Japanese survey of perioperative antibiotic prophylaxis in cataract surgery
A 2025 Japanese national survey reveals that while overall perioperative antibiotic use in cataract surgery has declined since previous years, intracameral antibiotics remain underutilized despite showing a lower rate of infectious endophthalmitis, particularly when using diluted moxifloxacin.
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Every year, millions of people around the world undergo cataract surgery, a routine procedure that restores vision by replacing a cloudy lens inside the eye with a clear, artificial one. While this operation is generally safe, it carries a small but serious risk: a severe infection inside the eye known as endophthalmitis. This condition can rapidly destroy vision if not treated immediately. To prevent such infections, surgeons have long relied on antibiotics, typically administered as eye drops before and after the operation, or sometimes injected directly into the eye. However, the overuse of antibiotics is a growing global concern, as it can lead to bacteria becoming resistant to the drugs, rendering them useless when they are truly needed. The medical community is now trying to find a balance: protecting patients from infection without contributing to the crisis of drug-resistant superbugs.
In Japan, a team of researchers recently set out to understand how eye surgeons are navigating this delicate balance. They conducted a nationwide survey to see what methods doctors are actually using during cataract surgery and whether these habits are changing. The study, which gathered responses from hundreds of surgeons across twelve different regions of the country, reveals a shifting landscape in how these operations are performed. The findings suggest that while doctors are becoming more cautious about using antibiotics in the traditional ways, they have not yet widely adopted a more direct method of protection that is gaining popularity elsewhere in the world.
The researchers sent questionnaires to ophthalmologists in February and March of 2025, asking them to report on their specific practices. They received answers from nearly 800 surgeons, representing a wide mix of university hospitals, public facilities, private clinics, and independent practices. The data showed that the vast majority of surgeons still use antibiotic eye drops before and after the surgery, with nearly all of them continuing this practice. However, the duration of this treatment has changed significantly. In the past, many surgeons prescribed these drops for months at a time. Now, most stop the treatment within two weeks, and very few continue it for more than two months. This shift indicates a conscious effort by the medical community to reduce the total amount of antibiotics patients are exposed to, likely in response to concerns about antibiotic resistance.
Despite the reduction in eye drops, the use of other preventive measures has also declined. The survey found that fewer surgeons are using antibiotic-containing irrigation fluids to wash the eye during the operation, and fewer are injecting antibiotics under the conjunctiva, the thin membrane covering the white part of the eye. The most notable finding, however, concerns the use of intracameral antibiotics, a technique where a small amount of medicine is injected directly into the front chamber of the eye at the end of the surgery. In many Western countries, this method has become the standard of care because it delivers a high concentration of the drug exactly where it is needed. In Japan, however, this practice remains rare. Only about one in ten surgeons reported using it, a number that has barely changed since previous surveys conducted a decade ago.
Among the small group of Japanese surgeons who do use this direct injection method, there is a distinct preference for a specific type of antibiotic called moxifloxacin. Almost all of them use this drug, while others like cefuroxime or vancomycin are not used at all. Furthermore, the way they administer the drug is unique. Instead of injecting a tiny, precise dose, most of these surgeons use a technique they call "flushing." They dilute the antibiotic with a larger volume of fluid and flush it through the eye to wash the entire inner surface, including the area behind the artificial lens. This method is designed to ensure the medicine reaches every corner of the eye, rather than relying on a single drop that might miss the most vulnerable spots.
The researchers also looked at the outcomes of these different approaches to see if they made a difference in infection rates. Across the more than 250,000 surgeries reported in the study, there were 54 cases of infection, a very low rate overall. When the researchers broke down the numbers, they found that the infection rate was slightly lower for patients who received the intracameral antibiotic flushing compared to those who did not. Specifically, among the patients who received the diluted moxifloxacin flush, the infection rate was extremely low. The study did not find any serious side effects from this method, such as damage to the eye's inner lining, suggesting that when done correctly, this approach is safe.
The authors of the study conclude that while Japanese surgeons are successfully reducing their reliance on long-term antibiotic eye drops, they have been slow to embrace the direct injection method that is common in other parts of the world. They suggest that this hesitation may be due to the fact that there is no commercially available, pre-packaged solution for this specific use in Japan, meaning surgeons must mix the drugs themselves in the operating room, which carries a risk of error. The researchers note that if this method is used properly, it could play a vital role in preventing eye infections without contributing to the problem of antibiotic resistance. For now, the trend in Japan is one of careful reduction in traditional methods, with a quiet, growing interest in a more direct, albeit less common, alternative.
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