ASCRS News: EyeWorld Journal Club
Spring 2026
by Ethan Adre, MD, Deanna Dang, MD, Ryan Emmert, DO, Preston O’Brien, DO, Tyler Pfister, MD, Anushka Raj, MD, Jibran Sharieff, MD, Nitish Sood, MD, Megan Sweeney, MD, Dean McGee Eye Institute ophthalmology residents, Andrew Melson, MD, Residency Program Director
Introduction
Residency Program Director
Dean McGee Eye Institute
Oklahoma City, Oklahoma
Cataract surgery is the most common ophthalmic surgery and is among the most effective and safest operations worldwide; however, rare complications may result in devastating visual outcomes. One particularly feared complication is acute postoperative endophthalmitis (POE), which results in rapid, profound vision loss. Large-scale databases such as the Intelligent Research in Sight (IRIS) Registry report that, as of 2013–2017, 0.04% of cataract surgeries performed in the U.S. resulted in POE.1 Posterior capsular rupture (PCR) has been shown to increase this risk by more than 6-fold and is likely due to factors such as prolonged operative time and vitreous exposure.2 Given the high global volume of cataract surgeries, even small improvements in POE incidence may translate into clinically significant prevention opportunities, particularly in cases such as those with PCR.
In recent years, administration of intracameral antibiotics (ICA) has been widely adopted by ophthalmologists due to their ability to decrease the risk of POE; however, none of the studies demonstrating their efficacy have ever analyzed their effect on POE rates in cataract surgeries with intraoperative PCR. PCR cases represent a distinct, higher-risk subgroup in which ICA efficacy may differ. Hence, this systematic review and meta-analysis aims to address this knowledge gap and better inform clinical treatment strategies.
Methods
A systematic review and meta-analysis were conducted based on available studies published up to May 21, 2024, on PubMed, Embase, and Cochrane CENTRAL. There were no language or publication year restrictions. Eligible studies needed to be categorized as a randomized controlled trial or an observational study, report the incidence of endophthalmitis in patients with posterior capsular rupture during cataract surgery, and compare prophylactic intracameral antibiotics to no intracameral antibiotics. Cataract extraction via manual small incision cataract surgery or phacoemulsification was included. Animal studies, case reports, single-arm studies, and review articles were excluded. Each selected study underwent evaluation by two independent reviewers.
The authors of included studies were contacted to obtain data regarding the baseline characteristics, incidence of endophthalmitis, and any incomplete or unclear data. Risk of bias within individual studies and publication bias were assessed by two authors independently and a funnel plot, respectively.
R software version 4.3.2 was utilized for statistical analysis followed by Mantel-Haenszel random effects model for binary endpoints. Odds ratio and 95% confidence interval were utilized as measures of effect size with statistical significance defined as p<0.05. Variability between studies was analyzed via the I2 statistic and Cochrane’s Q statistic, with statistical significance defined as p≤0.10. Sensitivity analysis was conducted via leave-one-out methodology. An additional subgroup analysis was performed based on the type of intracameral antibiotic.
Results
From 1,660 initial search results, 193 unique studies were identified. After evaluation, 10 studies were included in the systemic review, and 9 studies, including 2 randomized controlled trials, met inclusion criteria for the meta-analysis. Across all studies, 153,742 patients experienced posterior capsule rupture, of whom 50,207 (33.6%) received intracameral antibiotics.
Postoperative endophthalmitis occurred less frequently in the ICA group compared to the non-ICA group (0.1% vs. 0.2%; OR 0.41; 95% CI 0.26–0.65). Sub-group analysis demonstrated a statistically significant reduction in POE with moxifloxacin (OR 0.33; 95% CI 0.19–0.57), whereas cefuroxime (OR 0.71; 95% CI 0.32–1.55) and vancomycin (OR 0.27; 95% CI 0.04–1.79) did not reach significance. The cefuroxime (6,044 patients) and vancomycin (667 patients) subgroups were limited by smaller sample sizes.
Sensitivity analyses using leave-one-out methodology and funnel plot assessment suggested minimal risk for publication bias.
