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. 2016 Nov 8;11(11):e0166141. doi: 10.1371/journal.pone.0166141

Perioperative Antibiotics to Prevent Acute Endophthalmitis after Ophthalmic Surgery: A Systematic Review and Meta-Analysis

Jinzhu Huang 1, Xiaofang Wang 2, Xiaohong Chen 3, Qiuyue Song 4, Wen Liu 1, Laichun Lu 5,*
Editor: Michele Madigan6
PMCID: PMC5100907  PMID: 27824933

Abstract

Background

Post-operative endophthalmitis is a rare and dreaded complication in ophthalmic operations because it often induces irreparable vision loss. Although many ophthalmological studies aimed at reducing the rate of endophthalmitis have been performed around the world, controversy continues to surround some issues, including the choice of antimicrobials and their route of administration, duration and timing. The aim of this study is to investigate some of these unresolved issues.

Methods

A systematic review and meta-analysis of randomized controlled trials and observational studies was performed. The PubMed, EMBASE, Cochrane Library and Clinical Trials databases were searched to identify studies published until Feb. 2016. The relative risk (RR) for each clinical outcome data is presented with 95% confidence intervals (CIs). Pooled estimates of effects were calculated using random-effect models.

Results

Thirty-four studies from twenty-four reports involving 1264797 eyes were included in this analysis. Endophthalmitis occurred, on average, in one out of 6177 eyes when intracameral vancomycin/moxifloxacin were used and in one out of 1517 eyes when intracameral vancomycin/moxifloxacin were not used. The relative risk (95% CI) of endophthalmitis was reduced to 0.20 (0.10, 0.42) when intracameral antibiotics were used (p<0.0001). The subconjunctival injection of antibiotics was not superior to other administration routes included in this study (RR = 1.67, 95% CI (0.55, 5.05), p = 0.36). A statistically significant difference was found in the rate of endophthalmitis between the use and lack of use of topical antibiotics (RR = 0.65, 95% CI (0.43, 0.99), p = 0.04). However, no statistically significant difference was found in microbial isolation rates between these groups (RR = 0.77, 95% CI (0.34, 1.75), p = 0.53). When long-term and short-term use of topical antibiotics before surgery were compared, a statistically significant difference was found in microbial isolation rates (RR = 0.57, 95% CI (0.44, 0.74), p<0.0001).

Conclusions

This meta-analysis concluded intracameral antibiotics are effective at preventing endophthalmitis in ocular surgery. A randomized controlled trial confirms the efficacy of cefuroxime but recent large cohort studies support the efficacy of vancomycin/moxifloxacin intracamerally. Intracameral antibitoics are superior to subconjunctival injections but that irrigation antibitoic data are not of enough quality to make a comparison. Different results were found in two clinical outcomes between the use or lack of use of topical antibiotic therapy, we did not find sufficient evidence to conclude that its use prevents endophthalmitis.

