Aqueous Chlorhexidine for Intravitreal Injection Antisepsis

Sophie J. Bakri, MD


January 20, 2017

Aqueous Chlorhexidine for Intravitreal Injection Antisepsis: A Case Series and Review of the Literature

Merani R, McPherson ZE, Luckie AP, et al
Ophthalmology. 2016;123:2588-2594

Study Summary

Povidone-iodine is the most commonly used antiseptic for the ocular surface. It is also used for the prophylaxis of infection in eyes undergoing intravitreal injection. Published endophthalmitis rates are very low. However, some patients are allergic or sensitive to povidone-iodine and require alternative prophylaxis.

This study described the role of aqueous chlorhexidine as an alternative antiseptic. Chlorhexidine gluconate 0.1% was used in two centers, and chlorhexidine acetate 0.05% was used in one center. Chlorhexidine was flushed across the conjunctiva, eyelids, and lashes. Surgeons had different preferences for speculum, drape, and topical anesthetic use.

The authors reviewed 40,535 consecutive intravitreal injections. Three cases of endophthalmitis were identified (0.0074%), of which only one was culture-positive. Only one case of suspected allergy to chlorhexidine was documented.

Published rates of endophthalmitis after intravitreal injections where povidone-iodine was used as prophylaxis are 0.03%-0.06%.[1,2]

The authors noted that using aqueous chlorhexidine gluconate rather than preparations containing alcohol or detergents is essential because the latter can cause corneal epithelial toxicity.


This is the largest report of 0.05% aqueous chlorhexidine for intravitreal injection preparation. It is important to use only the aqueous form of chlorhexidine on the surface of the eye, not the alcohol-based version.

The study highlights the need for more research in this area, namely ascertaining the optimal contact time for chlorhexidine and studying pain scores with povidone-iodine and chlorhexidine.

For the time being, most surgeons will continue to use povidone-iodine as the preferred and established method of preparation for ocular procedures, but this study highlights that aqueous chlorhexidine in the form of chlorhexidine gluconate 0.1% and chlorhexidine acetate 0.05% are alternatives to be considered.



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