Postoperative Endophthalmitis

Key points at a glance

Key points of this disease

• Postoperative endophthalmitis is a serious complication associated with cataract surgery that causes severe intraocular inflammation. It is classified by onset time into acute (within 1 week), subacute (within 1 month), and delayed-onset (after 1 month).
• The overall incidence is approximately 0.04–0.05% and is decreasing. With the widespread use of intracameral antibiotics, it has decreased to 0.063% since 2010.
• The most common causative organism in acute cases is coagulase-negative staphylococci (CNS). Enterococci and Pseudomonas aeruginosa are associated with rapid progression and poor prognosis.
• The typical causative organism in delayed-onset cases is Cutibacterium acnes (formerly Propionibacterium acnes), which forms a biofilm within the lens capsule and remains latent, a condition known as chronic pseudophakic endophthalmitis.
• Acute type: eye pain, hypopyon, and vitreous opacity progress within hours, and treatment strategy must be determined within 48 hours.
• Delayed type: characterized by white plaque formation on the posterior IOL surface, with mild eye pain. Emergency vitrectomy is not required; priority is given to detailed examination.
• Differentiation from TASS (toxic anterior segment syndrome), endogenous uveitis, and PUPPI is important.
• For acute type, based on EVS results, early vitrectomy is recommended for visual acuity of light perception or worse.
• For delayed type, in confirmed C. acnes cases, IOL removal plus total capsulectomy is the final option to prevent recurrence.
• The foundation of prevention is preoperative povidone-iodine disinfection and intracameral antibiotic administration at the end of surgery.

1. What is postoperative endophthalmitis?

Severe intraocular inflammation related to cataract surgery is collectively called endophthalmitis. It is mainly caused by bacterial infection, but sterile inflammation (TASS) can also occur. It is broadly classified by onset time as follows.

Classification	Onset time	Main causative bacteria	Urgency
Acute	Within 1 week postoperatively	CNS, Staphylococcus aureus, Gram-negative rods, Enterococcus	Requires emergency surgery
Subacute	Within 1 month after surgery	Low-virulence organisms such as S. epidermidis	Urgent evaluation needed
Delayed-onset	1 month or more after surgery	C. acnes, S. epidermidis, etc.	Prioritize detailed examination; emergency surgery not required

Acute type follows a fulminant course and does not heal without invasive procedures. Delayed-onset type often presents as chronic anterior uveitis over months to years, primarily involving C. acnes sequestered within the lens capsule forming biofilms and proliferating.

Note that late-onset infection after glaucoma filtration surgery (bleb-related endophthalmitis) differs in that Gram-negative bacilli are also causative and acute onset is more common; therefore, it is distinguished from the scope of this article.

2. Epidemiology

The incidence of postoperative endophthalmitis after cataract surgery is currently low, approximately 0.04–0.1%. The US IRIS Registry (2013–2017) reported 0.04%, and a large meta-analysis reported an overall rate of 0.066%^{1, 2)}. The introduction of intracameral antibiotics has been shown to further reduce the incidence^{2, 6, 11, 13)}.

Most cases of acute postoperative endophthalmitis occur within 1 week after surgery; therefore, severe eye pain and rapid vision loss in the early postoperative period require urgent evaluation³⁾.

Frequency data for delayed-onset endophthalmitis alone are limited, but the incidence of non-infectious chronic inflammation (PUPPI: Prolonged Undifferentiated Postoperative Pseudophakic Iridocyclitis) has been estimated at 1.68% of cataract surgery patients in a large study⁴⁾, highlighting the magnitude of the problem of chronic postoperative inflammation, both infectious and non-infectious.

3. Etiology and Pathogenic Microorganisms

Infection route

Route	Details
Intraoperative infection	The most common route is bacteria attached to the IOL being brought into the eye. Contamination can also occur through wound contact during injector insertion.
Postoperative infection	In the early postoperative period when wound closure is insufficient, bacteria on the ocular surface may reflux into the anterior chamber due to intraocular-extracular pressure differences.

The patient’s own eyelid margin and conjunctival normal flora are the main sources of infection ³⁾. Clear corneal incisions have a weaker valve structure than scleral tunnel incisions, making postoperative reflux more likely ³⁾.