Introduction

Post-operative endophthalmitis is a complication that can follow all ophthalmic procedures. Endophthalmitis is a calamitous event that can result in a patient suffering the loss of sight. Since 2000, the reported frequency of endophthalmitis is low worldwide, ranging from 0% to 0.63% [1]. Coagulase-negative Staphylococcus species are the organisms that are most frequently isolated from patients who develop postoperative endophthalmitis after cataract surgery. It is followed by coagulase-positive Staphylococcus species, Streptococcus species, Enterococcus species, and Corynebacterium species [2–7]. In pars plana vitrectomies, the reported bacteria include coagulase-negative Staphylococcus species, Pseudomonas species, Propionibacterium species, Enterococcus species, and Bacillus species [8]. Preoperative, intraoperative, and postoperative risk factors have been reported by some ophthalmologists. Diabetes mellitus, an immunocompromised state, chronic blepharitis, lacrimal passage infection, contaminated eyedrops, contact lens use, contralateral prosthesis and gender are preoperative factors, while the application of 2% xylocaine gel before povidone-iodine instillation, prolonged surgery, secondary surgery, posterior capsular rupture, vitreous loss and contaminated irrigating solution are intraoperative factors. Wound leakage, vitreous incarceration and behaviors (e.g., eye rubbing and personal hygiene) are associated with the development of post-operative endophthalmitis [9]. To reduce its incidence, many measures have been employed by ophthalmologists around the world. These include the use of topical antibiotics, intracameral antibiotics, subconjunctival antibiotic injections, lash trimming, saline irrigation, and antibiotic-containing irrigating solutions. However, the most frequent measure is the use of povidone–iodine before surgery to decrease contamination by ocular microbes and prevent postoperative endophthalmitis [10–12]. Not all of these techniques have been found to influence clinical outcomes. Intracameral cephalosporin (cefazolin, cefuroxime) has been shown to be effective in randomized controlled trials and meta-analyses [13–14]. An increasing number of ophthalmologists have supported the use of intracameral cefuroxime to prevent postoperative endophthalmitis because of the ESCRS study. However, as a result of the severe drug resistance of the causal bacteria, some new intracameral antibiotics, such as vancomycin and moxifloxacin, have been suggested to avoid endophthalmitis [15–21]. The subconjunctival injection and topical application of antibiotics have also been used by some ophthalmology centers, but the results of different reports have varied. This paper focuses on the use of intracameral vancomycin/moxifloxacin and the subconjunctival injection and topical application of antibiotics. The timing of topical drops was also analyzed. We sought to use a systemic review and meta-analysis to discuss those controversial issues.

Materials and Methods

Search Strategy

A comprehensive literature search was performed to identify studies published until Feb. 2016. The PubMed, EMBASE, Cochrane Library, and Clinical Trials databases were the main sources that were searched. Other routes (e.g., hand-search and library resource sharing) were also considered. Ophthalmologic surgical procedures, cataract extractions, vitrectomies, keratoplasties, intraocular lens implantations, glaucoma procedures, strabotomies, retinal detachment repair, laser in situ keratomileusis, laser-assisted subepithelial keratectomy, antimicrobial, antibacterial agents, antibiotic prophylaxis, anti-infective agent and eye surgery were the search terms that were used. The specific searching strategy is described in S1 Table.

Inclusion and Exclusion Criteria

Studies were included if they met the following criteria: (i) random studies and observational studies, (ii) compared endophthalmitis rates or microbial isolation rates in two comparable populations, (iii) received/did not receive intracameral vancomycin/moxifloxacin therapy, or received/did not receive subconjunctival antibiotic injection, or received/did not receive topical antibiotics or compared administration with different timing, (iv) published from January 2000-February 2016 (reduced the influence of new operations), and (v) exceeded 1000 individuals if the study reported endophthalmitis rates and 50 if it reported microbial isolation rates. Studies were excluded if they: (i) were not written in English, (ii) were incomplete or included duplicated data, (iii) did not contain any predetermined clinical outcomes, (iv) could not be pooled with other included studies, (v) did not instill topical antibiotics (in terms of the group received topical antibiotics), and (vi) had no conformity at baseline with other studies in the timing (antibiotic drops and povidone–iodine were administered before surgery) and site of the analyzed specimen (conjunctival sac).

Data extraction

The data were extracted independently by two authors (JZH and XHC). A standardized form was designed before the extraction to collect information including first author, publication date, mean age, male (%), type of surgery, study design, follow-up time, no. of eyes, therapeutic regimen, timing and clinical outcomes. If disagreements arose between these two authors, all final decisions were made by LCL and QYS after a discussion.

Quality assessment

Randomized controlled trials (RCT) and observational studies were included in our analysis, and the quality assessment of those data is described in the S1 File. Observational studies were evaluated using the Newcastle–Ottawa scale (NOS) [22]. Nine items comprised the check list, and every item accounted for 1 point in each of three parts (selection, comparability and exposure). If a score was larger than 6, the study was determined to be of high quality. RCTs were assessed using the recommendations of the Cochrane Collaboration [23].

