Use of Intracameral Antibiotics Prophylaxis in Patients with Posterior Capsular Rupture during Cataract Surgery: a Systematic Review and Meta-analysis

Posterior capsular rupture (PCR) during cataract surgery predisposes patients to postoperative endophthalmitis (POE). However, little is known about the prophylactic use of intracameral antibiotics (ICA) to prevent POE after PCR. Therefore, we conducted this systematic review and meta-analysis to assess the efficacy of ICA in preventing POE in patients with PCR. PCR increases the risk of POE by over 6-fold, emphasizing the need for targeted prophylactic strategies. This study focuses on the clinical importance of ICA in reducing the incidence of POE in this high-risk population. We searched PubMed, Embase and Cochrane for articles published up to May 21th, 2024, with the following strategy: (cataract OR phaco OR "Cataract Extraction" OR "manual small incision cataract surgery" OR phacoemulsification OR "extracapsular cataract extraction" OR ECCE) AND (intracameral OR "Intracameral Injection" OR "irrigating infusion fluid" OR "anterior chamber injection") AND (antibiotic OR moxifloxacin OR cefuroxime OR vancomycin OR cephalosporin OR prophylaxis). We included studies reporting the incidence of endophthalmitis in patients with PCR during cataract surgery and a comparison of prophylactic intracameral antibiotics with no intracameral antibiotics. Statistical analysis was conducted using R software version 4.3.2. The protocol was registered in PROSPERO (CRD42024558144). The initial search yielded 1,660 results. After removing duplicate records and ineligible studies, 193 remained and were thoroughly reviewed based on the inclusion criteria. Nine studies consisting of two randomized controlled trials and seven observational studies were included in the meta-analysis. There were a total of 153,690 patients, with 50,207 (33,6%) patients in the ICA group and 103,483 (67.3%) in the No ICA group. There was a significantly lower incidence of endophthalmitis in the ICA group (OR 0.41; 95% CI 0.26 to 0.65; p < 0.001; I2 = 9%). Independently, the use of prophylactic intracameral moxifloxacin was also related with a lower risk of endophthalmitis (OR 0.33; 95% CI 0.19 to 0.57; p < 0.001; I2 = 33%). Our findings suggest that the use of intracameral antibiotics is efficient in preventing postoperative endophthalmitis in patients who had PCR during cataract surgery.