# Intracameral injection
An intracameral injection places medication directly into the anterior chamber of the eye, the fluid-filled space between the cornea and the iris. It is used most often at the end of cataract surgery, when a single injection of antibiotic reduces the risk of postoperative endophthalmitis, and it also delivers mydriatics, anesthetics, steroids, miotics, anti-VEGF agents, antiglaucoma drugs, and alkylating agents.[1](https://pubmed.ncbi.nlm.nih.gov/36757304/) The antibiotics in routine prophylactic use are cefuroxime and moxifloxacin; vancomycin has been used off-label, but routine prophylactic use is now advised against because of hemorrhagic occlusive retinal vasculitis.[1](https://pubmed.ncbi.nlm.nih.gov/36757304/)
| Key fact | Detail |
|---|---|
| Standard antibiotic doses | Cefuroxime 1 mg in 0.1 mL; moxifloxacin 0.5 mg (typically 0.1 mL); vancomycin 1 mg in 0.1 mL[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC12928780/) |
| Landmark trial | ESCRS randomized trial, 16,603 patients, 24 units in nine countries; absence of cefuroxime raised endophthalmitis risk 4.92-fold[3](https://strathprints.strath.ac.uk/3443/) |
| Aqueous levels | Cefuroxime reaches about 2614 mg/L at 30 seconds after injection; moxifloxacin half-life in the anterior chamber exceeds 1 hour[4](https://www.escrs.org/media/uljgvpn1/english_2018_updated.pdf) • [5](https://link.springer.com/article/10.1007/s00417-013-2294-7) |
| Main toxicity risks | Dilution errors, toxic anterior segment syndrome, and hemorrhagic occlusive retinal vasculitis with vancomycin[6](https://pmc.ncbi.nlm.nih.gov/articles/PMC6258587/) |
| Regulatory status | Aprokam (cefuroxime 50 mg powder) is approved in Europe; no FDA-approved intracameral cefuroxime product exists in the United States[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC12928780/) • [6](https://pmc.ncbi.nlm.nih.gov/articles/PMC6258587/) |
| Current guidance | The 2024 ESCRS recommendations endorse intracameral cefuroxime 1 mg in 0.1 mL at the end of surgery (GRADE +++).[7](https://escrs.org/media/ooama3sf/european-society-of-cataract-and-refractive-surgeons-recommendations-for-cataract-surgery-2024-executive-summary.pdf) |
## How it works
Topical and systemic routes face the cornea, conjunctiva, and blood-ocular barriers, so only a small fraction of a dose reaches the aqueous humor. Injecting into the anterior chamber bypasses these barriers and produces a high therapeutic concentration at the target site immediately, with minimal systemic exposure.[1](https://pubmed.ncbi.nlm.nih.gov/36757304/) The standard cefuroxime dose of 1 mg in 0.1 mL achieves aqueous concentrations exceeding the minimum inhibitory concentrations (MICs) of most pathogens that cause postoperative endophthalmitis immediately after injection.[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC12928780/) Measured values after injection are 2614 ± 209 mg/L at 30 seconds and 1027 ± 43 mg/L in a second group of patients.[4](https://www.escrs.org/media/uljgvpn1/english_2018_updated.pdf)
Injection still involves dilution and washout. A 0.1 mL injection of 500 µg/mL moxifloxacin underwent a 3.3-fold dilution in the human anterior chamber, to 152.33 µg/mL.[5](https://link.springer.com/article/10.1007/s00417-013-2294-7) In rabbits, aqueous moxifloxacin fell to 52% of baseline at 1 hour and 15% at 3 hours, indicating a half-life greater than 1 hour.[5](https://link.springer.com/article/10.1007/s00417-013-2294-7) [Cefuroxime](https://www.edgepedia.org/cefuroxime) is eliminated more slowly: about half of the injected dose leaves the anterior chamber roughly 4 to 5 hours after surgery.[6](https://pmc.ncbi.nlm.nih.gov/articles/PMC6258587/) Systemic absorption is negligible; after a 200 µL Mydrane injection, maximum plasma lidocaine was 1.45 ng/mL, far below levels producing systemic effects.[8](https://www.medicines.org.uk/emc/product/7254/smpc)
