Secondary Logo

Journal Logo

Prevention of postcataract endophthalmitis: evidence-based medicine

Yu, Charles Q.; Ta, Christopher N.

Current Opinion in Ophthalmology: January 2012 - Volume 23 - Issue 1 - p 19–24
doi: 10.1097/ICU.0b013e32834cd5a9

Purpose of review To provide a summary of current peer-reviewed publications on the methods of prophylaxis against postcataract endophthalmitis.

Recent findings Preoperative application of povidone–iodine remains the standard protocol for the prevention of postoperative endophthalmitis. More recent evidence suggests that intracameral cefuroxime administered at the conclusion of surgery significantly reduces the risk of endophthalmitis. However, its clinical use has been limited because of a lack of commercially available antibiotic indicated for intraocular injection. Although topical antibiotic application continues to be a controversial topic with respect to the types of antibiotic prescribed and dosage, most ophthalmologists do prescribe an antibiotic for the perioperative period. Resistance against antibiotics, including the very popular classes of fluoroquinolones, is rising. Most notably, methicillin resistance continues to increase over time.

Summary Prevention of postcataract endophthalmitis remains a difficult topic to study given the low incidence. In addition to appropriate wound construction, a combination of povidone–iodine and antibiotics provide a reasonable approach in reducing the risk of this rare but serious infection.

The Byers Eye Institute at Stanford, Palo Alto, California, USA

Correspondence to Christopher N. Ta, The Byers Eye Institute at Stanford, 2452 Watson Court, Palo Alto, CA 94303, USA. E-mail:

Back to Top | Article Outline


Endophthalmitis following cataract surgery is a serious though rare complication. Despite aggressive treatment, only about half of patients with endophthalmitis achieve 20/40 or better vision and many are left without light perception [1,2]. The organisms responsible are skin and conjunctival flora, usually bacterial and rarely fungal, which gain access to the anterior chamber or vitreous cavity of the eye at the time of surgery or during the postoperative period [3]. The Endophthalmitis Vitrectomy Study showed that 70% of infections are caused by coagulase-negative Staphylococcus, followed by 9.9% Staphylococcus aureus, 2.2% Enterococcus, and another 5.9% Gram-negative bacteria [1,4]. Fungi are estimated to cause 3% of cases [5].

Overall, the incidence of postoperative endophthalmitis is very low. A recent systematic review found a rate of 0.265% from 2000 to 2003, compared with 0.087% in the previous decade [6]. This low incidence has made it difficult for prospective studies to be adequately powered to detect significant changes in outcome in terms of number of cases of endophthalmitis. To date, only two agents have been demonstrated to be effective in reducing the rate of postoperative endophthalmitis in prospective studies: preoperative topical povidone–iodine and intraoperative intracameral cefuroxime [3,7▪▪].

Although the exact regimens of prophylactic antiseptic and antibiotics vary, both are always administered in the perioperative period. Several extensive reviews have been written regarding this topic [8–11]. Here, we seek to review the most up-to-date evidence and provide our opinion with regard to methods of endophthalmitis prophylaxis for cataract surgery.

Box 1

Box 1

Back to Top | Article Outline


Risk factors for the development of postoperative endophthalmitis logically include conditions which increase the number of ocular bacteria. Retrospective studies suggest that blepharitis and ectropion are associated with an increased risk of developing endophthalmitis [8–11]. Other studies have shown that patients with chemosis, hyperemia, and discharge have an increased number of antibiotic-resistant bacteria [12,13]. Intraoperative complications, specifically break in the posterior capsule or vitreous loss, also greatly increase the risk of endophthalmitis [14]. A recent, retrospective, chart review from Spain of 1325 known diabetics showed a higher quantity of conjunctival bacteria, including staphylococcus, streptococcus, enterococcus, and klebsiella than in patients without diabetes [15]. This is consistent with the earlier studies showing increased risk of endophthalmitis in diabetics [16,17]. Though scrubbing at home by the patient in the days prior to surgery has been suggested, there have been no studies regarding its effectiveness. A study of 617 suspected cases of endophthalmitis in Canada found a 10-fold increase in incidence in those with intraoperative complication of capsular rupture [18▪]. It has also been reported that topical anesthesia has been retrospectively associated with increased risk of endophthalmitis (odds ratio 11.8, 95% confidence interval 2.4–58.7, n = 27) [19]. Prospective data with a larger sample size is needed, however, before suggestions can be made with regard to method of anesthesia.

