Intracameral Antibiotics During Cataract Surgery

Evidence and Barriers

Aravind Haripriya; David F. Chang


Curr Opin Ophthalmol. 2018;29(1):33-39. 

In This Article


Numerous recent review articles and editorials have debated the safety, efficacy, and necessity of using intracameral antibiotic prophylaxis.[56–59] A recent Cochrane review[60**] analyzed all major studies published through December 2016 and concluded that the 2007 ESCRS RCT successfully demonstrated the efficacy of intracameral antibiotic prophylaxis for reducing endophthalmitis. There was no definitive conclusion regarding the best antibiotic to use, which may depend on the clinical setting. The present review also underscored the fact that clinical trials with rare outcomes require very large sample sizes and are very costly to conduct. Olson in his editorial concludes that availability of an FDA-approved intracameral antibiotic would increase acceptance and adoption of intracameral antibiotic prophylaxis.[61] However, this would require an additional RCT and Javitt's 2016 editorial further summarized the multiple reasons that a prospective randomized placebo controlled trial is so difficult, expensive, impractical, and potentially unethical to perform.[62]

The main benefit of a level 1 RCT is to prevent confounding surgical factors apart from the intracameral antibiotic from separately reducing the endophthalmitis rate. We believe that the Aravind intracameral moxifloxacin data are among the strongest non-RCT evidence to date. To maximize efficiency and cost-effectiveness, all cataract surgical protocols are highly standardized at and between every AECS hospital, including use of the same supplies, IOLs, surgical equipment and instruments, sterilizers, prepping methods, surgical techniques, and electronic health records. The strength of our most recently reported AECS data is that very high volumes of cases were done in a relatively short period of time within a single hospital network with standardized surgical systems. No other major changes were introduced during the study period, thereby minimizing potential surgical covariables. Comparable intracameral moxifloxacin efficacy was found whether looking at more than 100 000 consecutive cases during 1 year at a single center, or more than 1 million cases over 4 years at 10 centers, and the observed rates were consistent when analyzing quarterly volumes ranging from 50 000 to 90 000 cases (Figure 1). Intracameral moxifloxacin efficacy was consistently demonstrated whether looking at individual high volume surgeons, individual hospitals, specific surgical methods (phaco or MSICS), or the highest risk subgroup (PCR). We concur with the 2016 American Academy of Ophthalmology Cataract Preferred Practice Pattern's assessment of the published literature that concluded 'there is mounting evidence that injecting intracameral antibiotics as a bolus at the conclusion of surgery is an efficacious method of endophthalmitis prophylaxis'.[63**]