## How it is done
The commonest prophylactic regimen is cefuroxime 1 mg in 0.1 mL of normal saline injected into the anterior chamber (or the capsular bag) at the close of surgery; 16 of 21 practice guidelines reviewed up to 2023 recommended exactly this dose.[9](https://www.dovepress.com/systematic-review-of-clinical-practice-guidelines-forpost-cataract-sur-peer-reviewed-fulltext-article-OPTH) [Moxifloxacin](https://www.edgepedia.org/moxifloxacin) is typically 0.5 mg in 0.1 mL, and vancomycin 1 mg in 0.1 mL.[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC12928780/) The ASCRS 2023 clinical advisory on moxifloxacin set the dose at 0.5 mg, achievable with 0.1 mL of a 0.5% solution or 0.5 mL of a 0.1% solution.[9](https://www.dovepress.com/systematic-review-of-clinical-practice-guidelines-forpost-cataract-sur-peer-reviewed-fulltext-article-OPTH)
Several administration methods have been published to standardize dosing: bag and chamber flushing with diluted moxifloxacin, described by Kazuki Matsuura, Chikako Suto, Junsuke Akura, and Yoshitsugu Inoue in 2012, irrigates the chamber and the area behind the intraocular lens;[10](https://doi.org/10.1007/s00417-012-2098-1) Steve A. Arshinoff and Milad Modabber published a dilution and administration scheme in 2016;[11](https://doi.org/10.1016/j.jcrs.2016.10.017) and Neal H. Shorstein and Susanne Gardner analyzed how injection volume determines the delivered moxifloxacin dose in 2019.[12](https://doi.org/10.1016/j.jcrs.2019.04.020) A Finnish dilution error that gave 16 patients 50 to 100 times the recommended cefuroxime dose, blinding eight of the 16 eyes, shows why independent concentration checks matter.[13](https://crstodayeurope.com/topics/general/factors-influencing-adoption-intracameral-antibiotics-and-steroids/47551/)
## Origin
Prophylactic intracameral cefuroxime at the close of cataract surgery was first implemented clinically by Per G. Montan, Gisela Wejde, Gabor Koranyi, and [Margareta Rylander](https://www.edgepedia.org/margareta-rylander), whose report appeared in the Journal of Cataract & Refractive Surgery in 2002.[14](https://doi.org/10.1016/s0886-3350%2801%2901269-x) The ESCRS guidelines credit the establishment of the practice.[4](https://www.escrs.org/media/uljgvpn1/english_2018_updated.pdf)
The landmark study is the ESCRS multicenter randomized placebo-controlled trial, led by the late Peter Barry of Dublin, which began in September 2003 and was stopped early in January 2006 because the cefuroxime benefit was already clear.[15](https://europepmc.org/article/MED/16631047) • [16](https://www.ovid.com/jnls/jcrs/fulltext/10.1016/j.jcrs.2016.11.007~intraocular-antibiotics-during-cataract-surgery-risks-and) The final study recruited 16,603 patients at 24 ophthalmology units in nine European countries, using a 2 × 2 factorial design of intracameral cefuroxime and topical perioperative levofloxacin.[3](https://strathprints.strath.ac.uk/3443/) [Endophthalmitis](https://www.edgepedia.org/endophthalmitis) incidences in the four groups were 13/3438 (0.38%), 10/3424 (0.29%), 3/3408 (0.09%), and 2/3428 (0.06%).[6](https://pmc.ncbi.nlm.nih.gov/articles/PMC6258587/)
