Eyeworld

SPRING 2026 | EYEWORLD | 23 R software version 4.3.2 was utilized for statistical analysis followed by Mantel-Haenszel random effects model for binary endpoints. Odds ratio and 95% confidence interval were utilized as measures of effect size with statisti- cal significance defined as p<0.05. Variability between studies was analyzed via the I 2 statistic and Cochrane's Q statistic, with statistical sig- nificance defined as p≤0.10. Sensitivity analysis was conducted via leave-one-out methodology. An additional subgroup analysis was performed based on the type of intracameral antibiotic. Results From 1,660 initial search results, 193 unique studies were identified. After evaluation, 10 studies were included in the systemic review, and 9 studies, including 2 randomized controlled tri- als, met inclusion criteria for the meta-analysis. Across all studies, 153,742 patients experienced posterior capsule rupture, of whom 50,207 (33.6%) received intracameral antibiotics. Postoperative endophthalmitis occurred less frequently in the ICA group compared to the non-ICA group (0.1% vs. 0.2%; OR 0.41; 95% CI 0.26–0.65). Sub-group analysis demonstrated a statistically significant reduction in POE with moxifloxacin (OR 0.33; 95% CI 0.19–0.57), whereas cefuroxime (OR 0.71; 95% CI 0.32– 1.55) and vancomycin (OR 0.27; 95% CI 0.04– 1.79) did not reach significance. The cefuroxime (6,044 patients) and vancomycin (667 patients) subgroups were limited by smaller sample sizes. Sensitivity analyses using leave-one-out methodology and funnel plot assessment sug- gested minimal risk for publication bias. Discussion PCR is a well-established risk factor for POE, in- creasing the risk by more than 6-fold compared to uncomplicated cataract surgery. 2,3 While the efficacy of ICA in routine cataract surgery is supported by robust evidence, data specific to PCR cases have historically been limited. This systematic review and meta-analysis directly addresses this gap and demonstrates that ICA prophylaxis is associated with a statistically significant reduction in POE among patients experiencing PCR during cataract surgery. In the pooled analysis of more than 150,000 PCR cases, the use of ICA was asso- ciated with a 59% relative risk reduction in the odds of POE compared with no ICA (OR 0.41; 95% CI 0.26–0.65; p<0.001), with low between-study heterogeneity. Although the ab- solute reduction in POE incidence was modest (0.2% to 0.1%), this effect is clinically mean- ingful given the severe visual consequences associated with endophthalmitis. The calcu- lated number needed to treat (NNT) of 874 is substantially lower than NNTs reported in prior meta-analyses evaluating ICA in unselected cataract surgery populations, supporting a more favorable cost-benefit ratio when ICA is applied selectively to this high-risk subgroup. Subgroup analyses demonstrated that intracameral moxifloxacin was associated with a statistically significant reduction in POE, where- as cefuroxime and vancomycin did not reach statistical significance. These findings should be interpreted with caution, as the cefuroxime and vancomycin subgroups were limited by smaller sample sizes and low event rates. Nonetheless, the observed benefit of moxifloxacin is biologi- cally plausible given its broad-spectrum antibi- otic coverage, concentration-dependent bacte- ricidal activity, and favorable pharmacokinetic profile within the anterior chamber. Its lipophil- ic properties allow for rapid penetration and sustained aqueous humor concentrations above the minimum inhibitory concentration for com- mon endophthalmitis pathogens, which may be particularly advantageous in PCR cases where posterior segment exposure may be increased. Safety considerations are especially relevant in PCR cases, where disruption of the posterior capsule may facilitate greater diffusion of intra- cameral antibiotics into the vitreous cavity. Van- comycin has been associated with hemorrhagic occlusive retinal vasculitis (HORV), a rare but devastating complication with poor visual outcomes, raising concern regarding its routine prophylactic use. Cefuroxime, while effective against gram-positive organisms, has limited gram-negative coverage and has been associ- ated with toxic anterior segment syndrome, particularly when compounded. In contrast, continued on page 24

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