Causative organisms of acute type

• Coagulase-negative staphylococci (CNS): Most common. S. epidermidis is representative ³⁾
• Staphylococcus aureus: Rapid tissue destruction due to toxin production. MRSA is also increasing.
• Streptococcus species: Moderate virulence, e.g., hemolytic streptococci.
• Gram-negative rods such as Pseudomonas aeruginosa: Severe inflammation due to endotoxins, high risk of progression to panophthalmitis.
• Enterococcus: Poor prognosis. Cephems are ineffective.

Gram-positive bacteria account for the majority (approximately 94%) ³⁾.

Causative organisms of late-onset type

• Cutibacterium acnes: The most representative causative organism of late-onset type. Anaerobic gram-positive bacillus, normal flora of skin and conjunctival sac. Forms biofilm and proliferates within the lens capsule, causing onset months to years after surgery. Difficult to detect because it localizes to the IOL haptic and folds of the posterior capsule.
• Staphylococcus epidermidis: Low-virulence gram-positive coccus, also a major causative organism in postoperative endophthalmitis overall⁵⁾

Acute vs. late-onset comparison

Item	Acute type	Late-onset type
Onset time	Within 1 week postoperatively	1 month or more postoperatively
Eye pain	Severe (pain in 75%)	Mild or absent
Causative organisms	CNS, S. aureus, gram-negative bacilli, etc.	C. acnes, S. epidermidis, etc.
Course	Acute / fulminant	Chronic / persistent
White plaque	Rare	Characteristic of C. acnes infection
Emergency surgery	Necessary	Not necessary (prioritize detailed examination)

4. Risk factors

Risk factors for postoperative endophthalmitis in general

The main risk factors based on the ESCRS multicenter RCT (16,603 eyes) are shown below⁶⁾.

Risk factor	Increased risk	Source
Posterior capsule rupture/vitreous loss	Up to 10-fold (OR 4.95, 95% CI 1.68-14.6)	3, 6)
No intracameral cefuroxime use	4.92-fold (95% CI 1.87-12.9)	6)
Clear corneal incision	5.88-fold (95% CI 1.34-25.9)	6)
Silicone IOL (vs. acrylic)	3.13-fold (95% CI 1.47-6.67)	6)
Advanced age/immunocompromise	Significant	3)
Wound leak (postoperative day 1) / inferior incision	Significant	3)
Prolonged surgery time / surgeon inexperience	Significant	3)
Active blepharitis / lacrimal sac obstruction	Significant	3)

Risk Factors for Chronic Postoperative Inflammation after Cataract Surgery (PUPPI)

A large-scale epidemiological study using the IRIS Registry (7,513,604 patients) identified risk factors associated with chronic inflammation after cataract surgery⁴⁾.

• Female (IRR 1.14, 95% CI 1.12-1.15)
• Diabetes (IRR 1.87, 95% CI 1.84-1.90)
• Bilateral surgery (IRR 1.10, 95% CI 1.09-1.12)
• Age 51-60 years (highest incidence at 1.80%)

5. Clinical Features and Diagnosis

5-1. Acute Type

Subjective symptoms:

• Decreased vision (present in 94%, rapidly progressive) ³⁾
• Severe eye pain (pain in 75%). Accompanied by ciliary injection
• Redness (ciliary injection, perikeratic injection)
• Discharge and eyelid swelling (characteristic of infectious endophthalmitis, usually not seen in TASS)

Progression of clinical findings:

Early to intermediate findings

Anterior chamber inflammation (cells and flare): Appears from the earliest stage. Progresses within hours.

Fibrin exudation: Protein exudation in the anterior chamber. Progresses to hypopyon.

Hypopyon: Characteristic finding of infectious endophthalmitis. White layered pus accumulates at the bottom of the anterior chamber.

Ciliary injection: Becomes clear along with eye pain in the hypopyon stage.

Corneal edema: Often localized (in contrast to diffuse limbus-to-limbus edema in TASS).

Advanced to severe findings

Vitreous opacity: Makes fundus visualization difficult. It is an indicator of rapid deterioration, and after vitreous seeding, it does not heal without invasive procedures.

Retinal hemorrhage, infiltration, necrosis: Leads to irreversible visual dysfunction.

Eyelid swelling and discharge: Characteristic of infectious endophthalmitis and an important distinguishing feature from TASS.