## Variants
**Intracameral mydriatics and anesthesia.** Mydrane (Laboratoires Théa) combines [tropicamide](https://www.edgepedia.org/tropicamide) 0.02%, phenylephrine 0.31%, and lidocaine 1% in a preservative-free 0.2 mL dose injected slowly just after the first incision; the phase III trial by Marc Labetoulle, Oliver Findl, and colleagues randomized 555 patients and found non-inferior capsulorhexis feasibility (98.9% versus 94.7% responders) with treatment-related ocular adverse events below 3% in both groups.[17](https://doi.org/10.1136/bjophthalmol-2015-307587) • [8](https://www.medicines.org.uk/emc/product/7254/smpc) Intracameral phenylephrine is also used for intraoperative floppy iris syndrome, the triad David F. Chang and John R. Campbell described in tamsulosin-treated patients in 2005.[18](https://doi.org/10.1016/j.jcrs.2005.02.027)
## Applications
The ESCRS result translated into large service-level reductions. Reported endophthalmitis rates fell from roughly 0.3% to 1.2% before intracameral cefuroxime to 0.014% to 0.08% afterward, a 7- to 28-fold reduction.[4](https://www.escrs.org/media/uljgvpn1/english_2018_updated.pdf) A Swedish study of 225,471 patients, 95% of whom received intracameral cefuroxime without postoperative topical antibiotics, reported an endophthalmitis rate of 0.045%.[13](https://crstodayeurope.com/topics/general/factors-influencing-adoption-intracameral-antibiotics-and-steroids/47551/) For moxifloxacin, Aravind Haripriya, David F. Chang, and colleagues reported a fourfold reduction in endophthalmitis among 116,714 cataract surgeries over 14 months at Aravind Eye Hospital in Madurai, India.[19](https://doi.org/10.1016/j.ophtha.2015.09.037) • [20](https://www.healio.com/news/ophthalmology/20241120/intracameral-antibiotic-prophylaxis-where-do-we-stand) A meta-analysis of 8 studies with 123,819 eyes found anterior chamber moxifloxacin reduced endophthalmitis with an odds ratio of 0.29 (95% CI 0.15 to 0.56).[21](https://onlinelibrary.wiley.com/doi/10.1155/2020/7242969) A broader meta-analysis by Randy C. Bowen and colleagues in 2018 compared cefuroxime, moxifloxacin, and vancomycin directly.[22](https://doi.org/10.1136/bjophthalmol-2017-311051) After posterior capsular rupture, a meta-analysis of 9 studies with 153,690 patients found intracameral antibiotics still reduced endophthalmitis (OR 0.41; 95% CI 0.26 to 0.65; [number needed to treat](https://www.edgepedia.org/number-needed-to-treat) 874).[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC12928780/) A selective strategy can also work: the Rotterdam Eye Hospital achieved about 0.03% endophthalmitis across 56,598 procedures (2016 to 2022) using 1% povidone-iodine with antibiotics given only after posterior capsular rupture.[23](https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2820065) A Brazilian university hospital that introduced routine preservative-free moxifloxacin 0.5 mg in January 2019 significantly reduced endophthalmitis across 21,178 surgeries (2014 to 2023) without increasing bacterial resistance.[24](https://link.springer.com/article/10.1186/s40942-026-00845-y) The 2024 ESCRS recommendations state that intracameral antibiotic therapy should be used because it is effective and safe, with a specific recommendation for cefuroxime 1 mg in 0.1 mL at the end of surgery (GRADE +++).[7](https://escrs.org/media/ooama3sf/european-society-of-cataract-and-refractive-surgeons-recommendations-for-cataract-surgery-2024-executive-summary.pdf)