Outcomes analyzed

In the current data set, the rate of endophthalmitis was the best and most direct clinical outcome that could be used to measure the effect of prophylactic antimicrobial agents. However, because postoperative endophthalmitis is rare, some studies also selected the microbial isolation rate as their outcome. In the analysis in this study, the rate of endophthalmitis was used as the primary outcome, and the microbial isolation rate was the secondary outcome.

Statistical analysis

In this meta-analysis, we used risk ratios (RR) with 95% confidence intervals (CIs) to present dichotomous outcomes or enumeration data and random-effect models to calculate pooled estimates of effects. In light of fact that the rate of endophthalmitis was low, in case-control studies, the odds ratio (OR) was considered to be approximately equal to the RR. The I2 statistic was used to assess heterogeneity among studies. We considered the I2 values from 0% to 24%, 25% to 50% and greater than 50% to indicate low, moderate and high heterogeneity, respectively [23]. To decrease heterogeneity and increase reliability, a subgroup analysis was performed for every comparable group. Forest plots, the risk of bias in randomized controlled trials and the above-mentioned traits were analyzed using RevMan version 5.1. Furthermore, the analyses to determine sensitivity and publication bias analysis using Stata version 12.0.

Results

Results of the search and study characteristics

Up to February 2016, a total of 688 reports were identified through database searches, and 34 studies included in 24 reports involving 1264797 eyes were included in the final analysis [2, 13, 15–21, 24–38]. The detailed screening process is described in Fig 1. Of the remaining reports, there were nine RCTs [13, 30–37] and fourteen observational studies [2, 15–21, 24–29, 38]. A total of 21 studies reported the rate of postoperative endophthalmitis [2, 13, 15–21, 24, 27–29, 38], and 13 studies reported the microbial isolation rate [25, 26, 30–37]. Thirty studies [2, 13, 15–21, 24, 27–30, 33–37, 38] included only eyes that received cataract surgery, but an additional four studies [25–26, 31–32] included other intraocular surgeries. The characteristics of the included studies are shown in Table 1.

Fig 1. Flow diagram showing the selection process used to include studies in the meta-analysis.

Fig 1

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Table 1. Main characteristics of the studies included in the meta-analysis.

