Endophthalmitis After Routine Phacoemulsification: A One-Year Comparative Study Of Intracameral Moxifloxacin Versus No Intracameral Prophylaxis

To evaluate one-year (Jan 1–Dec 31, 2024) endophthalmitis rates in 450 routine cataract surgeries using intracameral preservative-free moxifloxacin (ICM group) vs. 450 without intra cameral moxifloxacin group (No-ICM), all by single surgeon across cataract grades/IOLs (monofocal, multifocal, EDOF). Rare ICM-linked acute depigmentation of iris /IOP spikes prompted selective use of ICM for high-risk cases (e.g., longstanding Diabetics with posterior capsule tear).

This study was conducted at a high-volume advanced cataract and refractive surgery centre in Chennai, India, serving both urban and referred patients. It represents a single-surgeon, one-year retrospective comparative study (January–December 2024) of 900 consecutive phacoemulsification procedures (450 intracameral moxifloxacin vs. 450 standard topical prophylaxis), performed using uniform surgical protocols and standardised perioperative care pathways.

This retrospective study reviewed 900 consecutive phacoemulsification cases under topical anesthesia (Jan–Dec 2024), all pupil sizes/cataract grades/IOL types (monofocal, multifocal, EDOF). Exclusions: corneal edema, keratitis, uveitis, glaucoma. Two groups: 450 received intracameral preservative-free moxifloxacin 0.1 mL (500 µg) end-surgery (+topical qid x1wk); 450 comparison group received topical moxifloxacin only. Follow-up: Day 1, 5, 15, 6 weeks, 3 months. Outcomes: BCVA (LogMAR), IOP, fundus evaluation, acute endophthalmitis signs, iris depigmentation, toxic anterior segment syndrome, posterior capsule rupture (Zeiss Lumera i, Centurion system used).

No cases of culture-positive or acute clinical endophthalmitis were observed in either group (0% vs 0%; P=1.0), remaining below AIOS benchmark rates for culture-positive (0.02%–0.09%) and clinical acute endophthalmitis (0.04%–0.15%). Posterior capsule rupture occurred in 3% of cases in both groups (P=0.9). Mean BCVA improvement was comparable (0.1 LogMAR; P=0.8).

Iris depigmentation occurred in 4 eyes in the intracameral group (0.88%). All cases developed dilated pupils (4–5 mm) with IOP elevation in the second week and were managed with topical steroids with oral and topical antiglaucoma medications. One case required 3 months for complete clinical resolution. No infective events were observed among 180 high-risk eyes (diabetes >10 years).

In this single-surgeon one-year study of 900 cataract procedures, no cases of endophthalmitis were observed in either group, with or without routine intracameral moxifloxacin. However, intracameral use was associated with acute iris depigmentation, persistent pupillary dilation, and transient intraocular pressure elevation requiring medical management.

These findings suggest that routine intracameral administration may not confer additional benefit in low-incidence settings and highlight the importance of a selective, risk-stratified approach to antibiotic prophylaxis. The results call for large, multicentric, adequately powered randomised controlled trials to establish evidence-based standards and to avoid indiscriminate dosing practices.