Endophthalmitis Prophylaxis Failures in Patients Injected With Intracameral Antibiotic During Cataract Surgery


  • No statistical difference exists in endophthalmitis rate between moxifloxacin and cefuroxime.

  • Successful endophthalmitis prophylaxis depends on intracameral moxifloxacin dose.

  • Intracameral cefuroxime does not cover Enterococcus and Pseudomonas .


To estimate the association of cefuroxime and moxifloxacin in relation to the occurrence of endophthalmitis following phacoemulsification cataract surgery.


Retrospective clinical cohort study.


We studied patients with noncomplex phacoemulsification cataract surgery in Kaiser Permanente Northern California during 2014-2019. Data were obtained for acute, postoperative endophthalmitis within 90 days of phacoemulsification, including culture and antibiogram results, intracameral and topical antibiotic agent, and dose. In a post hoc analysis, we also examined preoperative anterior chamber depth (ACD) and postoperative anterior chamber volume (ACV).


Of 216,141 surgeries, endophthalmitis occurred in 0.020% of moxifloxacin-injected eyes and 0.013% of cefuroxime eyes (relative risk 1.62 with 95% CI 0.82-3.20, P = .16). Of the 34 (0.016%) cases of endophthalmitis, cefuroxime 1 mg was injected into 13 eyes and moxifloxacin 0.1% into 21 eyes. Organisms with antibiograms were identified in 12 (35%) cases. Of these, bacteria recovered from cefuroxime-injected eyes were resistant to cefuroxime in all cases (4/4), with Enterococcus comprising half of these. In eyes injected with moxifloxacin 0.1%, 6 out of 7 organisms were sensitive to moxifloxacin injected with 0.1 mL and in 1 eye injected with 1 mL. Streptococcus was the most common organism recovered (6/9) in moxifloxacin-injected eyes. Preoperative ACD and postoperative calculated ACV were higher in eyes injected with moxifloxacin.


Endophthalmitis cases with positive cultures were generally related to organism resistance in cefuroxime eyes but to sensitive organisms in moxifloxacin eyes. Moxifloxacin doses may have been insufficient in eyes with larger ACV.

E ndophthalmitis is a rare, sight-threatening complication following cataract surgery. Recent evidence suggests that topical antibiotic instillation reduces the incidence by half, while the addition of intracameral antibiotic injection further reduces risk by up to 7-fold.

The European Medicines Agency approved cefuroxime for intracameral injection during cataract surgery in 2012. Commercial preparations of moxifloxacin have been available in India since 2013. Despite the continued lack of an FDA-approved product in the United States, surgeons are increasingly adopting this technique, requiring the sourcing of compounded antibiotic.

The established dosage of cefuroxime injection is 1 mg in 0.1 mL (1%) solution. , , Moxifloxacin is currently more commonly injected in the United States for endophthalmitis prophylaxis ; however, there is no established standard dose as yet.

On average, more than 35,000 cataract surgeries are performed annually in Kaiser Permanente Northern California. During ongoing monthly postphacoemulsification endophthalmitis surveillance in 2018, we identified a trend of increasing cases (Supplemental Figure 1; Supplemental Material available at AJO.com). We undertook this study to identify factors that could explain this trend, including antibiotic drug choice.


This study was approved by the Kaiser Foundation Research Institute’s institutional review board and the informed consent requirement was waived owing to the retrospective design. The study was conducted according to the principles described in the Declaration of Helsinki.


Kaiser Permanente Northern California is a closed, staff-model, integrated healthcare delivery system with capitated payment that provides comprehensive care to 4 million persons, or 40% of insured individuals in the region. Physicians practice in 1 medical group and use the same type of office and surgical equipment. Some techniques and practices, such as injection of an intracameral antibiotic during cataract surgery, are standardized, while others, such as antibiotic choice, are selected by the surgeon according to their own preference.

Study Population

We included phacoemulsification surgeries performed between January 1, 2014 and December 31, 2019. Cataract surgeries that were combined with planned retinal procedures, corneal transplants, or glaucoma surgery were excluded, as were surgeries performed by retinal or oculoplastic specialists.

Data Collection

Acute, postoperative, infectious endophthalmitis was defined as occurring after the first postoperative day through the 90th day after phacoemulsification and was analyzed through March 30, 2020. Preliminary endophthalmitis was defined as having 1 or more of the diagnostic codes listed in the Supplemental Table (Supplemental Material available at AJO.com). Endophthalmitis was confirmed when the diagnosis was recorded by a retina specialist within 90 days of surgery and treatment included injection of intravitreal antibiotics. Endophthalmitis cases were validated using medical record review by a study ophthalmologist (N.S.), including review of the operative report, follow-up visits, visits to retinologists, microbiology results, and other pertinent information.

Intracameral agent and dosage were obtained from electronic pharmacy records and validated from the operative report. Ambiguities in dosage were confirmed with the operating surgeon. Topical antibiotics dispensed were obtained from pharmacy records.