First Autdor, Date Age Male(%) Type of Surgery Study Design Follow-up Time No. of Eyes Tderapeutic Regimen Timing Clinical Outcomes Tde Quality of tde Study
T C T C T C
Intracameral Antibiotic VS No Intracameral
Rush,2015 71.0 49.4 CAS COS 3 months 9386 11333 IC vancomycin, PVI PVI PE PE RPE High
Anijeet,2010 NA NA CAS COS 6 weeks 12702 3904 IC vancomycin, PVI PVI PE PE RPE Moderate
Rudnisky,2014 NA NA CAS CCS 6 weeks 11818 59739 IC vancomycin No intracameral antibiotic PE PE RPE Moderate
Rudnisky,2014 NA NA CAS CCS 6 weeks 3738 59739 IC moxifloxacin No intracameral antibiotic PE PE RPE Moderate
Shorstein,2013 74.0 NA CAS CCS 12 months 1890 3655 IC moxifloxacin, PVI PVI PE PE RPE Moderate
Haripriya,2016 NA NA CAS COS 6 weeks 38160 78554 IC moxifloxacin, PVI PVI PE PE RPE High
Matsuura,2013 NA NA CAS COS 1 month 18794 15958 IC moxifloxacin, PVI PVI PE PE RPE Moderate
Friling,2013a NA 38.3 CAS COS 10 months 6897 2804 IC moxifloxacin, PVI PVI PE PE RPE High
Galvis,2014 67.2 NA CAS COS 2 weeks 1618 1056 IC moxifloxacin, PVI PVI PE PE RPE Moderate
Subconjunctival Injection Antibiotic VS No Subconjunctival Injection
Jabbarvand,2016b 79.0 NA CAS RCS 6 weeks 69120 25290 SI antibiotic +PVI IC+PVI PE PE RPE Moderate
Jabbarvand,2016c 79.0 NA CAS RCS 6 weeks 69120 76800 SI antibiotic +PVI topical antibiotic +PVI PE PE RPE Moderate
Jabbarvand,2016d 79.0 NA CAS RCS 6 weeks 69120 260744 SI antibiotic +PVI PVI PE PE RPE Moderate
Asencio,2015 71.5 NA CAS CCS 6 weeks 5068 9217 SI gentamicin +PVI Irrigation BBS+ vancomycin+ gentamicin +PVI PE PE RPE High
Tan,2012 NA NA CAS COS 1 month 29539 20638 SI gentamicin+ cefazolin +PVI IC cefazolin +PVI PE PE RPE Moderate
Yu-Wai,2008 NA NA CAS COS 3 weeks 19425 17318 SI cefuroxime +PVI IC cefuroxime +PVI PE PE RPE Moderate
Colleaux,2000b NA NA CAS COS NA 8856 5030 SI gentamicin ± cefazolin PVI +Topical antibiotic PE PE RPE Moderate
Topical Antibiotic VS No Topical Antibiotic
ESCRS,2007a NA NA CAS RCT 6 weeks 4000 3997 Topical levofloxacin +IC cefuroxime +PVI Placebo +IC cefuroxime +PVI PE PE RPE High
ESCRS,2007b NA NA CAS RCT 6 weeks 3984 3990 Topical levofloxacin +PVI Placebo +PVI PE PE RPE High
Coskun,2011a NA 51.2 CAS RCT NA 54 53 Topical ciprofloxacin PVI PE PE MIR Moderate
Coskun,2011b NA 51.2 CAS RCT NA 57 53 Topical ofloxacin PVI PE PE MIR Moderate
Eyal,2009 69.7 48.9 OCS RCT 72 hours 237 227 Topical moxifloxacin +PVI PVI PE PE MIR Moderate
First Author, Date Age Male(%) Type of Surgery Study Design Follow-up Time No. of Eyes Therapeutic Regimen Timing Clinical Outcomes The Quality of the Study
T C T C T C
Kaspar,2008 67.8 34.1 OCS RCT 10 days 67 65 Topical levofloxacin +PVI PVI PE PE MIR High
Colleaux,2000a NA NA CAS COS NA 12152 1734 Topical Tobramycin or Gentamicin or Ofloxacin or Polymyxin-trimethoprim SI antibiotic +PVI PE PE RPE Moderate
Friling,2013b NA NA CAS COS 10 months 7307 396894 Topical chloramphenicol or fusidic acid IC antibiotic +PVI PE PE RPE High
Jabbarvand,2016a 79.0 NA CAS RCS 6 weeks 76800 260744 Topical ciprofloxacin +PVI PVI PE PE RPE Moderate
Long time VS Short Time of Topical Antibiotic
Bing,2015 70.6 50.4 CAS RCT 5 days 69 64 Topical neomycin/polymyxin-B Topical neomycin/polymyxin-B 1d 1h MIR Moderate
Inoue,2008a 74.0 46.3 CAS RCT 5 days 79 76 Topical levofloxacin Topical levofloxacin 3d 1h MIR Moderate
Inoue,2008b 74.0 46.3 CAS RCT 5 days 79 89 Topical levofloxacin Topical levofloxacin 3d 1d MIR Moderate
Inoue,2008c 74.0 46.3 CAS RCT 5 days 89 76 Topical levofloxacin Topical levofloxacin 1d 1h MIR Moderate
Lingmin,2009 71.1 50.8 OCS RCT 10 days 57 63 Topical moxifloxacin Topical moxifloxacin 3d 1d MIR Moderate
Ta,2002 NA NA CAS RCT 10 days 43 48 Topical ofloxacin Topical ofloxacin 3d 1h MIR High
Ta,2007 NA NA CAS RCT 6 days 50 50 Topical levofloxacin Topical levofloxacin 3d 1d MIR High
Christopher,2008 69.3 68.3 OCS COS 5 days 60 60 Topical moxifloxacin Topical moxifloxacin 1d 1h MIR Moderate
Jason,2008 67.7 58.3 OCS COS 5 days 60 60 Topical gatifloxacin Topical gatifloxacin 1d 1h MIR Moderate
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Footnotes:Age: Mean age or median age.