Progression to panophthalmitis: Higher risk with Gram-negative bacilli (e.g., Pseudomonas aeruginosa) and Streptococcus species.

5-2. Delayed-onset type

Subjective symptoms:

• Chronic, persistent anterior uveitis symptoms (redness, decreased vision)
• Onset months to years after surgery
• Ocular pain is often mild due to low-virulence organisms
• Discharge and eyelid swelling are less prominent than in the acute type

Characteristic clinical findings:

• White plaque on the posterior lens capsule (IOL): Characteristic of C. acnes infection. A biofilm-like white deposit localized on the IOL surface or posterior capsule, frequently seen in delayed-onset endophthalmitis due to C. acnes.
• Anterior chamber inflammation, keratic precipitates (KP), fibrin: Typical findings of chronic iridocyclitis.
• Vitreous opacity: Mild to moderate.
• Hypopyon: May be present in severe cases.

When late-onset bilateral ocular inflammation occurs, endogenous uveitis is likely, so a thorough examination is necessary. If symptoms develop long after surgery and are bilateral, sympathetic ophthalmia should also be considered in the differential diagnosis.

5-3. Tests and Definitive Diagnosis

Test	Purpose
Slit-lamp examination	Assessment of anterior chamber inflammation (cells, flare), fibrin, hypopyon, and white plaques on the posterior surface of the IOL
Gonioscopy	Detection of angle hypopyon not visible by slit lamp
Fundus examination / wide-field fundus camera	Evaluation of vitreous opacity and retinal lesions within visible range
B-mode ultrasound	Assessment of vitreous opacity and retinal detachment when fundus view is poor
Aqueous humor / vitreous fluid sampling	Submitted for smear, aerobic + anaerobic culture, and PCR. For late-onset cases, anaerobic culture for at least 14 days is essential for C. acnes
PCR testing	Can detect bacterial DNA even in culture-negative cases. For C. acnes, target the 16S rRNA gene
Electroretinogram (ERG)	b-wave reduction is a poor prognostic factor

Definitive diagnosis is made by identifying the causative organism. Although the identification rate is not necessarily high, it is essential for selecting sensitive antibiotics and differentiating from sterile endophthalmitis, and must always be performed.

Q What is the probability of endophthalmitis after cataract surgery?

A

In modern times, it is approximately 0.04–0.05% (1 in 2,000–2,500 cases). Some reports indicate that using intracameral antibiotics (e.g., cefuroxime 1 mg/0.1 mL) reduces the rate to 0.02%. The ESCRS multicenter RCT showed that the risk of endophthalmitis was reduced by about fivefold in the intracameral cefuroxime group.

Q If my eye hurts the day after cataract surgery, is it endophthalmitis?

A

Mild pain and redness the day after surgery are often normal postoperative reactions. However, if there is severe eye pain, rapid vision loss, or hypopyon, endophthalmitis should be suspected and emergency evaluation is necessary. Infectious endophthalmitis often presents with severe eye pain 3–7 days after surgery, while TASS typically occurs 12–48 hours postoperatively with mild pain.

Q Can endophthalmitis occur more than a year after cataract surgery?

A

C. acnes can form biofilms within the lens capsule and remain dormant, so cases developing several years after surgery have been reported. If persistent anterior chamber inflammation is observed long after surgery, delayed-onset endophthalmitis should be considered. Identifying a white plaque on the posterior surface of the IOL with a slit lamp is a diagnostic clue.

6. Differential Diagnosis

Differentiation from TASS (most important in acute type)

Item	Acute endophthalmitis	TASS
Onset time	3–7 days postoperatively	12–48 hours postoperatively
Eye pain	Severe (pain in 75%)	Mild or absent
Eyelid swelling	Characteristic	Usually absent
Eye discharge	Present	Absent
Corneal edema	Often localized	Diffuse (limbus to limbus)
Posterior segment	Vitreous opacity, retinal lesions	Usually not involved
Steroid response	Poor	Rapid
Course	Rapid worsening within hours	Slow

Management when TASS cannot be ruled out

If infectious endophthalmitis cannot be ruled out, collect cultures and start antibiotics and steroids simultaneously. Rapid worsening (within hours) suggests infection; consider early vitrectomy. For slow worsening, consider TASS, delayed-onset endophthalmitis, or endogenous uveitis; none require emergency surgery, and careful evaluation is needed.

