The Anterior Chamber Injection of Moxifloxacin Injection to Prevent Endophthalmitis after Cataract Surgery: A Meta-analysis

Author: Wang XL, Huang XY, Wang Z, Sun W.

Geographical coverage: Japan, Brazil, Turkey, Canada, Colombia, and the USA
Sector: Cataract surgery
Sub-sector: Antibiotics
Equity focus: Not reported
Study population: Patients with cataract
Review type: Effectiveness review
Quantitative synthesis method: Meta-analysis
Qualitative synthesis method: Not applicable

Background: Endophthalmitis is a rare but serious complication following cataract surgery, which often results in poor visual prognosis. Its incidence ranges from 0 to 0.63%, prompting the development of several preventive strategies such as povidone iodine, antibiotic eye drops, subconjunctival injections, and anterior chamber injections. In 2007, a multicentre trial by the European Association of Cataract and Refractive Surgeons (ESCRS) highlighted the effectiveness of intracameral cefuroxime. Since then, anterior chamber antibiotic injections have gained increasing attention. However, concerns over bacterial resistance and adverse reactions have shifted focus toward alternatives like vancomycin and moxifloxacin. Cefuroxime’s limited effectiveness against resistant strains and vancomycin’s risk of retinal vasculitis have made moxifloxacin a more favourable choice. However, study conclusions have been inconsistent.

Objective: This meta-analysis was conducted to inform the rational use of antibiotics in the perioperative period.

Main findings: The review included eight studies (123,819 eyes). Of these, two were randomised controlled trials (RCTs), two were case-control studies, and four were cohort studies. Two studies were conducted in Japan, two in Brazil, and one each in Turkey, Canada, Colombia, and the USA. The included studies were generally of good methodological quality. The RCTs had a low risk of bias; among the non-RCT studies, two were rated as high quality and four as medium quality.

Meta-analysis showed that an anterior chamber injection of moxifloxacin significantly reduced the incidence of endophthalmitis after cataract surgery (odds ratio [OR]: 0.29, 95% confidence interval [CI]: 0.15–0.56; P = 0.0002). However, the meta-analysis found no significant differences between the moxifloxacin injection group and the non-moxifloxacin injection group in uncorrected visual acuity (standardised mean difference [SMD]: −0.13, 95% CI: −0.62 to 0.35; P = 0.60), best-corrected visual acuity (SMD: −0.27, 95% CI: −1.28 to 0.74; P = 0.60), intraocular pressure (SMD: −0.04, 95% CI: −0.02 to 0.01; P = 0.22), corneal oedema (OR: 1.03, 95% CI: 0.23 to 4.69; P = 0.97), central corneal thickness (SMD: −0.01, 95% CI: −0.07 to 0.05; P = 0.77), or corneal endothelial cell density (SMD: 0.00, 95% CI: −0.06 to 0.07; P = 0.94).

Methodology: Searches were conducted in PubMed, Embase, the Cochrane Library, and a clinical trial database to identify RCTs, case-control studies, and cohort studies involving patients undergoing cataract surgery and evaluating anterior chamber injection of moxifloxacin. The search covered literature from the inception of the databases to April 2019. Two reviewers independently screened the articles; any discrepancies were resolved by consulting a third reviewer. Relevant data were extracted. The methodological quality of the included studies was assessed using Cochrane’s risk-of-bias tool for RCTs and the Newcastle-Ottawa Scale for case-control and cohort studies. The findings were synthesised using a fixed- or random-effects model meta-analysis, depending on the level of heterogeneity. Heterogeneity was assessed using Cochran’s Q test and the I² statistic. Sensitivity analyses were performed to evaluate the influence of a single study on the pooled estimate. A subgroup analysis was performed based on the clinical characteristics of the included studies, and publication bias was assessed using a funnel plot.

Applicability/external validity: The authors noted that the review included only two RCTs, with the remainder being non-RCT studies. Some of the included studies had short follow-up periods and small sample sizes, and there was a lack of direct comparison between moxifloxacin and cefuroxime. Therefore, large-sample, multicentre, high-quality RCTs are needed to provide higher-quality evidence in the future.

Geographic focus: The review did not apply any geographical limits; the included studies were conducted in Japan, Brazil, Turkey, Canada, Colombia, and the USA.

Summary of quality assessment: Overall, there is low confidence in this review’s conclusions about the effects of the intervention. The searches were comprehensive, with clearly defined inclusion and exclusion criteria. Study quality was assessed using Cochrane’s risk-of-bias tool for RCTs and the Newcastle-Ottawa Scale for non-RCTs, and the results of these assessments were reported. Two reviewers screened the articles, and a list of included studies was provided. Characteristics of the included studies were clearly presented. Data were synthesised using fixed- or random-effects meta-analysis, depending on the level of heterogeneity. Heterogeneity was evaluated using Cochran’s Q test and the I² statistic. Subgroup and sensitivity analyses were also conducted, and heterogeneity was appropriately discussed. However, no list of excluded studies was provided, and it was unclear whether any language restrictions were applied. The review did not report whether reference lists were checked or whether authors or experts were contacted for additional studies. Furthermore, it did not specify whether data extraction was performed independently by two reviewers.