Abbreviations: NA = not available, T = treatment group, C = control group, CAS = cataract surgery, OCS = ocular surgery, COS = cohort study, CCS = case-control study, RCT = randomized controlled trial, RCS = retrospective cross-section study, IC = intracameral, SI = subconjunctival injection, PVI = povidone-iodine, PE = perioperation, 1d = 1 day before surgery, 3d = 3 days before surgery, 1h = within 1 hour before surgery, RPE = rate of postoperative endophthalmitis, MIR = microbial isolation rate.

The Rate of Postoperative Endophthalmitis

Intracameral Antibiotic

Nine studies compared patients who received/did not receive intracameral vancomycin/moxifloxacin therapy [15–21, 38]. A significant difference was found in the meta-analysis results, which suggested that the rate of postoperative endophthalmitis was lower in the intracameral vancomycin/moxifloxacin group (OR = 0.20, 95% CI (0.10, 0.42), p<0.0001, I2 = 45%) (Fig 2A). In the subgroup analysis, the results in the moxifloxacin group was homologous (OR = 0.21, 95%CI (0.12, 0.37), p<0.00001, I2 = 0%) (Fig 2A). However, there was heterogeneity in the vancomycin group (OR = 0.11, 95%CI (0.01, 1.55), p = 0.10, I2 = 81%) (Fig 2A).

Fig 2.

Fig 2

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Forest plot of the Rate of Postoperative Endophthalmitis (A: the effect of including and not including Intracameral Antibiotics; B: the effect of using VS not using subconjunctival antibiotic injections; C: the effect of using VS not using Topical Antibiotics). The vertical line indicates no difference between the groups. RRs are represented by diamond shapes, and 95% CIs are depicted by horizontal lines. Squares indicate point estimates, and the size of each square indicates the weight of the given study in the meta-analysis. M-H, Mantel-Haenszel random-effects model.

Subconjunctival antibiotic injections

Seven studies reported the use of subconjunctival antibiotic injections [2, 24, 27–29]. When patients who received subconjunctival antibiotic injections were compared to those who did not, no significant difference was found (OR = 1.67, 95% CI (0.55, 5.05), p = 0.36, I2 = 85%) (Fig 2B). Because I2 = 85%, three subgroup analyses were performed to increase reliability. The results suggested that a significant difference was found between the subconjunctival antibiotic injections group and the intracameral antibiotic and irrigation groups (intracameral antibiotic: OR = 3.76, 95% CI (1.92, 7.37), p = 0.0001, I2 = 0%; irrigation: OR = 10.07, 95% CI (3.09, 32.88), p = 0.0001) (Fig 2B). When the subconjunctival antibiotic injection group was compared to the topical or PVI (povidone-iodine) group, there was no significant difference (OR = 0.43, 95% CI (0.15, 1.20), p = 0.11, I2 = 68%) (Fig 2B).

Topical Antibiotic

The meta-analysis results revealed that there was a significant difference among the five studies (2, 13, 20, 24) that reported the rate of postoperative endophthalmitis (OR = 0.65, 95% CI (0.43, 0.99), p = 0.04, I2 = 0%) (Fig 2C). However, when subgroups were analyzed, no significant difference was found except for in a retrospective study (OR = 0.49, 95% CI (0.26, 0.89), p = 0.02) (Fig 2C).

Microbial Isolation Rate

Topical Antibiotic

There were four studies [30–32] that provided a microbial isolation rate, and the results of these studies suggested that there was no significant difference (OR = 0.77, 95% CI (0.34, 1.75), p = 0.53, I2 = 72%) (Fig 3A). A subgroup analysis was performed, but the results were similar (only topical antibiotic: OR = 0.74, 95% CI (0.17, 3.27), p = 0.69, I2 = 83%; topical antibiotic + PVI: OR = 0.77, 95% CI (0.19, 3.09), p = 0.71, I2 = 77%) (Fig 3A).

