33 , 34 All costs were based on the US
Government–funded health insurance plan, Medicare. Ad-
justments were made based on Consumer Price Index infla-
tion to reflect 2022 dollar amounts.35 Health state utility

VOL. 247 TOPICAL ANTIBIOTIC PROPHYLAXIS CEA 153

values and health care resource utilization were discounted
at 3% per year.36
• INDIVIDUAL-LEVEL SIMULATION: Each simulated indi-
vidual’s characteristics including age and sex were sampled
randomly from program evaluation and review technique
(PERT)37 and Bernoulli distributions, respectively, to rep-
resent patient heterogeneity. They then traversed the top-
ical antibiotic prophylaxis arm of the model and then the
no-prophylaxis arm. For each simulated patient and strat-
egy, the model output included discounted, quality-adjusted
life-years (QALYs), and discounted lifetime costs. For each
individual, i, the difference between strategies for these
quantities, the incremental costs and QALYs, Ci and Ei,
respectively, were calculated.
The individual-level simulation output was summarized
by averaging incremental costs and n QALYs across the 500
1 Ci
000

simulations: avg(C ) = n
and avg(E ) =
n
Ei
1
n
where n = 500 000 and i is an element of 1 to n.
, Among the 500 000 individual-level simulations, the mod-
We also calculated the average number of individuals with
endophthalmitis and ultimate vision outcomes for the 2
strategies.
• PARAMETER-LEVEL SIMULATION: Model input parame-
ters were obtained from studies in which a point estimate
was reported for a given parameter but also CIs around the
point estimate representing the uncertainty regarding the
true value of the parameter (Table 1).20 , 33 , 34 , 38–42 The CIs
around the point estimates for antibiotic efficacy and cost
accounted for differences in effectiveness and cost of vari-
ous antibiotic agents that could be used. We accounted for
this uncertainty by replacing the fixed-point input param-
eter estimates employed in the individual-level simulation
with distributions. One thousand parameter-level simula-
tions were run. For each, a set of input parameters was sam-
pled from their respective distributions and then used in
an individual-level simulation as described above. To limit
computational burden, we simulated 500 000 individuals
for each parameter set. Thus, the total number of simu-
lated individuals for the parameter-level simulations was
1000 × 500 000 = 5 × 108 . For each parameter set, k,
we calculated average Ck and average Ek as described
above.
• COST-UTILITY ANALYSES: For the individual-level sim-
ulation, the overall incremental cost-effectiveness ratio
of topical antibiotics vs no antibiotics was calculated as
avg(C) / avg(E). A cost-effectiveness criterion of incre-
mental cost-effectiveness ratio ≤$50 000 per QALY gained
was assumed.43 A strategy dominated another if it was less
costly, avg(C) <0, and more effective, avg(E) >0.
The results of the parameter-level simulation were
presented graphically. We plotted an incremental cost-
effectiveness scatterplot of each of the 1000 pairs of aver-
age (Ck) and average (Ek) values. A cost-effectiveness
154 AMERICAN JOURNAL OF OPHTHALMOLOGY
acceptability curve (CEAC) was generated by varying the
value of the cost-effectiveness criterion from 0 to 100 000
$/QALY gained and, for each value, calculating the propor-
tion of parameter-level simulations that met the criterion
of cost-effectiveness.
• ADDITIONAL ANALYSES: Threshold analysis—as an ex-
tension of the sensitivity analyses—was applied to the
model to demonstrate the maximum cost for prophylaxis
and incidence of endophthalmitis after cataract surgery that
would result in the intervention being considered cost-
effective. Additionally, simulations and cost utility analyses
were conducted in which costs and QALYs were not dis-
counted.
RESULTS
eled average age was 65.45 years (SD 0.47) with 60% fe-
male patients. Modeling results based on specific inputs
chosen by the authors suggested that the average percent-
age of endophthalmitis following cataract surgery for pre-
operative topical antibiotic prophylaxis vs no-prophylaxis
was 0.034% (95% CI 0%-0.2%) and 0.042% (95% CI 0%-
0.3%), respectively—an absolute risk reduction of 0.008%
and a relative risk reduction of 19.05% (Table 2).
The average life-time percentage of a suboptimal vision
outcome for prophylaxis and no-prophylaxis was 4.49%
(95% CI 0%-5.8%) and 4.50% (95% CI 0%-5.8%), re-
spectively. The average life-time costs for cataract surgery
with prophylaxis vs no-prophylaxis were $2486.67 (95%
CI $2193.61-$2802.44) and $2409.03 (95% CI $2129.94-
$2706.69), respectively; these amounts resulted in an aver-
age life-time incremental cost of $77.64 for prophylaxis.
The average across strategies of the undiscounted life ex-
pectancy without quality-adjustment was 21.39 (SD 0.47)
years. The average, undiscounted QALYs for a life-time
horizon was 15.49071 (95% CI 11.65752-18.62562) and
15.49036 (95% CI 11.65819-18.62912) for prophylaxis
and no-prophylaxis, respectively. The average, discounted,
QALYs associated with prophylaxis and no-prophylaxis
were 10.33495 (95% CI 7.81629-12.38158) and 10.33498
(95% CI 7.81284-12.38316), respectively. The average
incremental QALYs was small, –0.00003 (equivalent to
less than a quality-adjusted hour). The incremental cost-
effectiveness ratio was therefore –77.64/0.00003 = –$2.6
million. Because preoperative topical antibiotic prophy-
laxis was more costly but generated fewer QALYs, it was
dominated by no-prophylaxis.
The results for the 2-year time horizon were comparable
to life-time horizon for prophylaxis vs no-prophylaxis with
average costs for cataract surgery with prophylaxis vs no-
prophylaxis of $2486.41 (95% CI $2192.43-$2802.30) and
$2408.93 (95% CI $2128.82-$2705.91), respectively. The
MARCH 2023
 TABLE 1. Baseline Characteristics, Probabilities, Costs, and Utility Input Parameters for the Decision Model

