Are Postoperative Topical Antibiotic Drops Still Needed?

Is there still a need for topical antibiotic drops after cataract surgery? Anders Behndig MD, PhD and Andrzej Grzybowski MD, PhD debated this question at the 2024 ESCRS Congress in Barcelona.

When using intracameral antibiotics, omitting postoperative eye drops after cataract surgery does not increase the rate of endophthalmitis, Professor Behndig asserted. However, this procedure may have some caveats that can weigh the scales in favour of antibiotic topical treatment options, Prof Grzybowski countered.

“Since we started using intracameral antibiotics in Sweden, our rates of endophthalmitis went down, and it keeps going down,” Prof Behndig observed. “Very few in our country now use postoperative antibiotic eye drops.”

Only 23 cases of suspected endophthalmitis were recorded in 151,000 cataract procedures in 2023, with only 10 cultures positive. According to Prof Behndig, these were most commonly caused by an Enterococci infection that is notably resistant to cefuroxime, used in 64% of intracameral injections.

Limits of cefuroxime

“There are important limitations to cefuroxime,” argued Prof Grzybowski. “This antibiotic is not active not only against Enterococci but also against methicillin-resistant Staphylococcus aureus, Staphylococcus epidermis, and Pseudomonas aeruginosa.”

Citing data from multiple studies, Prof Grzybowski observed different rates of postoperative endophthalmitis, from 0.05% to 0.68%. These variations can be explained by many variables, starting with the patient’s country, ocular surface microbiome, presence of blepharitis and other infections, and especially surgical instrument contamination—all of which he stressed need careful consideration when administering antibiotics intracamerally.

Other considerations include not operating on patients with a background infection and ensuring the provision of appropriate antiseptics and good sterilisation of the surgical instruments. Finally, it is crucial to avoid a leaking surgical wound. A leaking corneal wound, if untreated with topical antibiotics, can increase the risk of endophthalmitis 44-fold, Prof Grzybowski explained.

Topical antibiotics could certainly be used as a complement in selected, complicated cases, Prof Behndig said. However, they represent consumption of a different sort.

“For every 7 million cataract surgeries done each year in Europe, intracameral cefuroxime already prevents 1,400 endophthalmites,” he observed. “How many antibiotic drops do we use? For the same number of surgeries, we require 35,000 kg of levofloxacin eye drops, equal to 175 kgs of the substance alone.” Performing a prospective randomised study to answer this question once and for all would require enormous resources, he added.

According to Prof Grzybowski, there is no clear legal support in both national and international societies—with widely varying positions between countries.

“To prevent postoperative endophthalmitis, the surgeon should consider preoperative irrigation of povidone iodine, with no topical antibiotics. Surely the surgery needs to be uncomplicated, with a sealed wound,” he observed. “If the use of intracameral antibiotics is associated postoperatively with a topical treatment, it is very important to use them in high concentration for a relatively short time; no longer than 5–7 days and certainly with no tapering.”

Profs Behndig and Grzybowski spoke during the Journal of Cataract and Refractive Surgery symposium at the 2024 ESCRS Congress in Barcelona.

Anders Behndig MD, PhD is the co-chair of EUREQUO, former President of the Swedish National Cataract Register and Swedish Ophthalmological Society, and Professor at Umeå University Hospital, Sweden. anders.behndig@umu.se

Andrzej Grzybowski MD, PhD is the past-president of EVER; Professor at the University of Warmia and Mazury, Olsztyn, Poland; and Head of Institute for Research in Ophthalmology, Foundation for Ophthalmology Development, Poznań, Poland.