Main differential diagnoses for delayed-onset type

Differential diagnosis	Key differentiating features
TASS	Onset within 12–48 hours postoperatively. Sterile. Characterized by diffuse corneal edema.
Acute infectious endophthalmitis	Onset within 1 week postoperatively. Severe eye pain with eyelid swelling and discharge. Requires emergency surgery.
Endogenous uveitis	Consider when late-onset and bilateral. Systemic workup for HLA-B27, sarcoidosis, etc. is necessary.
Sympathetic ophthalmia	Consider when onset occurs long after surgery and is bilateral.
PUPPI (persistent pseudophakic uveitis)	Chronic iridocyclitis of unknown cause after excluding infection, IOL malposition, retained lens fragments, and recurrent uveitis 4, 7)
IOL malposition / iris chafing	Mechanical irritation due to IOL malposition. Evaluated by ultrasound biomicroscopy (UBM).
Retained lens fragments	Inflammatory reaction due to retained cortical or nuclear fragments after surgery. Confirmed by posterior segment observation.

Clinical note

Late-onset endophthalmitis caused by C. acnes and PUPPI (non-infectious chronic inflammation) have similar clinical presentations and are easily confused. PUPPI is diagnosed after reliably excluding infectious late-onset endophthalmitis. Even if culture is negative, infection cannot be ruled out; therefore, if infection is clinically suspected, treatment should proceed as for infection.

Q How do you differentiate endophthalmitis from TASS?

A

Important differentiating points include time of onset (TASS: 12–48 hours, acute endophthalmitis: 3–7 days), degree of eye pain (TASS: mild, endophthalmitis: severe), and presence of eyelid swelling. Corneal edema pattern is also helpful (TASS: diffuse limbus-to-limbus, endophthalmitis: localized). If differentiation is difficult, cultures should be obtained and antibiotics and steroids started simultaneously.

Q What is the difference between late-onset endophthalmitis and PUPPI?

A

Delayed-onset endophthalmitis is caused by bacterial infections such as C. acnes, whereas PUPPI is a chronic iridocyclitis of unknown cause diagnosed after excluding infection, IOL dislocation, and retained lens fragments. Since both conditions are clinically similar, anaerobic culture and PCR testing of aqueous humor and vitreous fluid are necessary for differentiation. Because treatment strategies differ (infectious: antibiotics + surgery; non-infectious: steroid therapy), accurate differentiation is important.

7. Treatment

7-1. Treatment flow by severity for acute type

Stage 1: Anterior chamber inflammation phase (no hypopyon)

• Increase frequency of antibiotic eye drops (every 1–2 hours)
• Daily follow-up, watch for signs of infection
• If worsening, proceed to intracameral injection

Intracameral injection (off-label use):

• Vancomycin hydrochloride: 10 mg/mL solution 0.1 mL
• Ceftazidime: 20 mg/mL solution 0.1 mL

Stage 2: Hypopyon phase (no vitreous opacity)

• Anterior chamber washout + intracameral and intravitreal injection (off-label use):
  • Vancomycin 1 mg/0.1 mL
  • Ceftazidime (Modacin) 2 mg/0.1 mL
• Vitreous fluid collection (culture and sensitivity testing)

Stage 3: Vitreous opacity phase

• Vitrectomy (perform as early as possible)
  • Vitreous removal
  • Intracapsular lens irrigation + posterior capsulotomy
  • Intravitreal antibiotic injection (vancomycin 1 mg/0.1 mL + ceftazidime 2 mg/0.1 mL)
• IOL can be preserved if inflammation is not severe

Management of recurrence: IOL removal + total capsulotomy

7-2. Recommendations from the Endophthalmitis Vitrectomy Study (EVS)

The EVS is an important RCT that established treatment guidelines for postoperative endophthalmitis⁸⁾.

