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. 2013 Jul 15;7(7):CD006364.
doi: 10.1002/14651858.CD006364.pub2.

Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery

Emily W Gower  1 , Kristina Lindsley, Afshan A Nanji, Ilya Leyngold, Peter J McDonnell
Affiliations

Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery

Emily W Gower et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Endophthalmitis is a severe inflammation of the anterior and/or posterior chambers of the eye that may be sterile or associated with infection. It is a potentially vision-threatening complication of cataract surgery. Prophylactic measures for endophthalmitis are targeted against various sources of infection.

Objectives: The objective of this review was to evaluate the effects of perioperative antibiotic prophylaxis for endophthalmitis following cataract surgery.

Search methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to October 2012), EMBASE (January 1980 to October 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to October 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 25 October 2012. We also searched for additional studies that cited any included trials using the Science Citation Index.

Selection criteria: We included randomized controlled trials that enrolled adults undergoing cataract surgery (any method and incision type) for lens opacities due to any origin. Trials that evaluated preoperative antibiotics, intraoperative (intracameral, subconjunctival or systemic) or postoperative antibiotic prophylaxis for acute endophthalmitis were included. We did not include studies that evaluated antiseptic preoperative preparations using agents such as povidone iodine, nor did we include studies that evaluated antibiotics for treating acute endophthalmitis after cataract surgery.

Data collection and analysis: Two review authors independently reviewed abstracts and full-text articles for eligibility, assessed the risk of bias for each included study, and abstracted data.

Main results: Four studies met the inclusion criteria for this review, including 100,876 adults and 131 endophthalmitis cases. While the sample size is very large, the heterogeneity of the study designs and modes of antibiotic delivery made it impossible to conduct a formal meta-analysis. Interventions investigated in the studies included the utility of adding vancomycin and gentamycin to the irrigating solution compared with standard balanced saline solution irrigation alone, use of intracameral cefuroxime and/or topical levofloxacin perioperatively, periocular penicillin injections and topical chloramphenicol-sulphadimidine drops compared with topical antibiotics alone, and mode of antibiotic delivery (subconjunctival versus retrobulbar injections). Two studies with adequate sample sizes to evaluate a rare outcome found reduced risk of endophthalmitis with antibiotic injections during surgery compared with topical antibiotics alone: risk ratio (RR) 0.33, 95% confidence interval (CI) 0.12 to 0.92 (periocular penicillin versus topical chloramphenicol-sulphadimidine) and RR 0.21, 95% CI 0.06 to 0.74 (intracameral cefuroxime versus topical levofloxacin). Another study found no significant difference in endophthalmitis when comparing subconjunctival versus retrobulbar antibiotic injections (RR 0.85, 95% CI 0.55 to 1.32). The fourth study which compared irrigation with balanced salt solution (BSS) alone versus BSS with antibiotics was not sufficiently powered to detect differences in endophthalmitis between groups. The risk of bias among studies was low to unclear due to information not being reported.

Authors' conclusions: Multiple measures for preventing endophthalmitis following cataract surgery have been studied. One of the included studies, the ESCRS (European Society of Cataract and Refractive Surgeons) study, was performed using contemporary surgical technique and employed cefuroxime, an antibiotic commonly used in many parts of the world. Clinical trials with rare outcomes require very large sample sizes and are quite costly to conduct; thus, it is unlikely that additional clinical trials will be conducted to evaluate currently available prophylaxis. Practitioners should rely on current evidence to make informed decisions regarding prophylaxis choices.

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Figures

Figure 1
Figure 1. Results from searching for studies for inclusion in the review
Figure 2
Figure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study
See this image and copyright information in PMC

References

References to studies included in this review

    1. Christy NE, Sommer A. Antibiotic prophylaxis of postoperative endophthalmitis. Annals of Ophthalmology. 1979;11(8):1261–5. - PubMed
    1. Christy NE, Lall P. A randomized, controlled comparison of anterior and posterior periocular injection of antibiotic in the prevention of postoperative endophthalmitis. Ophthalmic Surgery. 1986;17(11):715–8. - PubMed
    1. Barry P, Gardner S, Seal D, Gettinby G, Lees F, Peterson M, et al. Clinical observations associated with proven and unproven cases in the ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery. Journal of Cataract and Refractive Surgery. 2009;35(9):1523–31. - PubMed
    1. Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW, et al. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study. Journal of Cataract and Refractive Surgery. 2006;32(3):407–10. - PubMed
    1. Endophthalmitis Study Group. European Society of Cataract and Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. Journal of Cataract and Refractive Surgery. 2007;33(6):978–88. - PubMed

References to studies excluded from this review

    1. Camesasca FI, Bianchi C, Beltrame G, Caporossi A, Piovella M, Rapisarda A, et al. Control of inflammation and prophylaxis of endophthalmitis after cataract surgery: a multicenter study. European Journal of Ophthalmology. 2007;17(5):733–42. - PubMed
    1. Kolker AE, Freeman MI, Pettit TH. Prophylactic antibiotics and postoperative endophthalmitis. American Journal of Ophthalmology. 1967;63(3):434–9. - PubMed
    1. Maloof A, Saw V. Prophylactic intracameral vancomycin. Journal of Cataract and Refractive Surgery. 2004;30(8):1610–1. - PubMed
    1. Paganelli F, Cardillo JA, Melo LAS, Lucena DR, Silva AA, Oliveira AG, et al. A single intraoperative sub-Tenon's capsule injection of triamcinolone and ciprofloxacin in a controlled-release system for cataract surgery. Investigative Ophthalmology and Visual Science. 2009;50(7):3041–7. - PubMed
    1. Peyman GA, Sathar ML, May DR. Intraocular gentamicin as intraoperative prophylaxis in South India eye camps. British Journal of Ophthalmology. 1977;61(4):260–2. - PMC - PubMed

Additional references

    1. Barry P, Gardner S, Seal D, Gettinby G, Lees F, Peterson M, et al. Clinical observations associated with proven and unproven cases in the ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery. Journal of Cataract and Refractive Surgery. 2009;35(9):1523–31. - PubMed
    1. Chang MA, Congdon NG, Baker SK, Bloem MW, Savage H, Sommer A. The surgical management of cataract: barriers, best practices and outcomes. International Ophthalmology. 2008;28(4):247–60. - PubMed
    1. Delyfer MN, Rougier MB, Leoni S, Zhang Q, Dalbon F, Colin J, et al. Ocular toxicity after intracameral injection of very high doses of cefuroxime during cataract surgery. Journal of Cataract and Refractive Surgery. 2011;37(2):271–8. - PubMed
    1. . Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Archives of Ophthalmology. 1995;113(12):1479–96. - PubMed
    1. Foster A. Cataract and “Vision 2020-the right to sight” initiative. British Journal of Ophthalmology. 2001;85(6):635–7. - PMC - PubMed

References to other published versions of this review

    1. Leyngold I, Nanji AA, Chuck RS, Behrens A, Vedula SS, McDonnell PJ, Gower EW. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database of Systematic Reviews. 2007;(1) doi: 10.1002/14651858.CD006364. - DOI - PMC - PubMed

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