Back to Top | Article Outline


Some investigators have attributed an apparent increase in the incidence of postcataract endophthalmitis over the past decade to more widespread use of the clear corneal incision [6]. Retrospective data appear to agree with such an assertion [20]. However, other studies have found no significant difference [21–23,24▪▪]. More recently, a case series of 815 patients who underwent cataract surgery in a 5-year period by a single surgeon showed a rate of postoperative endophthalmitis to be 1.3% in sutureless surgeries vs. 0% in sutured wounds [25]. The relationship between the clear corneal incision and postcataract endophthalmitis remains controversial. Although data have been collected on the use of ocular bandages as well as more novel techniques such as laser welding and bubble injection, they have not been evaluated with regard to their effects on endophthalmitis risk or bacteria concentration in the anterior chamber [26–29]. There is inadequate evidence at this time to advise specific types of wound closure. A study has suggested that surface tears can influx into the wound following cataract surgery, especially in the presence of postoperative hypotony or eye rubbing [30]. Therefore, it is essential to construct a watertight wound and to place a suture if there is any uncertainty.

Back to Top | Article Outline


Povidone–iodine is the only topical prophylactic agent to have shown to reduce endophthalmitis in a prospective manner [3]. Numerous other studies have demonstrated the reduction of conjunctival bacterial concentration with various regimens of povidone–iodine [31–34]. Although povidone–iodine is universally used in every case of ocular surgery unless the patient has an allergy, there is no consensus with regard to the povidone–iodine concentration, duration, or timing of application. The most common concentration of 5% is generally recommended [33–37]. We conducted a randomized prospective study in 39 patients, showing no difference in conjunctival cultures obtained at the beginning and conclusion of surgery when using 10% povidone–iodine vs. 5%, arguing against the need for higher concentrations [38]. Although there is demonstration of the toxicity of povidone–iodine in animal models and in vitro, the clinical significance has not been clearly evaluated [39–43]. A recent study examining the addition of 0.25% povidone–iodine to irrigation solution during cataract surgery found no change in surface bacteria but a significant decrease in positive bacterial cultures of anterior chamber aspirates (5 vs. 0%, n = 404) [44]. However, the potential for intraocular povidone–iodine toxicity must weigh against any possible benefit. Overall, the published evidence strongly supports the application of povidone–iodine to the periorbital area and ocular surface at the time of cataract surgery.

Back to Top | Article Outline


Topical antibiotics are used in conjunction with povidone–iodine to achieve superior antisepsis and theoretically reduce the incidence of endophthalmitis [45,46]. A majority of surgeons use antibiotics preoperatively, and nearly all prescribe them postoperatively, typically for approximately 1 – 2 weeks [45]. No prospective trial has yet demonstrated the efficacy of topical antibiotic in reducing the risk of postoperative endophthalmitis. As with povidone–iodine studies, the quantity of bacterial cultured from the conjunctiva and anterior chamber serves as a measure of efficacy, although there is no direct evidence proving that reducing conjunctival bacterial flora decreases the risk of endophthalmitis. Fluoroquinolones are most commonly prescribed by ophthalmologists because of their broad-spectrum of activity against both Gram-positive and Gram-negative bacteria. The particular antibiotics used have changed with time. Prior to the introduction of levofloxacin, ciprofloxacin and ofloxacin were commonly prescribed. Our previous work has shown that topical ofloxacin administered 3 days prior to surgery was more effective in reducing conjunctival bacteria than applied 1 h before surgery [47,48].