Fig 3.

Fig 3

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Forest plot of the Microbial Isolation Rate (A: the effect of using VS not using Topical Antibiotics; B: the effect of Long-term VS Short-term use). The vertical line indicates no difference between the groups. RRs are represented by diamond shapes, and 95% CIs are depicted by horizontal lines. Squares indicate point estimates, and the size of each square indicates the weight of the given study in the meta-analysis. M-H, Mantel-Haenszel random-effects model.

Timing

When long-term and short-term use of a topical antibiotic before ocular surgery was analyzed, nine studies that had consistent baselines were included (25–26, 33–37). The meta-analysis revealed that short-term use was associated with an increased incidence of microbial isolation (OR = 0.57, 95% CI (0.44, 0.74), p<0.0001, I2 = 40%) (Fig 3B). Because there was moderate heterogeneity (I2 = 40%), a subgroup analysis was performed. A significance difference was found in the group that included two RCTs and that compared application between three days and within one hour before surgery (OR = 0.40, 95% CI (0.26, 0.63), p<0.0001, I2 = 0%) (Fig 3B). A significance difference was also found in the group that included two non-RCTs and that compared results between groups that were administered at one day and within one hour before surgery (OR = 0.56, 95% CI (0.39, 0.80), p = 0.002, I2 = 0%) (Fig 3B). There was no difference between the other two subgroups (3 days VS 1 day, RCT: OR = 0.57, 95% CI (0.32, 1.02), p = 0.06, I2 = 41%; 3 days VS 1 day, RCT: OR = 0.76, 95% CI (0.44, 1.32), p = 0.36, I2 = 49%) (Fig 3B).

Publication Bias and Sensitivity Analysis

There was no significant publication bias according to the Begg’s and Egger’s funnel plot asymmetry tests that were performed in the meta-analysis (S2 File). The results of the sensitivity analysis were diverse, and the details are described in S3 File. In the group comparison between using and not using intracameral antibiotics, sensitivity was not influenced by the studies that were omitted obviously. The sensitivity analysis for receiving or not receiving subconjunctival antibiotic injections demonstrated that three studies (Colleaux,2000b, Jabbarvand,2016c and Jabbarvand,2016d) influenced the pooled effect size, and these studies were therefore deleted. New results that were similar to those of the subgroup analysis revealed that intracameral and irrigation antibiotics were superior to subconjunctival injections. In the case of topical antibiotics, we excluded the study (Jabbarvand, 2016a) because it influenced the sensitivity in the group that used RPE as a clinical outcome. When we then reanalyzed the data, we found that there was no statistical difference. Hence, that study should be deleted to increase the conclusion’s reliability. In the group in which MIR was used as the outcome, we re-conducted a subgroup analysis according to classifications of quinolone, but the result was similar to the previous result. The sensitivity analysis for the timing of application of topical antibiotics demonstrated that the study (Inoue, 2008c) exhibited slightly more influence on the pooled effect size than other studies, and this study was therefore deleted. The new result was almost the same as the initial result, but the heterogeneity was smaller. Because of the variety of available antibiotics, we also reanalyzed new subgroups according to the classifications of the drugs that were used. The result was similar to the previous result, but the heterogeneity was larger.

