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The routine use of intracameral antibiotics may not be necessary to prevent endophthalmitis after cataract surgery, a retrospective cohort study suggested.

From 2016 to 2022 at a single specialized hospital, the incidence of postoperative endophthalmitis was 0.000 (95% CI 0.000-0.000) with the use of disinfection with 1% povidone iodine before surgery and prophylactic intracameral antibiotics for complicated surgical procedures only, reported Vincent Bourgonje, PhD, of Rotterdam Ophthalmic Institute in the Netherlands, and colleagues.

During this time period, 17 postoperative endophthalmitis cases of 56,598 procedures were recorded compared with 36 of 27,114 procedures from 1993 to 1999 (incidence rate 0.001) and 62 of 68,335 from 2000 to 2010 (incidence rate 0.001), they wrote in .

Of the 17 cases from 2016 to 2022, five yielded no growth in cultures. The other cases yielded coagulase negative staphylococci (n=8) and single cases of Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus mitis, and Enterococcus faecalis.

Of note, a PubMed literature search until September 2023 for the incidence of postoperative endophthalmitis after routine antibiotic prophylaxis found 37 studies with an overall incidence of 0.000 (95% CI 0.000-0.000).

"Application of prophylactic antibiotics only in complicated cataract operations" -- when a tear occurred in the posterior lens capsule, which happened in 0.75% of cases -- "did not lead to a higher incidence of endophthalmitis," co-author Jeroen van Rooij, MD, of Rotterdam Eye Hospital, told 乌鸦传媒. "Our practice to use 1% povidone iodine instead of 5% to 10% may have contributed to this result."

Bourgonje and colleagues noted that unpublished data showed that "when intravitreal injections for macular degeneration were introduced in our center, we managed to cut down an initial rise in endophthalmitis rate by means of standardization of the antiseptic protocol with 1% povidone iodine."

"Endophthalmitis is a devastating infection with a very low incidence after intraocular surgery," van Rooij explained. "It occurs mostly within a week after the surgery, and in about 50% of the cases, leads to a significant and permanent loss of vision in the affected eye."

Treatment includes repeated intraocular application of antibiotics and, in some cases, surgical removal of the vitreous body, he said. "In severe cases, even removal of the contents of the interior eye with subsequent total loss of vision of the affected eye is needed."

At Rotterdam Eye Hospital, cataract procedures since 2000 were performed with "a relatively low concentration of povidone iodine" -- 1% -- while the standard around the world is 5%, he noted.

There are reasons to avoid antibiotics, van Rooij said, pointing out that doing so can reduce costs and side effects, such as allergic reactions. "Some believe that routine antibiotic prophylaxis in cataract surgery can lead to antibiotic resistance," he added.

In an , Vincent Daien, MD, PhD, of Gui de Chauliac Hospital in Montpellier, France, and colleagues, noted that they "were surprised to read such controversy again" in light of studies linking a five-fold reduction in risk of postoperative endophthalmitis after cataract surgery with intracameral antibiotic cefuroxime injection.

They also questioned the need to reduce use of antibiotics in these cases, since commercially available solutions of cefuroxime were approved by the European Medicines Agency in 2012, "thus nullifying the risk of overdosage" that could lead to adverse events.

Still, "this case series may raise more questions as to whether selective use of intracameral antibiotics might be equally effective when used routinely and that further assessment of this possibility probably would be worthwhile," they concluded.

For this study, the researchers used incidence data from the ongoing endophthalmitis register of the Rotterdam Eye Hospital, a specialized hospital providing secondary and tertiary ophthalmological care, when intracameral antibiotics were used only during cataract procedures with occurrence of a posterior capsular tear, as well as results from cohorts described in the literature when routine antibiotics were used.

They included all patients who had cataract surgery at the Rotterdam Eye Hospital from 1993 to 2022.

The authors noted limitations to their study, such as its retrospective nature. They added that "the patient group, level of training, internal protocols, and facilities might not be fully comparable to general hospitals nor academic centers."

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