In the last decade, due in part to the reports of resistance of bacteria to ciprofloxacin and ofloxacin, there has been increased use of the broad-spectrum fluoroquinolones with improved efficacy against Gram-positive bacteria. These include levofloxacin, moxifloxacin, and gatifloxacin. More than 80% of surveyed American Society of Cataract and Refractive Surgery (ASCRS) members used either moxifloxacin or gatifloxacin as their choice of antibiotic in 2007 [45]. One retrospective study suggested a significantly lower rate of endophthalmitis following a change to the newer broad-spectrum fluoroquinolones [49]. This study also found a significantly higher rate of endophthalmitis in patients who received moxifloxacin prophylaxis compared with patients who were prescribed gatifloxacin (0.1 vs. 0.015%, P = 0.04), though this remains controversial because of the methods of data analysis [49]. A recent publication of cultures from cases of endophthalmitis in Brazil showed the susceptibility of coagulase-negative Staphylococcus of 79.5 and 89.5% to gatifloxacin and moxifloxacin, respectively [50]. Moxifloxacin has also shown to have better penetration to the aqueous humor than gatifloxacin in several studies [51–54]. Gatifloxacin was shown to have no additional benefit when used together with povidone–iodine in patients undergoing intravitreal injection when applied just prior to the procedure. However, a similar finding was also observed with moxifloxacin [55▪,56▪]. The optimal dose regimen of topical antibiotic is unknown. A study of 148 patients did not find a difference in bacterial conjunctival cultures with moxifloxacin when given 1 day prior to surgery compared to the day of surgery [57]. Our own study showed no difference between using moxifloxacin 1 day prior to surgery compared with 3 days prior to surgery [58]. However, a 1-day application of gatifloxacin was shown to be more effective in reducing conjunctival bacterial flora than if the antibiotic was administered just 1 h before surgery [59]. Although there is no evidence proving a correlation between the presence of conjunctival bacterial flora at the time of surgery and the risk of endophthalmitis, it is prudent to prescribe an antibiotic 1–3 days prior to surgery. This should be weighed against the cost, side-effects, and risk of overuse of antibiotics.

Besifloxacin is the newest fluoroquinolone developed for ophthalmic use. It is approved for the treatment of conjunctivitis and has been shown to have good ocular penetration and to be the most potent fluoroquinolone against a variety of Gram-positive and Gram-negative organisms [60,61]. Its efficacy and side-effect profile has been compared with moxifloxacin in treating conjunctivitis and was found to be similar in both aspects [62]. Other studies, however, have suggested it has poor ocular penetration [63,64]. It is unclear, however, the clinical significance of ocular penetration with regard to the prevention of endophthalmitis. Besifloxacin was found to be effective in treating endophthalmitis in a rabbit model [65]. One possible advantage of besifloxacin is that the proprietary vehicle, DuraSite, theoretically allows the drug to adhere to the ocular surface for a longer period of time. Also, as besifloxacin is not available as a systemic medication, it has the potential to have a lower resistance profile. Although a few studies have found poor ocular penetration, besifloxacin has been shown to be effective in a rabbit model and is a promising new antibiotic.

Back to Top | Article Outline


Only 13 and 15% of surgeons who responded to the 2007 ASCRS survey use subconjunctival and intracameral antibiotic, respectively [45]. In Europe, however, the British Ophthalmologic Surveillance Unit recommended the use of subconjunctival cefuroxime given its ease of delivery and few potential side-effects [66].

The only prospective randomized clinical trial ever conducted evaluating the role of antibiotics in reducing the risk of postoperative endophthalmitis was the European Society of Cataract and Refractive Surgeon (ESCRS) Study. This study group conducted a trial with 16 603 patients and demonstrated an endophthalmitis incidence of 0.247% in those treated with topical levofloxacin alone compared with a rate of 0.049% in those treated with both topical levofloxacin and intracameral cefuroxime. Lack of intracameral cefuroxime was associated with a significant increase in the incidence of endophthalmitis (0.062 vs. 0.296%, P < 0.0005), whereas lack of topical levofloxacin was not (0.148 vs. 0.210%, P = 0.353) [7▪▪] (Fig. 1). All patients also received povidone–iodine. As a result of this study, the ESCRS recommended the administration of intracameral cefuroxime at the conclusion of surgery [67]. Intracameral cefuroxime is now a common practice in Europe, with 61% of surveyed ophthalmologic units in the United Kingdom National Health Services using intracameral cefuroxime in 2010 [68]. Further studies have shown that intracameral cefuroxime is also cost-effective [69,70]. Despite the evidence for the administration of intracameral cefuroxime, its use has not become widespread in the USA. It has been speculated that the main reasons for not adopting this regimen is because of a lack of commercially available ophthalmic formulation. As the medication has to be compounded by the pharmacy, there is a concern for potential errors which could cause toxicity. Given the different practice patterns in Europe and the USA, we should expect to see a lower incidence of postcataract endophthalmitis in Europe if intracameral cefuroxime is superior to the current United States regimen. In contrast, the incidence of postoperative endophthalmitis is as of yet quite similar between the two continents [24▪▪,49]. As long as the incidence of postoperative endophthalmitis in the USA remains low and comparable to Europe, and there continues to be a lack of commercially available single-dose intraocular antibiotic in the USA, we can expect that the adoption of intracameral antibiotics to be slow in the USA.