Discussion
PCR is a well-established risk factor for POE, increasing the risk by more than 6-fold compared to uncomplicated cataract surgery.2,3 While the efficacy of ICA in routine cataract surgery is supported by robust evidence, data specific to PCR cases have historically been limited. This systematic review and meta-analysis directly addresses this gap and demonstrates that ICA prophylaxis is associated with a statistically significant reduction in POE among patients experiencing PCR during cataract surgery.
In the pooled analysis of more than 150,000 PCR cases, the use of ICA was associated with a 59% relative risk reduction in the odds of POE compared with no ICA (OR 0.41; 95% CI 0.26–0.65; p<0.001), with low between-study heterogeneity. Although the absolute reduction in POE incidence was modest (0.2% to 0.1%), this effect is clinically meaningful given the severe visual consequences associated with endophthalmitis. The calculated number needed to treat (NNT) of 874 is substantially lower than NNTs reported in prior meta-analyses evaluating ICA in unselected cataract surgery populations, supporting a more favorable cost-benefit ratio when ICA is applied selectively to this high-risk subgroup.
Subgroup analyses demonstrated that intracameral moxifloxacin was associated with a statistically significant reduction in POE, whereas cefuroxime and vancomycin did not reach statistical significance. These findings should be interpreted with caution, as the cefuroxime and vancomycin subgroups were limited by smaller sample sizes and low event rates. Nonetheless, the observed benefit of moxifloxacin is biologically plausible given its broad-spectrum antibiotic coverage, concentration-dependent bactericidal activity, and favorable pharmacokinetic profile within the anterior chamber. Its lipophilic properties allow for rapid penetration and sustained aqueous humor concentrations above the minimum inhibitory concentration for common endophthalmitis pathogens, which may be particularly advantageous in PCR cases where posterior segment exposure may be increased.
Safety considerations are especially relevant in PCR cases, where disruption of the posterior capsule may facilitate greater diffusion of intracameral antibiotics into the vitreous cavity. Vancomycin has been associated with hemorrhagic occlusive retinal vasculitis (HORV), a rare but devastating complication with poor visual outcomes, raising concern regarding its routine prophylactic use. Cefuroxime, while effective against gram-positive organisms, has limited gram-negative coverage and has been associated with toxic anterior segment syndrome, particularly when compounded. In contrast, moxifloxacin has demonstrated a favorable safety profile in intracameral use, with broad antimicrobial coverage and no widely reported cases of retinal toxicity, even when compounded from systemic formulations. These factors further support the preferential consideration of moxifloxacin when ICA is used in PCR patients.
Another important consideration is antimicrobial stewardship in the context of widespread antibiotic prophylaxis. While concerns have been raised regarding the potential for ICA to contribute to local antimicrobial resistance, current evidence suggests that the high intraocular concentrations achieved with intracameral dosing are unlikely to induce clinically meaningful resistance. Moreover, the targeted use of ICA in a clearly defined high-risk population, such as patients with PCR, likely mitigates these concerns and supports a favorable risk-benefit balance.
Limitations of this meta-analysis should be acknowledged. The majority of included studies were observational in nature, and detailed PCR-specific clinical variables such as vitreous loss, anterior vitrectomy, intraocular lens fixation technique, and wound integrity were inconsistently reported. Although the total sample size was large, the overall incidence of POE remained low, limiting statistical power for subgroup analysis of individual antibiotics. Additionally, visual outcome data following POE were unavailable, precluding assessment of whether ICA influenced final visual prognosis. Some large, randomized trials evaluating ICA in cataract surgery could not be included due to the absence of PCR-specific subgroup data.
Despite the limitations, this meta-analysis provides the most comprehensive evidence to date supporting the use of intracameral antibiotics in cataract surgeries complicated by PCR. For centers that already employ routine ICA, continuation of this practice in PCR cases is well supported. For centers that do not routinely use ICA, selective prophylaxis in PCR patients should be strongly considered as an evidence-based strategy to mitigate the substantially increased risk of postoperative endophthalmitis.
