New evidence for effectiveness of intracameral moxifloxacin for postcataract surgery endophthalmitis prophylaxis
Year: 2025
Type: article
Abstract: Endophthalmitis is a rare but potentially devastating complication of cataract surgery. Although all surgeons can agree that rarity is desirable, the sparsity of cases does have the unfortunate complication of limiting our ability to rigorously compare different strategies for preventing postoperative endophthalmitis. The seminal trial on intracameral antibiotics for prevention of postoperative endophthalmitis, led by the late Peter Barry and the ESCRS Endophthalmitis Study Group, provided strong evidence for the effectiveness of intracameral cefuroxime in a 2007 manuscript summarizing findings in 16 603 patients.1 That report remains one of the most frequently cited papers ever published in Journal of Cataract & Refractive Surgery (JCRS). In this issue of JCRS, Sharma et al. present a prospective randomized clinical trial of intracameral moxifloxacin conducted across 3 tertiary eye centers in northern and central India (page 67). A total of 60 000 eyes undergoing phacoemulsification with intraocular lens implantation were enrolled between 2018 and 2024, with patients randomized in a 1:1 fashion to receive either intracameral moxifloxacin 0.5% through the paracentesis at the conclusion of surgery or no intracameral antibiotic. Both groups were prepped with povidone–iodine 5% in the cul-de-sac for at least 3 minutes of exposure before surgery (as in the ESCRS study) and received 0.5% moxifloxacin drops to be used 3 times a day beginning 3 days before surgery and continuing for 1 month postoperatively. Scheduled follow-ups occurred at day 1, week 1, week 3, and week 6.1 The results demonstrated a protective effect of intracameral moxifloxacin relative to moxifloxacin drops alone. Endophthalmitis occurred in 6 eyes (0.02%) that received intracameral prophylaxis compared with 16 eyes (0.05%) in the control group, and this difference equated to a 2.5-fold reduction in the odds ratio of endophthalmitis. Although the rate of posterior capsular rupture (PCR) was similar in both groups (less than 2%), PCR was common among the cases of endophthalmitis (3 of 6 [50%] in the intracameral group and 6 of 16 [37%] in the control group). There were no significant differences between groups in age, sex, or percentage of wounds sutured vs only hydrated (<4%). The microbiological profile was consistent with prior literature, with coagulase-negative Staphylococcus being the most common isolate. The findings provide evidence that a single intracameral dose of moxifloxacin is effective in reducing the incidence of acute bacterial endophthalmitis after cataract surgery, with the additional practical implication that nonpreserved moxifloxacin 0.5% is widely commercially available without need for a compounding pharmacy. What sets this study apart is its unprecedented scale and prospective design: With 30 000 eyes in each arm, it represents the largest prospective randomized trial ever published on prophylaxis for postcataract surgery endophthalmitis. As the study compares intracameral administration in a design that incorporated preoperative and postoperative topical moxifloxacin administration across both groups, it does not address the effectiveness of intracameral administration alone when not performed in combination with topical antibiotics. However, for the same reason, the design provides a strong causal inference for the independent effect of intracameral moxifloxacin over drops alone. The study centers used a single-use bottle of moxifloxacin for both the injection and the postoperative regimen in each case, which lowers cost and removes barriers to ensuring the patient goes home with drops. One peculiarity of the results in this study was the relatively late onset of endophthalmitis relative to other studies. Although cases still occurred within the 6-week period that defines acute postoperative endophthalmitis, the median onset time was 28 days and 21 days for the intracameral and control groups, respectively. This is later than the typical window of 1 to 2 weeks, and we can only speculate as to possible reasons, such as the extended regimen of preoperative and postoperative topical moxifloxacin or a delay in clinical inflammation due to a concurrent 6-week topical steroid taper beginning with 6 drops per day, for example. We applaud the authors and their teams for putting forth an important new study in support of the role of intracameral moxifloxacin in postcataract surgery infection prophylaxis.
Author: William J. Dupps
Language: English
Subfield: Ophthalmology
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7116779141