We conducted a post hoc analysis of preoperative biometric measurements in eyes with endophthalmitis that included preoperative anterior chamber depth (ACD), central corneal thickness (CCT), white-to-white length (WTW), axial length (AL), lens thickness (LT), and corneal radius (R), obtained from the Lenstar LS 900 (Haag-Streit, Mason, Ohio, USA). The intraocular lens (IOL) model was obtained from the operative reports. We calculated the postoperative, pseudophakic ACD using Olsen’s formula. We then calculated the estimated pseudophakic anterior chamber volume (ACV) as a dome cap using the aqueous depth (ACD – CCT) as the height and the WTW as the dome base ( www.fxsolver.com/browse/formulas/Volume+of+Spherical+Dome+%28or+cap%29 ).

Relative risk and 95% confidence intervals (CI) were computed to estimate the association between cefuroxime vs moxifloxacin injection and endophthalmitis. We used the Student t test to compare days to diagnosis and pseudophakic ACD and ACV between cefuroxime- and moxifloxacin-injected eyes and χ 2 test to compare complication rates between groups.


There were 34 cases of endophthalmitis in 216,141 eye surgeries (0.016%) ( Table 1 ). An injected agent other than cefuroxime and moxifloxacin was injected in 7,817 eyes (3.6%), while an intracameral agent could not be identified in 3,669 surgical cases (1.7%). No eyes in these 2 groups developed endophthalmitis. The group injected with moxifloxacin experienced an infection rate of 0.020%, which was slightly higher than the cefuroxime group (0.013%) (relative risk 1.62 with 95% CI 0.82-3.20, P = .16).

Table 1

Endophthalmitis Frequency in Patients Injected With Intracameral Antibiotic During Cataract Surgery, 2014-2019.

Injection Agent Cases/Surgeries Endophthalmitis Frequency RR (95% CI)
Cefuroxime 13/97,801 0.013% Ref
Moxifloxacin 21/106,854 0.020% 1.62 (0.82-3.20) P = .16
Total 34/216,141 a 0.016%

CI = confidence interval; RR = relative risk.

a Includes 7,817 eyes treated with antibiotics other than cefuroxime and moxifloxacin and 3,669 eyes with no intracameral injection.

Of the 34 endophthalmitis cases, 13 eyes were injected with cefuroxime, 19 eyes with 0.1 mL of moxifloxacin 0.1%, 1 eye with 0.5 mL of moxifloxacin 0.1%, and 1 eye with 1 mL of moxifloxacin 0.1% ( Table 2 ). Laboratory testing was conducted in 33 cases and in 14 of these (42%) an organism was identified.

Table 2

Endophthalmitis Cases Among Patients Injected With Intracameral Antibiotic During Cataract Surgery, 2014-2019.

Year Organism ICA Sensitivity Topical Agent Topical Sensitivity Intraoperative Complications Days to Diagnosis Preop ACD Postop ACV
Cefuroxime 1 mg
2014 Enterococcus R None NA None 3 2.79 NC
2015 No growth Tobramycin None 22 2.88 0.242
2015 Pseudomonas R None NA None 3 2.92 0.216
2015 Enterococcus R Ofloxacin NR None 6 2.54 0.228
2016 Coag neg Staph R Poly/trim R None 28 2.16 0.216
2017 No growth Poly/trim None 14 3.06 0.311
2017 No growth Poly/trim None 22 2.92 0.272
2017 Strep NR Ofloxacin S None 6 3.77 0.303
2017 No growth Poly/trim Retained lens 33 3.58 0.286
2017 Not done Poly/trim Retained lens 11 3.27 0.224
2018 No growth Poly/trim None 56 2.41 0.226
2018 No growth Poly/trim None 4 2.55 0.249
2018 No growth Poly/trim None 67 3.14 0.297
Moxifloxacin 0.1% (0.1 mL)
2014 No growth Gatifloxacin None 49 3.23 NC
2014 No growth Gatifloxacin None 38 3.06 0.245
2014 Strep S Gatifloxacin S None 19 3.37 0.299
2014 No growth Poly/trim None 6 3.39 0.292
2015 Strep S Ofloxacin S Vitreous loss 26 2.95 0.244
2015 No growth Ofloxacin None 16 2.62 0.214
2016 Enterococcus R Gatifloxacin R Retained lens 3 3.03 0.325
2016 Strep NR Gatifloxacin NR None 23 3.63 0.340
2016 No growth Poly/trim Retained lens 5 2.56 NC
2017 Strep S Poly/trim NR None 26 3.95 0.315
2017 Staph aureus S Ofloxacin S None 29 3.81 0.371
2018 No growth Poly/trim None 21 3.32 0.307
2018 No growth None None 27 2.86 0.231
2018 No growth Gatifloxacin None 31 3.61 0.354
2018 Staph aureus S Poly/trim S None 32 2.79 0.255
2018 No growth None None 31 3.73 0.347
2019 No growth None None 5 3.09 0.276
2019 Strep S Poly/trim NR None 3 3.53 0.268
2019 No growth Neomycin/poly None 3 4.61 0.335
Moxifloxacin 0.1% (≥0.5 mL) a
2018 Strep S Poly/trim NR None 7 3.55 0.343
2019 No growth Poly/trim None 3 5.71 0.572

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Jul 10, 2021 | Posted by in OPHTHALMOLOGY | Comments Off on Endophthalmitis Prophylaxis Failures in Patients Injected With Intracameral Antibiotic During Cataract Surgery
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