Back to Top | Article Outline


Studies have examined the penetration of fluoroquinolones into the anterior chamber and found encouraging results [71–73]. There are, however, no studies evaluating the effect of these oral antibiotics on the quantity of bacteria in human eyes. There is insufficient evidence to recommend the routine use of systemic antibiotics given the potential for resistance and systemic side-effects. However, there may be a role for systemic antibiotics in complicated cases of cataract surgery, but it is unlikely that a study could be designed to support such a recommendation [8].

Back to Top | Article Outline


As with any widespread use of antibiotics, microbial resistance is an increasing concern for ophthalmologists. A study examined coagulase-negative staphylococcal isolates from cases of endophthalmitis and found that sensitivity to gatifloxacin and moxifloxacin had declined from 96.6 to 65.4% over the past decade [74]. Recently, investigators examining 32 cases of S. aureus endophthalmitis found that 41% were caused by methicillin-resistant S. aureus (MRSA) and less than half of these were sensitive to broad-spectrum fluoroquinolones [75]. Yet another study examining 97 cases of postcataract endophthalmitis found 38% of bacterial isolates to be resistant to fluoroquinolones, although they did not distinguish between specific fluoroquinolones [76]. In cases of ocular infections in general, a nationwide registry found that only 15.2% of MRSA isolates were susceptible to each of fluoroquinolones [77▪▪] (Table 1). Resistance will become an increasing concern and in the longer term may force a change in our antibiotic choices. It may be that eventually all fluoroquinolones will fall out of favor as we search for new ocular antibiotics that are effective against MRSA. Lastly, it is also of concern whether preoperative antibiotics select for antibiotic resistant bacteria. A study showed that a 3-day course of moxifloxacin was less likely to select for resistant bacteria than a 1-day course [78].

Table 1

Table 1

Back to Top | Article Outline


It is our recommendation that patients undergoing cataract surgery be evaluated and be treated for potential risk factors that can increase the chance of developing postoperative endophthalmitis. At the time of surgery, the area surrounding the eye as well as the ocular surface should be cleaned thoroughly with at least 5% povidone–iodine. Patient should be meticulously draped in a sterile manner. The wound construction should form a water-tight incision at the conclusion of the surgery and to ensure this a suture or sutures should be placed if necessary. The application of topical antibiotics is reasonable, although there is a paucity of data supporting their use. Intracameral cefuroxime has been shown to reduce the risk of endophthalmitis, but its adoption in the USA has been slow because of the lack of a commercially available unit dose for intraocular injection.

Back to Top | Article Outline



Back to Top | Article Outline

Conflicts of interest

There are no conflicts of interest.

Back to Top | Article Outline


Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest

Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 74–75).

Back to Top | Article Outline


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. Arch Ophthalmol 1995; 113:1479–1496.
2. Kernt M, Kampik A. Endophthalmitis: pathogenesis, clinical presentation, management, and perspectives. Clin Ophthalmol 2010; 4:121–135.
3. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone–iodine. Ophthalmology 1991; 98:1769–1775.
4. Han DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic isolates in the Endophthalmitis Vitrectomy Study. Am J Ophthalmol 1996; 122:1–17.
5. Kresloff MS, Castellarin AA, Zarbin MA. Endophthalmitis. Surv Ophthalmol 1998; 43:193–224.
6. Taban M, Behrens A, Newcomb RL, et al. Acute endophthalmitis following cataract surgery: a systematic review of the literature. Arch Ophthalmol 2005; 123:613–620.
Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg 2007; 33:978–988.

This paper describes a prospective, randomized, multicenter, clinical trial evaluating the efficacy of preoperative topical levofloxacin and intracameral cefuroxime in reducing the risk of postoperative endophthalmitis. The study found that intracameral cefuroxime significantly decreased the risk of endophthalmitis following cataract surgery.

