BACKGROUND: OBJECTIVES: SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to October 2012), EMBASE (January 1980 to October 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to October 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 25 October 2012. We also searched for additional studies that cited any included trials using the Science Citation Index. SELECTION CRITERIA: DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed abstracts and full-text articles for eligibility, assessed the risk of bias for each included study, and abstracted data. MAIN RESULTS: Four studies met the inclusion criteria for this review, including 100,876 adults and 131 endophthalmitis cases. While the sample size is very large, the heterogeneity of the study designs and modes of antibiotic delivery made it impossible to conduct a formal meta-analysis. Interventions investigated in the studies included the utility of adding vancomycin and gentamycin to the irrigating solution compared with standard balanced saline solution irrigation alone, use of intracameral cefuroxime and/or topical levofloxacin perioperatively, periocular penicillin injections and topical chloramphenicol-sulphadimidine drops compared with topical antibiotics alone, and mode of antibiotic delivery (subconjunctival versus retrobulbar injections). Two studies with adequate sample sizes to evaluate a rare outcome found reduced risk of endophthalmitis with antibiotic injections during surgery compared with topical antibiotics alone: risk ratio (RR) 0.33, 95% confidence interval (CI) 0.12 to 0.92 (periocular penicillin versus topical chloramphenicol-sulphadimidine) and RR 0.21, 95% CI 0.06 to 0.74 (intracameral cefuroxime versus topical levofloxacin). Another study found no significant difference in endophthalmitis when comparing subconjunctival versus retrobulbar antibiotic injections (RR 0.85, 95% CI 0.55 to 1.32). The fourth study which compared irrigation with balanced salt solution (BSS) alone versus BSS with antibiotics was not sufficiently powered to detect differences in endophthalmitis between groups. The risk of bias among studies was low to unclear due to information not being reported. AUTHORS' CONCLUSIONS: Multiple measures for preventing endophthalmitis following cataract surgery have been studied. One of the included studies, the ESCRS (European Society of Cataract and Refractive Surgeons) study, was performed using contemporary surgical technique and employed cefuroxime, an antibiotic commonly used in many parts of the world. Clinical trials with rare outcomes require very large sample sizes and are quite costly to conduct; thus, it is unlikely that additional clinical trials will be conducted to evaluate currently available prophylaxis. Practitioners should rely on current evidence to make informed decisions regarding prophylaxis choices.
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