Parameter Value Distribution Source

Baseline characteristics
Age, y, mean ± SD 70 ± 23 (most common PERT Ophthalmology.
age group: 65-74 y old) 2020;127(2):151-158.
Probability male, % 40 Br J Ophthalmol.
2004;88(12):1512-1517.
Probability endophthalmitis, % 0.04 (3629/8 542 838) Beta Ophthalmology.
2020;127(2):151-158.
Model probabilities
Relative risk of endophthalmitis with 0.72 (95% CI 0.27-184) Cochrane Database Syst
prophylaxis Rev. 2017;2017(2).

Parameter Value Parameter Value Source

Vision outcomes No Endophthalmitis Endophthalmitis Ophthalmology.
2020;127(2):151-158.
Excellent (20/25 or better) 8228/23 641 1/11
Good (20/30 to 20/50) 15 413/23 641 10/11
Poor (20/60 to 20/200) 5470/6839 7/14
Unilateral blindness (20/400 or worse) 1369/6839 7/14

Parameter Value Distribution Source

Utility (SD)
Cataract 0.699 (0.1398) Beta J Cataract Refract Surg.
2019;45(7):927-938.
Excellent (20/20 to 20/25) 0.9 (0.15) Beta JAMA Ophthalmol.
2021;139(4):389.
Good (20/30 to 20/50) 0.803 (0.211) Beta JAMA Ophthalmol.
2021;139(4):389.
Poor (20/60 to 20/200) 0.688 (0.168) Beta JAMA Ophthalmol.
2021;139(4):389.
Unilateral blindness (20/400 or worse) 0.45 (0.242) Beta JAMA Ophthalmol.
2021;139(4):389.
Bilateral blindness 0.365 (0.2127) Beta Br J Ophthalmol.
2001;85(3):327-331.

Parameter Value Distribution Source

Cost, $, mean (SD)
Topical antibiotic prophylaxis 78 (50) J Cataract Refract Surg.
2017;43(10):1322-1327.
Anesthesia 214 Retina. 2022;42(1):33-37.
Cataract 2193 (147) Gamma Retina. 2022;42(1):33-37.
Endophthalmitis 5062 (245) Gamma Retina. 2022;42(1):33-37.

PR = program evaluation and review technique, RR = relative risk.

Uncertainty was estimated by sampling 1000 trials. All dollar amounts are in US dollars.

average 2-year time horizon QALYs associated with prophy-
laxis and no-prophylaxis were 2.01011 (95% CI 1.57165-
2.37179) and 2.01009 (95% CI 1.57200-2.37135), respec-
tively.
The cost-effectiveness acceptability curve generated
from the parameter-level simulations is presented in
Figure 2. For life-time horizon, at a cost-effectiveness
threshold of $0, no-prophylaxis was cost-effective in 100%
of the parameter-level simulations. For cost-effectiveness
thresholds of $10 000 or greater, the proportions of
parameter-level simulations that were cost-effective re-
mained stable for the prophylaxis and no-prophylaxis
surgery, at 49% and 51%, respectively. For the 2-year time
horizon, for cost-effectiveness thresholds of $50 000/QALY
or greater, the proportion of parameter-level simulations in
which no-prophylaxis was cost-effective stabilized at 52%
to 54%.
The incremental cost-effectiveness scatterplot of the
probabilistic sensitivity analysis is presented in Supple-
mentary Figure S1. Prophylaxis was in the more effective
and more costly quadrant, and below the cost-effectiveness
threshold in 49% of the iterations. Prophylaxis was in the