8. Ou JI, Ta CN. Endophthalmitis prophylaxis. Ophthalmol Clin North Am 2006; 19:449–456.
9. Kim JY, Ali R, Cremers SL, Henderson BA. Perioperative prophylaxis for postcataract extraction endophthalmitis. Int Ophthalmol Clin 2007; 47:1–14.
10. Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based update. Ophthalmology 2002; 109:13–24.
11. Fintelmann RE, Naseri A. Prophylaxis of postoperative endophthalmitis following cataract surgery: current status and future directions. Drugs 2010; 70:1395–1409.
12. Scott IU, Flynn HW Jr, Feuer W. Endophthalmitis after secondary intraocular lens implantation. A case-report study. Ophthalmology 1995; 102:1925–1931.
13. Mino de Kaspar H, Shriver EM, Nguyen EV, et al. Risk factors for antibiotic-resistant conjunctival bacterial flora in patients undergoing intraocular surgery. Graefes Arch Clin Exp Ophthalmol 2003; 241:730–733.
14. Wallin T, Parker J, Jin Y, et al. Cohort study of 27 cases of endophthalmitis at a single institution. J Cataract Refract Surg 2005; 31:735–741.
15. Fernandez-Rubio ME, Rebolledo-Lara L, Martinez-Garcia M, et al. The conjunctival bacterial pattern of diabetics undergoing cataract surgery. Eye 2010; 24:825–834.
16. Phillips WB 2nd, Tasman WS. Postoperative endophthalmitis in association with diabetes mellitus. Ophthalmology 1994; 101:508–518.
17. Doft BH, Wisniewski SR, Kelsey SF, Fitzgerald SG. Diabetes and postoperative endophthalmitis in the endophthalmitis vitrectomy study. Arch Ophthalmol 2001; 119:650–656.
Hatch WV, Cernat G, Wong D, et al. Risk factors for acute endophthalmitis after cataract surgery: a population-based study. Ophthalmology 2009; 116:425–430.

In this retrospective study of more than 440 000 consecutive cataract surgeries in Toronto, Canada, the authors reported that the overall incidence of endophthalmitis was 1.4 per 1000 surgeries. There was a 10-fold increase in the rate of endophthalmitis in those patients with capsular rupture.

19. Garcia-Arumi J, Fonollosa A, Sararols L, et al. Topical anesthesia: possible risk factor for endophthalmitis after cataract extraction. J Cataract Refract Surg 2007; 33:989–992.
20. Al-Mezaine HS, Kangave D, Al-Assiri A, Al-Rajhi AA. Acute-onset nosocomial endophthalmitis after cataract surgery: incidence, clinical features, causative organisms, and visual outcomes. J Cataract Refract Surg 2009; 35:643–649.
21. Colleaux KM, Hamilton WK. Effect of prophylactic antibiotics and incision type on the incidence of endophthalmitis after cataract surgery. Can J Ophthalmol 2000; 35:373–378.
22. Miller JJ, Scott IU, Flynn HW Jr, et al. Acute-onset endophthalmitis after cataract surgery (2000–2004): incidence, clinical settings, and visual acuity outcomes after treatment. Am J Ophthalmol 2005; 139:983–987.
23. Lundstrom M, Wejde G, Stenevi U, et al. Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location. Ophthalmology 2007; 114:866–870.
Wykoff CC, Parrott MB, Flynn HW Jr, et al. Nosocomial acute-onset postoperative endophthalmitis at a university teaching hospital (2002–2009). Am J Ophthalmol 2010; 150:392.e2–398.e2.

The authors found in this retrospective study a decreasing rate of postoperative endophthalmitis from 1984 to 2009. The most recent incidence of postoperative endophthalmitis was 0.025% (2002–2009).

