allergy to povidone-iodine, I generally inquire further and emphasize
the importance of its use, because true allergies to povidone-iodine
are extremely rare. While chlorhexidine gluconate can be used in its
place, it is definitely a second-line agent, and is not quite as effective
in reducing the bacterial load in and around the eye.
• Keep the bag intact. Rupturing the capsular bag during cataract
surgery increases the risk of post-operative endophthalmitis. Thanks
to ever-improving fluidic control on phacoemulsification machines as
well as lens fragmentation devices and technology, the estimated risk
of posterior capsule rupture is less than 1%. Being proactive in pre-
venting this surgical complication is paramount in minimizing the
patient's risk of endophthalmitis. For instance, in patients with floppy
iris syndrome and poor dilation, consider pupillary expansion devices
or pharmaceutical agents to maintain mydriasis so that visualization
remains optimal throughout the entire case.
• Wound integrity. Corneal wound gaping can allow microorgan-
isms to enter the intraocular space, increasing the risk of post-opera-
tive infection. Always check your wounds at the end of the case, espe-
cially if any concurrent surgery (pars plana vitrectomy or a glaucoma
procedure, for example) was performed. I always tell my trainees who
doubt the integrity of a wound to place a suture through it.
• Antibiotics. There is growing evidence supporting the benefit of
intracameral antibiotics in the prevention of post-cataract endoph-
thalmitis. A large 2007 randomized prospective study conducted by
the ESCRS Endophthalmitis Study Group showed that intracameral
cefuroxime with or without topical levofloxacin drops decreased the
incidence of post-cataract endophthalmitis from 0.35% to 0.08% in
more than 16,500 cataract patients, a significant positive finding that
resulted in early termination of the study due to obvious benefit
(osmag.net/SxuE3J).
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