VOL. 247 TOPICAL ANTIBIOTIC PROPHYLAXIS CEA 155

FIGURE 2. Cost-effectiveness accessibility curves for (A) lifetime horizon and (B) 2-year time-horizon, summarizing the impact
of uncertainty on the probability of cost-effectiveness of preoperative topical antibiotic prophylaxis vs no prophylaxis for endoph-
thalmitis following cataract surgery, in relation to possible values of the cost-effectiveness threshold. All dollar amounts are in 2021
US dollars.

156 AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH 2023

 TABLE 2. Summary of the Cost-Effectiveness and Quality-Adjusted Life-Years (QALYs) Results and Clinical Outcomes for the
Preoperative Topical Antibiotic Prophylaxis Compared to No Prophylaxis for Lifetime Horizon
Variable
Cost, $, mean (SD)
Effectiveness, mean (SD)
Endophthalmitis, %, mean (SD)
Vision outcomes, %, mean (SD)
Excellent (20/20 to 20/25)
Good (20/30 to 20/50)
Poor (20/70 to 20/200)
Unilateral blindness (20/400 to NLP)
Bilateral blindness
NLP = no light perception.
All dollar amounts are in US dollars.
less effective and more costly quadrant in 50% of the itera-
tions.
Threshold analyses indicated that prophylaxis would be
cost-effective if the incidence of endophthalmitis after
cataract surgery was greater than 5.5% or if the cost of the
preoperative topical antibiotic prophylaxis was $0.75.
DISCUSSION
In the current simulation model of theoretical surgical cen-
ters in the United States, we aimed to determine the cost-
effectiveness of preoperative topical antibiotic prophylaxis
for the prevention of endophthalmitis following cataract
surgery. Despite using a liberal relative risk reduction of de-
veloping endophthalmitis in favor of prophylaxis vs no pro-
phylaxis, our findings illustrated that the general use of pre-
operative topical antibiotic prophylaxis is not cost-effective
for the prevention of endophthalmitis following cataract
surgery. Our model estimated that topical preoperative an-
tibiotic prophylaxis is not cost-effective based on the cost-
effectiveness criterion of ≤$50 000 per QALY gained. Ad-
ditionally, the probabilities of developing a suboptimal vi-
sion outcome with and without prophylaxis were very sim-
ilar (4.498%, 95% CI 0%-5.8%, vs 4.500%, 95% CI 0%-
5.8%), because of the low incidence of endophthalmitis
overall.
One of the key input parameters in our model included
the risk of endophthalmitis, which was assumed to be
0.042% based on data from the Intelligent Research in
Sight Registry (IRIS) published in 2020.11 Other studies
as of this writing on Medicare claims data in 2011-2019
have found an overall acute endophthalmitis incidence of
0.136% within 90 days of undergoing cataract surgery.10
Kim and associates13 calculated the risk of developing acute
endophthalmitis within 42 days of having cataract surgery
to be 0.063% in South Korea based on nationwide insur-
ance claims data in 2014-2017. Nonetheless, our study re-
VOL. 247 TOPICAL ANTIBIOTIC PROPHYLAXIS CEA
Prophylaxis No Prophylaxis
2486.67 (155.13) 2409.03 (146.98)
10.33 (1.17) 10.33 (1.17)
0.034 (0.07) 0.042 (0.08)
26.98 (1.40) 26.98 (1.41)
50.57 (1.58) 50.56 (1.58)
17.95 (1.21) 17.95 (1.22)
4.478 (0.65) 4.479 (0.65)
0.021 (0.04) 0.021 (0.05)
sults showed that prophylaxis would only be cost-effective
if the risk of postoperative endophthalmitis was 5.5% or
greater, indicating that the results of the study would not
have changed even if a higher risk had been assumed.
The findings from our study are aligned with the ESCRS,
RCOphth, and AAO guidelines, which do not recommend
topical preoperative antibiotic prophylaxis.18 , 24 , 25 Accord-
ing to the ESCRS Guidelines, the standard of care includes
the use of preoperative povidone-iodine.18 This is similar
to the RCOphth and AAO guidelines.24 , 25 In France, na-
tional guidelines emphasize that topical fluoroquinolones
should be avoided before cataract surgery because of the el-
evated risk of antimicrobial resistance.26 Indeed, an impor-
tant criticism of preoperative antibiotics is that they may
result in selection of more resistant pathogens and thereby
increase infection risk.28
Although major guidelines do not generally recommend
the use of topical preoperative antibiotic prophylaxis, stud-
ies have demonstrated that physician practices deviate from
these guidelines. In Italy, a survey of 80 Italian surgical cen-
ters indicated that wide-spectrum topical antibiotic prophy-
laxis is used in 76% of cases for cataract surgery.26 A Cana-
dian study reviewing practice patterns among 216 ophthal-