• Visual acuity of hand motion (HM) or better → vitreous tap + intravitreal antibiotic injection
• Visual acuity of light perception (LP) or worse → pars plana vitrectomy (PPV) + intravitreal antibiotic injection results in significantly better outcomes
• Systemic antibiotics (amikacin + ceftazidime): No significant additional benefit in the EVS⁸⁾

7-3. Eye drops and systemic administration

Eye drops (6 times daily):

1. Levofloxacin ophthalmic solution (1.5%)
2. Cefmenoxime ophthalmic solution (0.5%)
3. Betamethasone ophthalmic solution (0.1%)

Systemic administration (severe cases or risk of panophthalmitis):

• Imipenem/cilastatin: 1 g twice daily intravenously for 5 days
• Levofloxacin tablets: 500 mg once daily for 5 days

7-4. Stepwise treatment algorithm for delayed-onset type

Delayed-onset type does not require emergency vitrectomy. This is an important difference from acute type. First, perform a thorough examination to rule out TASS and endogenous uveitis as much as possible, then determine the treatment strategy stepwise while monitoring the course.

Step	Indication	Treatment
Step 1: Examination and differential diagnosis	All cases	Vitreous fluid collection → anaerobic culture and PCR; rule out TASS and endogenous uveitis
Step 2: Conservative treatment	Mild or first episode	Antibiotic eye drops + steroid eye drops; observe for improvement
Step 3: Vitrectomy	Worsening or recurrent cases	Vitrectomy + intravitreal vancomycin and ceftazidime
Step 4: IOL removal + total capsulectomy	Re-recurrence or confirmed C. acnes cases	Complete removal is the last resort because recurrence occurs if the capsule is left

Medications for conservative treatment (Step 2):

• Levofloxacin ophthalmic solution (Cravit 1.5%): 6 times daily
• Cefmenoxime ophthalmic solution (Bestron ophthalmic 0.5%): 6 times daily
• Betamethasone ophthalmic solution (Rinderon 0.1%): 6 times daily (anti-inflammatory)

Intravitreal injection and surgery (Step 3):

• Intravitreal vancomycin 1 mg/0.1 mL (off-label)
• Intravitreal ceftazidime 2 mg/0.1 mL (off-label)
• Vitrectomy removes vitreous opacity and collects specimens from the capsule for bacterial testing

IOL removal and total capsulectomy (Step 4):

Delayed-onset endophthalmitis caused by C. acnes has a high risk of recurrence if the IOL and lens capsule are preserved. In cases of re-recurrence or confirmed C. acnes, IOL removal and total capsulectomy are necessary. After IOL removal, consider visual correction with sutured IOL or scleral-fixated IOL.

Q Is surgery mandatory for the treatment of delayed-onset endophthalmitis?

A

In mild, first-episode cases, conservative treatment with antibiotic and steroid eye drops may improve the condition. However, in cases of worsening or recurrence, vitrectomy is necessary. For C. acnes, preserving the IOL and lens capsule can lead to recurrence, so ultimately IOL removal and total capsulectomy may be required.

8. Course and Prognosis

In acute cases, early vitrectomy improves visual prognosis. The EVS showed that early PPV significantly improved visual outcomes in cases with light perception or worse vision ⁸⁾. Enterococcus and Gram-negative rods (e.g., Pseudomonas aeruginosa) progress rapidly and have poor prognosis. Whether the IOL can be preserved depends on the severity of inflammation. Recurrent cases require removal of the IOL and lens capsule.

Delayed-onset cases have a better prognosis than acute cases, but in C. acnes infections, if biofilm remains in the lens capsule, recurrence is frequent. Biofilm is composed of a polysaccharide matrix produced by C. acnes, which hinders antibiotic penetration. This explains the difficulty in detection by culture and resistance to treatment (risk of recurrence), and why complete removal of the lens capsule is ultimately necessary.

9. Prevention

9-1. Basic Prevention Strategies

Infection prevention consists of a three-step approach.

• Preoperative: Reduction of microbial load on the ocular surface (povidone-iodine disinfection)
• Intraoperative: Minimization of microbial exposure and intracameral antibiotic administration
• Postoperative: Reduction of bacterial load until wound healing

Prevention is better than cure

Preoperative povidone-iodine disinfection and intracameral antibiotic administration at the end of surgery are the most evidence-based preventive methods. Intracameral cefuroxime 1 mg/0.1 mL reduces the risk of endophthalmitis by about fivefold.