Discussion

The low rate of postoperative endophthalmitis makes it difficult to conduct a large RCT to investigate the optimal method for preventing it [39]. Based on the currently available clinical evidence, preoperative preparation with 5% povidone-iodine solution has consensus approval among ophthalmologists. However, no consensus has been reached regarding the agent of choice, the administration route or the timing of antimicrobial prophylaxis, and no agent has been FDA-approved for this indication in ophthalmic procedures [1]. For these reasons, we performed this meta-analysis. However, because of the absence of relevant RCTs, we also included observational studies to resolve the problem mentioned above in this analysis. Since the ESCRS study, intracameral antibiotics have gradually gained acceptance around the world. Of those antibiotics, cefuroxime has been shown to be effective at reducing the rate of postoperative endophthalmitis. However, with the increase in resistant microorganisms, moxifloxacin and vancomycin have received an increasing amount of attention. The results of this meta-analysis show that intracameral moxifloxacin/vancomycin can prevent endophthalmitis. Unfortunately, no RCTs were included to address this point. Additionally, no study compared the use of cephalosporin with moxifloxacin or vancomycin. In addition to intracameral moxifloxacin/vancomycin, we also compared the results of administering subconjunctival antibiotic injections via other routes. According to our analysis, intracameral antibiotics were superior to subconjunctival injections, but subconjunctival injections were not superior to topical antibiotics or PVI. There is only one case-control study to compare irrigation antibiotics with subconjunctival injections, so the data is not enough quality to make a comparison. According to the results of this meta-analysis, we do not recommend subconjunctival antibiotic injections as a routine method for preventing endophthalmitis. Interestingly, when the timing of administration was not considered, topical antibiotics seemed to lose their value. The results were the same whether RPE or MIR was used as the clinical outcome. But there was a higher incidence of microbial isolation in short-term use than long-term use patients. The reason for this contradictory result might be that the efficiency of bacterial eradication varied with differences in the timing of topical antibiotics use. However, reducing the number of bacteria on the ocular surface is not the same as preventing endophthalmitis. Additionally, many topical antibiotics are used in combination, which makes it difficult to determine optimal timing [1]. The timing reported in the papers ranged from one hour to three days before the surgery [4, 11, 40–41]. Further investigations should be performed to optimize the best regimens. Given the results we obtained in the meta-analysis and the results from the ESCRS study, the use of topical antibiotics was not recommended.There are several limitations to our meta-analysis. First, few RCTs were included. Second, although we performed subgroup and sensitivity analyses, the I2 values remained large, especially in the topical antibiotic group, demonstrating that heterogeneity was high. The fact that we did not identify the reason for the heterogeneity may make the results unreliable. Third, some results were obtained from small sample studies. In addition, difficulties in diagnosing and defining endophthalmitis could also influence the primary data. For the studies that selected MIR as the clinical outcome, the method and duration of specimen cultivation might have made the results in the primary studies more diverse, which could have influenced our results.In conclusion, intracameral vancomycin/moxifloxacin therapy is effective for preventing postoperative endophthalmitis. Intracameral antibiotics are superior to subconjunctival injections, but that irrigation antibitoic data are not of enough quality to make a conclusion. Different results were found for topical antibiotic therapies between two clinical outcomes, and we did not find sufficient evidence to conclude that this technique prevents endophthalmitis. Long-term use of topical antibiotics before surgery appears to be more effective, but clearance the number of pathogens on the ocular surface is not the same as preventing endophthalmitis. So, topical antibiotics before surgery to prevent endophthalmitis were not recommended by this meta-analysis.

Supporting Information

S1 PRISMA Checklist. PRISMA Checklist for the meta-analysis.

(DOC)

Click here for additional data file. (63.5KB, doc)
S1 File. Quality assessment of included studies.

(DOCX)

Click here for additional data file. (137.5KB, docx)
S2 File. Publication bias.

(DOCX)

Click here for additional data file. (28.7KB, docx)
S3 File. Sensitivity analysis.

(DOCX)

Click here for additional data file. (161.3KB, docx)
S1 Table. Search strategy.

(DOC)

Click here for additional data file. (31KB, doc)

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The authors have no support or funding to report.

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Associated Data

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Supplementary Materials

S1 PRISMA Checklist. PRISMA Checklist for the meta-analysis.

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S1 File. Quality assessment of included studies.

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S2 File. Publication bias.

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S3 File. Sensitivity analysis.

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S1 Table. Search strategy.

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Data Availability Statement

All relevant data are within the paper and its Supporting Information files.

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