25. Thoms SS, Musch DC, Soong HK. Postoperative endophthalmitis associated with sutured versus unsutured clear corneal cataract incisions. Br J Ophthalmol 2007; 91:728–730.
26. Calladine D, Ward M, Packard R. Adherent ocular bandage for clear corneal incisions used in cataract surgery. J Cataract Refract Surg 2010; 36:1839–1848.
27. Hovanesian JA. Cataract wound closure with a polymerizing liquid hydrogel ocular bandage. J Cataract Refract Surg 2009; 35:912–916.
28. Menabuoni L, Pini R, Rossi F, et al. Laser-assisted corneal welding in cataract surgery: retrospective study. J Cataract Refract Surg 2007; 33:1608–1612.
29. Sim DA, Wong R, Griffiths MF. Injecting an air bubble at the end of sutureless cataract surgery to prevent inflow of ocular surface fluid. Eye 2007; 21:1444–1445.
30. Taban M, Sarayba MA, Ignacio TS, et al. Ingress of India ink into the anterior chamber through sutureless clear corneal cataract wounds. Arch Ophthalmol 2005; 123:643–648.
31. Apt L, Isenberg S, Yoshimori R, Paez JH. Chemical preparation of the eye in ophthalmic surgery. III: Effect of povidone–iodine on the conjunctiva. Arch Ophthalmol 1984; 102:728–729.
32. Apt L, Isenberg SJ, Yoshimori R, et al. The effect of povidone–iodine solution applied at the conclusion of ophthalmic surgery. Am J Ophthalmol 1995; 119:701–705.
33. Mino de Kaspar H, Chang RT, Singh K, et al. Prospective randomized comparison of 2 different methods of 5% povidone–iodine applications for anterior segment intraocular surgery. Arch Ophthalmol 2005; 123:161–165.
34. Ferguson AW, Scott JA, McGavigan J, et al. Comparison of 5% povidone–iodine solution against 1% povidone–iodine solution in preoperative cataract surgery antisepsis: a prospective randomised double blind study. Br J Ophthalmol 2003; 87:163–167.
35. Dereklis DL, Bufidis TA, Tsiakiri EP, Palassopoulos SI. Preoperative ocular disinfection by the use of povidone–iodine 5%. Acta Ophthalmol (Copenh) 1994; 72:627–630.
36. Wu PC, Li M, Chang SJ, et al. Risk of endophthalmitis after cataract surgery using different protocols for povidone–iodine preoperative disinfection. J Ocul Pharmacol Ther 2006; 22:54–61.
37. Trinavarat A, Atchaneeyasakul LO, Nopmaneejumruslers C, Inson K. Reduction of endophthalmitis rate after cataract surgery with preoperative 5% povidone–iodine. Dermatology 2006; 212 (Suppl 1):35–40.
38. Ta CN, Singh K, Egbert PR, de Kaspar HM. Prospective comparative evaluation of povidone–iodine (10% for 5 min versus 5% for 1 min) as prophylaxis for ophthalmic surgery. J Cataract Refract Surg 2008; 34:171–172.
39. Mac Rae SM, Brown B, Edelhauser HF. The corneal toxicity of presurgical skin antiseptics. Am J Ophthalmol 1984; 97:221–232.
40. Kashiwagi K, Saito K, Wang YD, et al. Safety of ozonated solution as an antiseptic of the ocular surface prior to ophthalmic surgery. Ophthalmologica 2001; 215:351–356.