mologists found that topical antibiotics were used preoper-
atively by 78% of cataract surgeons.27 In that study, mox-
ifloxacin was the most commonly used preoperative topi-
cal antibiotic (32%), whereas intraoperative topical povi-
done iodine antisepsis was used by 98%, intracameral an-
tibiotics were used by 15%, and subconjunctival antibiotics
by 11%.27 Additionally, a survey of more than 4000 Indian
ophthalmologists indicated a preference for both preopera-
tive and postoperative topical antibiotic use.28
To our knowledge, this is the first study that eval-
uates the cost-effectiveness of topical preoperative an-
tibiotic prophylaxis for endophthalmitis prior to cataract
surgery. However, other studies have previously ex-
plored the cost-effectiveness of other prophylactic mea-
sures for cataract surgery. Sharifi and associates44 indi-
cated a cost-effectiveness ratio of $1403 per case for the
157
use of intracameral cefuroxime, whereas topical fluoro-
quinolone would have had to be at least 8 times as
effective as preventing infection to achieve the same
cost-effectiveness.
Leung and associates45 found similar results in a cost-
effectiveness analysis comparing intracameral moxifloxacin
and perioperative topical antibiotic prophylaxis with peri-
operative topical antibiotics alone, concluding that adjunc-
tive intracameral moxifloxacin was more effective on the
basis of QALYs. This intervention was cost-effective and
cost-saving assuming total cost of US$22 or less. A study
based in Brazil of 16 902 eyes receiving cataract surgery be-
tween 2014 and 2017 found that the use of intracameral ce-
furoxime resulted in an 86% decrease in incidence of post-
operative endophthalmitis (95% CI 4%-49%) and would
lead to potential savings of US$2334 per every 568 patients
treated.46
Our threshold analysis suggested that prophylaxis would
have been cost-effective at a unit price of $0.75 or less. This
represents a large reduction of the true cost of topical an-
tibiotics. A 2017 study on cost comparison of commonly
used postoperative topical ophthalmic solutions reported a
cost per millilitre ranging from $8.75 to $153.50 for 7-day
courses of 9 different common medications.41 In our model,
prophylaxis was assumed to cost $78.12 based on a midrange
price for prophylaxis such as the price of levofloxacin.41 The
results of our study thus indicate that the cost of preopera-
tive topical levofloxacin prophylaxis would have to be 312
times lower to be cost-effective.
Despite preoperative topical antibiotic prophylaxis not
being cost-effective for the general population, we acknowl-
edge that there may be settings where risk of endophthalmi-
tis is higher and where prophylaxis use may be justified.
For instance, Pershing and associates11 analyzed outcomes
of 8 542 838 eyes receiving cataract surgery in the United
States and found that the risk of endophthalmitis was more
than double among pediatric populations relative to adults
(0.37% for patients aged 0-17 years vs 0.18% for patients
aged 18-44 years). Endophthalmitis also occurred 4 times as
often after combined cases compared with cataract surgery
alone.11
Funding/Support: Tina Felfeli has received grants from the Vanier Canada Graduate Scholarship, Canada Graduate Scholarship-Masters, the Vision Sci-
ence Research Program, and Postgraduate Medical Education Research Awards as part of postsecondary research funding. There are no other government
and nongovernment support to be acknowledged.
Financial Disclosures: The authors indicate no financial support or conflicts of interest. All authors attest that they meet the current ICMJE criteria for
authorship.
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158 AMERICAN JOURNAL OF OPHTHALMOLOGY
There are also lower-resource settings where endoph-
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shown that there remain many challenges to effectively de-
livering cataract surgery in some developing countries, such
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An important limitation of this study is the quality of
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$50 000 per QALY gained, general use of preoperative top-
ical antibiotic prophylaxis is not cost-effective compared
with no-prophylaxis for the prevention of endophthalmitis
following cataract surgery. Preoperative topical antibiotic
prophylaxis, however, would be cost-effective at a higher
incidence of endophthalmitis and/or a substantially lower
price for prophylaxis.
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