Routine Intracameral Antibiotics May Not Be Necessary After Cataract Surgery: Study

Endophthalmitis, a rare but devastating infection following intraocular surgery, can result in significant and permanent vision loss in the affected eye. Preventive measures traditionally include the application of intracameral antibiotics. However, the necessity and efficacy of routine antibiotic prophylaxis remain controversial, with concerns about cost, side effects, and antibiotic resistance.

This study reviewed data from cataract surgeries performed between 2016 and 2022 at a specialized hospital in Rotterdam. The incidence of postoperative endophthalmitis was compared across different periods and surgical practices, including times when routine antibiotic prophylaxis was standard. The study also analyzed cases where a lower concentration of povidone iodine (1%) was used instead of the more common 5% to 10%.

The study included all cataract surgeries performed from 1993 to 2022 at the Rotterdam Eye Hospital. For the period from 2016 to 2022, prophylactic intracameral antibiotics were used only in complicated surgeries, specifically when a tear occurred in the posterior lens capsule. The incidence of postoperative endophthalmitis was calculated and compared to historical data.

• Current Study Period (2016-2022): 17 cases of postoperative endophthalmitis were recorded out of 56,598 procedures (incidence rate 0.000, 95% CI 0.000-0.000).

• Historical Comparisons: From 1993 to 1999, 36 cases occurred in 27,114 procedures (incidence rate 0.001), and from 2000 to 2010, 62 cases occurred in 68,335 procedures (incidence rate 0.001).

• Pathogen Analysis: Of the 17 cases from 2016 to 2022, cultures yielded coagulase-negative staphylococci (n=8), Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus mitis, and Enterococcus faecalis. Five cases had no growth in cultures.

• Antibiotic Prophylaxis: The application of intracameral antibiotics in only complicated cases did not increase the incidence of endophthalmitis.

The study's findings suggest that routine intracameral antibiotics may not be necessary for preventing endophthalmitis in cataract surgeries. The practice of using 1% povidone iodine for disinfection, instead of the more common higher concentrations, may have contributed to the low infection rates observed. The study also highlights the potential benefits of reducing antibiotic use, including lower costs, fewer side effects, and decreased risk of antibiotic resistance.

Vincent Daien, MD, PhD, and colleagues, in an accompanying commentary, noted the controversy surrounding this issue. They pointed out previous studies that demonstrated a significant reduction in endophthalmitis risk with the routine use of intracameral antibiotics. However, they acknowledged that selective use of antibiotics, as shown in this study, warrants further investigation.

The authors noted several limitations, including the retrospective nature of the study and the specific setting of the Rotterdam Eye Hospital, which may not be fully comparable to general hospitals or academic centers. The findings are based on a specialized environment with potentially different patient demographics and surgical protocols.

This study provides evidence that routine intracameral antibiotics may not be necessary for preventing endophthalmitis after cataract surgery. Selective use of antibiotics in complicated cases, along with effective antiseptic protocols, can maintain low infection rates. These findings may influence future surgical practices and guidelines, emphasizing the importance of tailored prophylactic strategies.

Reference:

van Rooij, J., Nolte, K., van de Vondervoort, F., Lekkerkerk, S., Bourgonje, V., & Wubbels, R. (2024). Prophylactic intracameral antibiotics and endophthalmitis after cataract surgery. JAMA Ophthalmology. https://doi.org/10.1001/jamaophthalmol.2024.1716