9-2. Preoperative Disinfection

• Instill 5–10% povidone-iodine (PI) into the conjunctival sac for at least 3 minutes before surgery. Significantly reduces bacterial load ⁹⁾
• Repeated irrigation with 0.25% PI solution every 20–30 seconds during surgery (Shimada technique) is also effective ^{9, 10)}
• In case of PI allergy: use 0.02–0.05% chlorhexidine as an alternative ⁹⁾

9-3. Intracameral antibiotic administration (most evidence-based prophylaxis)

• Cefuroxime 1 mg/0.1 mL: ESCRS multicenter RCT (16,603 eyes) showed a 4.92-fold increase in endophthalmitis risk without use ⁶⁾. Meta-analysis: OR 0.26 (95% CI 0.15–0.45) ¹¹⁾. Approved formulation (Aprokam) available in Europe
• Moxifloxacin: Meta-analysis: OR 0.29 (95% CI 0.15–0.56) ¹²⁾. Reported to reduce baseline endophthalmitis rate from 0.07% to 0.02% ³⁾
• Intracameral vancomycin: Associated with hemorrhagic occlusive retinal vasculitis (HORV); routine prophylactic use is strongly discouraged ^{3, 11)}
• Large network meta-analysis shows that intracameral antibiotics significantly reduce postoperative endophthalmitis risk, with prophylactic efficacy demonstrated for cefuroxime, moxifloxacin, etc. ^{2, 13)}
• Adding topical antibiotics to intracameral antibiotics has not consistently shown further reduction in endophthalmitis incidence ^{9, 11, 14, 15)}
• Standard doses are not considered to cause significant adverse effects on corneal endothelium, but overdose has been reported to cause corneal edema and decreased endothelial cell density ^{16, 17)}

9-4. Other preventive measures

• IOL insertion using an injector (to avoid contact with the ocular surface)
• Confirm wound closure at the end of surgery, and finish with intraocular pressure of approximately 20 mmHg or higher by infusion fluid injection
• Adding antibiotics to infusion fluid: prophylactic effect not proven
• Pre- and postoperative topical antibiotic eye drops: reported to reduce ocular surface bacterial load, but evidence for directly lowering endophthalmitis incidence is not as strong as for intracameral administration ^{3, 9, 18, 19)}. Caution regarding selection of resistant bacteria with long-term or repeated use ¹⁸⁾

9-5. Topics in Research Stage

Information in Research Stage

The following information is in the research stage or limited to certain regions, and is not currently established as standard treatment.

• Standardization of intracameral antibiotics: Cefuroxime has an approved formulation (Aprokam) in Europe, but is not approved in the US or Japan. Cases have been reported where dilution errors in hospital-prepared formulations cause severe toxicity ³⁾
• Drop-free chemoprophylaxis: Some reports indicate that regimens using only intracameral antibiotics have no difference in infection rates compared to groups with combined eye drops ^{3, 15)}. However, prospective comparative trials are limited, and selection based on patient risk and wound condition is necessary.
• HORV (Hemorrhagic Occlusive Retinal Vasculitis): A delayed-onset ocular toxicity occurring after intracameral administration of vancomycin. The mechanism is unknown. Cases are being collected in the ASCRS/ASRS joint registry ³⁾
• Antibiotic resistance trends: An increase in fluoroquinolone-resistant CNS has been reported worldwide, prompting consideration of revisions to prophylactic regimens.
• Next-generation sequencing (NGS): Analysis of the intraocular microbiome is expected to improve diagnostic rates for culture-negative chronic endophthalmitis ⁴⁾
• New routes of administration: Transzonular and pars plana intravitreal antibiotic administration are being investigated, but large-scale RCTs are lacking ³⁾

For details on prevention strategies, refer to the separate article “Infection Prevention in Cataract Surgery.”

Q Are there ways to prevent endophthalmitis after cataract surgery?

A

Preoperative povidone-iodine disinfection and intracameral antibiotic administration (e.g., cefuroxime 1 mg/0.1 mL) at the end of surgery are the most evidence-based preventive methods. The ESCRS multicenter RCT showed that intracameral cefuroxime reduced the risk of endophthalmitis by about fivefold. Vancomycin is not recommended for routine prophylaxis due to the risk of hemorrhagic occlusive retinal vasculitis (HORV).

10. References

1. Pershing S, Lum F, Hsu S, Kelly SP, Chiang MF, Rich WL 3rd, Parke DW 2nd. Endophthalmitis after cataract surgery in the United States: IRIS Registry (Intelligent Research in Sight) 2013-2017. Ophthalmology. 2020;127(3):295-302. doi:10.1016/j.ophtha.2019.10.001. PMID: 31630607.