41. Alp BN, Elibol O, Sargon MF, et al. The effect of povidone iodine on the corneal endothelium. Cornea 2000; 19:546–550.
42. Jiang J, Wu M, Shen T. The toxic effect of different concentrations of povidone iodine on the rabbit's cornea. Cutan Ocul Toxicol 2009; 28:119–124.
43. Hansmann F, Below H, Kramer A, et al. Prospective study to determine the penetration of iodide into the anterior chamber following preoperative application of topical 1.25% povidone–iodine. Graefes Arch Clin Exp Ophthalmol 2007; 245:789–793.
44. Shimada H, Arai S, Nakashizuka H, et al. Reduction of anterior chamber contamination rate after cataract surgery by intraoperative surface irrigation with 0.25% povidone–iodine. Am J Ophthalmol 2011; 151:11.e11–17.e11.
45. Chang DF, Braga-Mele R, Mamalis N, et al. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey. J Cataract Refract Surg 2007; 33:1801–1805.
46. Masket S. Preventing, diagnosing, and treating endophthalmitis. J Cataract Refract Surg 1998; 24:725–726.
47. De Kaspar HM, Chang RT, Shriver EM, et al. Three-day application of topical ofloxacin reduces the contamination rate of microsurgical knives in cataract surgery: a prospective randomized study. Ophthalmology 2004; 111:1352–1355.
48. Ta CN, Egbert PR, Singh K, et al. Prospective randomized comparison of 3-day versus 1-h preoperative ofloxacin prophylaxis for cataract surgery. Ophthalmology 2002; 109:2036–2040.discussion 2031–2040.
49. Jensen MK, Fiscella RG, Moshirfar M, Mooney B. Third- and fourth-generation fluoroquinolones: retrospective comparison of endophthalmitis after cataract surgery performed over 10 years. J Cataract Refract Surg 2008; 34:1460–1467.
50. Melo GB, Bispo PJ, Yu MC, et al. Microbial profile and antibiotic susceptibility of culture-positive bacterial endophthalmitis. Eye 2011; 25:382–387.quiz 388.
51. Ong-Tone L. Aqueous humor penetration of gatifloxacin and moxifloxacin eye drops given by different methods before cataract surgery. J Cataract Refract Surg 2007; 33:59–62.
52. Gungor SG, Akova YA, Bozkurt A, et al. Aqueous humour penetration of moxifloxacin and gatifloxacin eye drops in different dosing regimens before phacoemulsification surgery. Br J Ophthalmol 2011; 95:1272–1275.
53. Ong-Tone L. Aqueous humor penetration of gatifloxacin and moxifloxacin eye drops given in different concentrations in a wick before cataract surgery. J Cataract Refract Surg 2008; 34:819–822.
54. Kim DH, Stark WJ, O’Brien TP, Dick JD. Aqueous penetration and biological activity of moxifloxacin 0.5% ophthalmic solution and gatifloxacin 0.3% solution in cataract surgery patients. Ophthalmology 2005; 112:1992–1996.
Moss JM, Sanislo SR, Ta CN. A prospective randomized evaluation of topical gatifloxacin on conjunctival flora in patients undergoing intravitreal injections. Ophthalmology 2009; 116:1498–1501.

