Review Of Escrs Multicentre Trial Of Intracameral Cefuroxime For Preventing Postoperative Endophthalmitis Following Cataract Surgery After 20 Years Of Use And Future Application

The ESCRS set up the first prospective, randomised, double-blind, placebo-controlled trial for use of intracameral (IC) cefuroxime during cataract surgery to prevent postoperative endophthalmitis. The study for analysis involved eight European countries from 2002 to 2007 including 16,211 operations using phacoemulsification. 

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The ESCRS mulitcentre study followed a retrospective study (National Swedish Registry) of IC cefuroxime (1 mg in 0.1 ml), from 1996 to 2000, that gave a low postoperative endophthalmitis rate of 0.06% (20/32,180 operations). The prospective trial confirmed the findings with an infection rate of 0.05% (2/4,052) with IC cefuroxime and  0.30% without (12/4,054);  prophylaxis gave a five-fold decrease in risk,  (p<0.05; 95% CI, 1.87-12.9).

Further studies have been conducted with IC moxifloxacin (0.5 mg in 0.1ml), not available in 2002. At Aravind Eye Hospital (India), a high‑volume registry analysis of cataract surgery with phacoemulsification, involving 194,252 patients between 2014 and 2016, demonstrated a seven times decrease in risk of postoperative endophthalmitis  with moxifloxacin  (0.01%, 11/89,358) than without (0.07%, 75/104,892), p<0.001. Retrospective studies have limitations with changes of  controls, technique, surgeons and intraocular lenses but it gave a similar difference albeit with lower overall infections. 

While moxifloxacin has greater antibacterial activity than cefuroxime, the principle established by the ESCRS trial - of a large reduction in postoperative endophthalmitis following use of an intracameral antibiotic at the time of cataract surgery - has held true and relevant for the future.  

The landmark multicentre trial was credited recently with transforming global practice patterns (AAO EyeNet, 2026).  IC cefuroxime is now used frequently in Europe while IC moxifloxacin is widely used in the USA and India,  countries where ready-to-use IC preparations are available commercially;  topical intensive  postoperative  moxifloxacin  use is an alternative when the IC formulation is not available.