2. Kato A, Horita N, Namkoong H, et al. Prophylactic antibiotics for postcataract surgery endophthalmitis: a systematic review and network meta-analysis of 6.8 million eyes. Sci Rep. 2022;12(1):17416. doi:10.1038/s41598-022-21423-w. PMID: 36258003.

3. Miller KM, Oetting TA, Tweeten JP, et al. Cataract in the Adult Eye Preferred Practice Pattern. Ophthalmology. 2022;129(1):P1-P126. doi:10.1016/j.ophtha.2021.10.006. PMID: 34780842.

4. Acharya B, Hyman L, Tomaiuolo M, Zhang Q, Dunn JP. Prolonged Undifferentiated Postoperative Pseudophakic Iridocyclitis. Ophthalmology. 2024.

5. Durand ML. Bacterial and fungal endophthalmitis. Clin Microbiol Rev. 2017;30(3):597-613. doi:10.1128/CMR.00113-16. PMID: 28580921; PMCID: PMC5473062.

6. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33(6):978-988. doi:10.1016/j.jcrs.2007.02.032. PMID: 17531690.

7. Soifer M, Mousa HM, Jammal AA, et al. Diagnosis and management of idiopathic persistent iritis after cataract surgery (IPICS). Am J Ophthalmol. 2022;234:250-258.

8. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol. 1995;113(12):1479-96.

9. European Society of Cataract and Refractive Surgeons. ESCRS Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery: Data, Dilemmas and Conclusions. Updated 2018. https://www.escrs.org/media/uljgvpn1/english_2018_updated.pdf

10. Shimada H, Nakashizuka H. Cataract surgery by intraoperative surface irrigation with 0.25% povidone-iodine. J Clin Med. 2021;10(16):3611. doi:10.3390/jcm10163611. PMID: 34441906.

11. Bowen RC, Zhou AX, Bondalapati S, et al. Comparative analysis of the safety and efficacy of intracameral cefuroxime, moxifloxacin and vancomycin on endophthalmitis prophylaxis during cataract surgery: a systematic review and meta-analysis. Br J Ophthalmol. 2018;102(10):1261-1268. doi:10.1136/bjophthalmol-2017-311702. PMID: 29703736.

12. Wang XL, et al. Anterior chamber injection of moxifloxacin for endophthalmitis prophylaxis after cataract surgery: a meta-analysis. J Ophthalmol. 2020;2020:7242969. doi:10.1155/2020/7242969. PMID: 32104535.

13. Gower EW, Lindsley K, Nanji AA, Leyngold I, McDonnell PJ. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database Syst Rev. 2017;2(2):CD006364. doi:10.1002/14651858.CD006364.pub3. PMID: 28192644; PMCID: PMC5375161.

14. Gower EW, et al. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database Syst Rev. 2017.

15. Passaro ML, Posarelli M, Avolio FC, Ferrara M, Costagliola C, Semeraro F, et al. Evaluating the efficacy of postoperative topical antibiotics in cataract surgery: A systematic review and meta-analysis. Acta Ophthalmol. 2025;103(6):622-633. PMID: 40018950.

16. Shahraki K, Makateb A, Shirzadi K, et al. Effects of intracameral cefuroxime on corneal endothelial cell counts and its morphology after cataract surgery. Interv Med Appl Sci. 2017;9(2):100-104. PMID: 28932504.

17. Diez-Alvarez L, Luaces-Rodriguez A, Benitez-Del-Castillo JM, et al. Ocular toxicity after inadvertent overdose of intracameral cefuroxime during cataract surgery. Arch Soc Esp Oftalmol (Engl Ed). 2021;96(11):571-577. PMID: 34756278.

18. Matsuura K, Miyazaki D, Inoue Y, Sasaki Y, Shimizu Y. Comparison of iodine compounds and levofloxacin as postoperative instillation; conjunctival bacterial flora and antimicrobial susceptibility following cataract surgery. Jpn J Ophthalmol. 2024;68(6):702-708. PMID: 39240403.

19. Totsuka N, Koide R. The effect of preoperative topical antibiotics in cataract surgery. Nippon Ganka Gakkai Zasshi. 2006;110(7):504-510. PMID: 16884070.