In this prospective randomized study of patients undergoing intravitreal injections, there was no additional benefit of preoperative topical antibiotics in eliminating conjunctival bacterial flora when used in conjunction with povidone–iodine.

Halachmi-Eyal O, Lang Y, Keness Y, Miron D. Preoperative topical moxifloxacin 0.5% and povidone–iodine 5.0% versus povidone–iodine 5. 0% alone to reduce bacterial colonization in the conjunctival sac. J Cataract Refract Surg 2009; 35:2109–2114.

In this prospective randomized study, patients scheduled for intraocular surgery received either povidone–iodine alone or povidone–iodine and moxifloxacin. The authors found no additional benefit with preoperative moxifloxacin in reducing conjunctival bacterial flora.

57. Vasavada AR, Gajjar D, Raj SM, Vasavada V. Comparison of 2 moxifloxacin regimens for preoperative prophylaxis: prospective randomized triple-masked trial. Part 1: Aqueous concentration of moxifloxacin. J Cataract Refract Surg 2008; 34:1379–1382.
58. He L, Ta CN, Hu N, et al. Prospective randomized comparison of 1-day and 3-day application of topical 0.5% moxifloxacin in eliminating preoperative conjunctival bacteria. J Ocul Pharmacol Ther 2009; 25:373–378.
59. Moss JM, Nguyen D, Liu YI, et al. Comparison of one-day versus one-hour application of topical gatifloxacin in eliminating conjunctival bacterial flora. Ophthalmology 2008; 115:2013–2016.
60. Haas W, Pillar CM, Hesje CK, et al. Bactericidal activity of besifloxacin against staphylococci, Streptococcus pneumoniae and Haemophilus influenzae. J Antimicrob Chemother 2010; 65:1441–1447.
61. Proksch JW, Granvil CP, Siou-Mermet R, et al. Ocular pharmacokinetics of besifloxacin following topical administration to rabbits, monkeys, and humans. J Ocul Pharmacol Ther 2009; 25:335–344.
62. McDonald MB, Protzko EE, Brunner LS, et al. Efficacy and safety of besifloxacin ophthalmic suspension 0.6% compared with moxifloxacin ophthalmic solution 0.5% for treating bacterial conjunctivitis. Ophthalmology 2009; 116:1615.e1–1623.e1.
63. Yoshida J, Kim A, Pratzer KA, Stark WJ. Aqueous penetration of moxifloxacin 0.5% ophthalmic solution and besifloxacin 0.6% ophthalmic suspension in cataract surgery patients. J Cataract Refract Surg 2010; 36:1499–1502.
64. Donnenfeld ED, Comstock TL, Proksch JW. Human aqueous humor concentrations of besifloxacin, moxifloxacin, and gatifloxacin after topical ocular application. J Cataract Refract Surg 2011; 37:1082–1089.
65. Norcross EW, Sanders ME, Moore Q 3rd, et al. Comparative efficacy of besifloxacin and other fluoroquinolones in a prophylaxis model of penicillin-resistant Streptococcus pneumoniae rabbit endophthalmitis. J Ocul Pharmacol Ther 2010; 26:237–243.
66. Kamalarajah S, Ling R, Silvestri G, et al. Presumed infectious endophthalmitis following cataract surgery in the UK: a case–control study of risk factors. Eye 2007; 21:580–586.
67. Barry P, Seal DV, Gettinby G, et al. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: preliminary report of principal results from a European multicenter study. J Cataract Refract Surg 2006; 32:407–410.
68. Murjaneh S, Waqar S, Hale JE, et al. National survey of the use of intraoperative antibiotics for prophylaxis against postoperative endophthalmitis following cataract surgery in the UK. Br J Ophthalmol 2010; 94:1410–1411.
69. Sharifi E, Porco TC, Naseri A. Cost-effectiveness analysis of intracameral cefuroxime use for prophylaxis of endophthalmitis after cataract surgery. Ophthalmology 2009; 116:1887.e1–1896.e1.
70. Garcia-Saenz MC, Arias-Puente A, Rodriguez-Caravaca G, Banuelos JB. Effectiveness of intracameral cefuroxime in preventing endophthalmitis after cataract surgery ten-year comparative study. J Cataract Refract Surg 2010; 36:203–207.
71. Hariprasad SM, Shah GK, Mieler WF, et al. Vitreous and aqueous penetration of orally administered moxifloxacin in humans. Arch Ophthalmol 2006; 124:178–182.
72. Kampougeris G, Antoniadou A, Kavouklis E, et al. Penetration of moxifloxacin into the human aqueous humour after oral administration. Br J Ophthalmol 2005; 89:628–631.
73. Garcia-Saenz MC, Arias-Puente A, Fresnadillo-Martinez MJ, Carrasco-Font C. Human aqueous humor levels of oral ciprofloxacin, levofloxacin, and moxifloxacin. J Cataract Refract Surg 2001; 27:1969–1974.
74. Miller D, Flynn PM, Scott IU, et al. In vitro fluoroquinolone resistance in staphylococcal endophthalmitis isolates. Arch Ophthalmol 2006; 124:479–483.
75. Major JC Jr, Engelbert M, Flynn HW Jr, et al. Staphylococcus aureus endophthalmitis: antibiotic susceptibilities, methicillin resistance, and clinical outcomes. Am J Ophthalmol 2010; 149:278.e1–283.e1.
76. Shirodkar AR, Flynn HW, Alliman K, et al. The comparison of clinical outcomes of endophthalmitis from fluoroquinolone-resistant and susceptible bacteria. Clin Ophthalmol 2010; 4:211–214.
Asbell PA, Colby KA, Deng S, et al. Ocular TRUST: nationwide antimicrobial susceptibility patterns in ocular isolates. Am J Ophthalmol 2008; 145:951–958.

In this multicenter study, ocular isolates were tested for antibiotic resistance. The authors reported that among methicillin susceptible staphylococcus bacteria, there was no difference among the fluoroquinolones. There was also an increase in the rate of methicillin-resistant staphylococcus isolated.

78. He L, Ta CN, Mino de Kaspar H. One-day application of topical moxifloxacin 0.5% to select for fluoroquinolone-resistant coagulase-negative Staphylococcus. J Cataract Refract Surg 2009; 35:1715–1718.

antibiotics; cataract; endophthalmitis; povidone–iodine; prophylaxis

© 2012 Lippincott Williams & Wilkins, Inc.