Conclusion
Posterior capsular rupture is a major intraoperative risk factor for postoperative endophthalmitis, yet evidence guiding targeted prophylaxis in this setting has been limited. This systematic review and meta-analysis demonstrate that intracameral antibiotic prophylaxis significantly reduces the risk of endophthalmitis in patients experiencing PCR. Although the absolute risk reduction is small, the severity of endophthalmitis and the substantially lower number needed to treat compared with routine cataract surgery support selective prophylaxis in this high-risk group.
Among available agents, intracameral moxifloxacin appears to offer the most favorable balance of efficacy, safety, and pharmacokinetic advantages in PCR cases, while evidence for cefuroxime and vancomycin remains limited and tempered by safety concerns. The consistency of findings in this meta-analysis supports the continued use of intracameral antibiotics in PCR cases at centers where they are routine and consideration of selective use where they are not. Until PCR-specific prospective data are available, intracameral antibiotic prophylaxis, particularly with moxifloxacin, represents a rational, evidence-based approach to mitigating the elevated risk of postoperative endophthalmitis.
Use of intracameral antibiotics prophylaxis in patients with posterior capsular rupture during cataract surgery: a systematic review and meta-analysis
Arteche MAT, et al. J Cataract Refract Surg. 2026. Online ahead of print.
- Topic: Posterior capsular rupture (PCR) during cataract surgery predisposes patients to postoperative endophthalmitis (POE). However, little is known about the prophylactic use of intracameral antibiotics (ICA) to prevent POE after PCR. Therefore, we conducted this systematic review and meta-analysis to assess the efficacy of ICA in preventing POE in patients with PCR.
- Clinical relevance: PCR increases the risk of POE by more than 6-fold, emphasizing the need for targeted prophylactic strategies. This study focuses on the clinical importance of ICA in reducing the incidence of POE in this high-risk population.
- Methods: We searched PubMed, Embase, and Cochrane for articles published up to May 21, 2024, with the following strategy: (cataract OR phaco OR “Cataract Extraction” OR “manual small incision cataract surgery” OR phacoemulsification OR “extracapsular cataract extraction” OR ECCE) AND (intracameral OR “Intracameral Injection” OR “irrigating infusion fluid” OR “anterior chamber injection”) AND (antibiotic OR moxifloxacin OR cefuroxime OR vancomycin OR cephalosporin OR prophylaxis). We included studies reporting the incidence of endophthalmitis in patients with PCR during cataract surgery and a comparison of prophylactic intracameral antibiotics with no intracameral antibiotics. Statistical analysis was conducted using R software version 4.3.2. The protocol was registered in PROSPERO (CRD42024558144).
- Results: The initial search yielded 1,660 results. After removing duplicate records and ineligible studies, 193 remained and were thoroughly reviewed based on the inclusion criteria. Nine studies consisting of two randomized controlled trials and seven observational studies were included in the meta-analysis. There was a total of 153,690 patients, with 50,207 (33,6%) patients in the ICA group and 103,483 (67.3%) in the No ICA group. There was a significantly lower incidence of endophthalmitis in the ICA group (OR 0.41; 95% CI 0.26 to 0.65; p<0.001; I²=9%). Independently, the use of prophylactic intracameral moxifloxacin was also related with a lower risk of endophthalmitis (OR 0.33; 95% CI 0.19 to 0.57; p<0.001; I2=33%).
- Conclusion: Our findings suggest that the use of intracameral antibiotics is efficient in preventing postoperative endophthalmitis in patients who had PCR during cataract surgery.
References
- Pershing S, et al. Endophthalmitis after cataract surgery in the United States: a report from the Intelligent Research in Sight Registry, 2013–2017. Ophthalmology. 2020;127:151–158.
- Cao H, et al. Risk factors for acute endophthalmitis following cataract surgery: a systematic review and meta-analysis. PLoS One. 2013;8:e71731.
- Miller KM, et al. Cataract in the Adult Eye Preferred Practice Pattern. Ophthalmology. 2022;129:P1–P126.
Contact
Melson: Andrew-Melson@dmei.org
Article Sidebar
ASCRS Annual Meeting Preview
Rom Kandavel, MD, EyeWorld Cataract Editorial Board member, shared what he is looking forward to at the 2026 ASCRS Annual Meeting:
“My favorite part of the ASCRS Annual Meeting is bringing valuable information back to my practice and making a meaningful improvement.”