## Limitations and alternatives
**Availability and cost.** No FDA-approved intracameral cefuroxime product exists in the United States, so cefuroxime must be reconstituted from powder or obtained from a compounding pharmacy.[6](https://pmc.ncbi.nlm.nih.gov/articles/PMC6258587/) Aprokam (cefuroxime 50 mg powder for solution) is one of at least two commercially available, government-approved intracameral formulations in Europe, alongside Ximaract, a single-use cefuroxime vial approved in the UK; commercial moxifloxacin exists only in India, and no commercial intracameral vancomycin formulation exists anywhere.[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC12928780/) Prophylactic cefuroxime is nonetheless cost-effective, with an incremental cost-effectiveness ratio of €2427 per QALY.[7](https://escrs.org/media/ooama3sf/european-society-of-cataract-and-refractive-surgeons-recommendations-for-cataract-surgery-2024-executive-summary.pdf)
**Toxicity.** Excessive cefuroxime can cause macular edema, retinal vascular leakage or infarction, uveitis, and toxic anterior segment syndrome (TASS), a sterile inflammatory reaction characterized by Nick Mamalis, Henry F. Edelhauser, and colleagues in 2006.[6](https://pmc.ncbi.nlm.nih.gov/articles/PMC6258587/) • [25](https://doi.org/10.1016/j.jcrs.2006.01.065) Toxicity affecting visual acuity was detected in nearly 3% of 503 analyzed cefuroxime cases, mostly attributed to local dilution errors.[23](https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2820065) Intracameral vancomycin is associated with hemorrhagic occlusive retinal vasculitis (HORV), possibly dose-dependently; the syndrome affected 11 eyes of 6 patients, a registry added 16 more cases, and American and international guidelines now advise against routine prophylactic vancomycin.[16](https://www.ovid.com/jnls/jcrs/fulltext/10.1016/j.jcrs.2016.11.007~intraocular-antibiotics-during-cataract-surgery-risks-and) • [24](https://link.springer.com/article/10.1186/s40942-026-00845-y)
**Compared with alternatives.** Preoperative povidone-iodine remains the only measure supported by level I evidence other than the cefuroxime trial itself.[6](https://pmc.ncbi.nlm.nih.gov/articles/PMC6258587/) Recent retrospective studies and meta-analyses find intracameral preservative-free topical fluoroquinolones equal or superior to cefuroxime in efficacy with comparable safety.[9](https://www.dovepress.com/systematic-review-of-clinical-practice-guidelines-forpost-cataract-sur-peer-reviewed-fulltext-article-OPTH) A 2025 double-blind randomized pilot study of 50 patients found intracameral levofloxacin (0.1 mL/0.5 mg) had a safety profile comparable to intracameral cefazolin (0.1 mL/1 mg), with no endophthalmitis cases in either group, and may suit penicillin-allergic patients while avoiding reconstitution errors.[26](https://www.nature.com/articles/s41598-025-17553-6)
## References
1. [Intracameral Drug Delivery: A Review of Agents, Indications, and Outcomes](https://pubmed.ncbi.nlm.nih.gov/36757304/)
2. [Use of intracameral antibiotics prophylaxis in patients with posterior capsular rupture during cataract surgery: systematic review and meta-analysis](https://pmc.ncbi.nlm.nih.gov/articles/PMC12928780/)
3. [Prophylaxis of postoperative endophthalmitis following cataract surgery: Results of the ESCRS multicenter study and identification of risk factors (2007)](https://strathprints.strath.ac.uk/3443/)
4. [ESCRS Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery (2018 update)](https://www.escrs.org/media/uljgvpn1/english_2018_updated.pdf)
5. [Comparison between intracameral moxifloxacin administration methods by assessing intraocular concentrations and drug kinetics (Matsuura et al., Graefes Arch Clin Exp Ophthalmol 2013)](https://link.springer.com/article/10.1007/s00417-013-2294-7)
6. [The Routine Use of Intracameral Antibiotics to Prevent Endophthalmitis After Cataract Surgery: How Good is the Evidence?](https://pmc.ncbi.nlm.nih.gov/articles/PMC6258587/)
7. [European Society of Cataract and Refractive Surgeons Recommendations for Cataract Surgery 2024: Executive Summary](https://escrs.org/media/ooama3sf/european-society-of-cataract-and-refractive-surgeons-recommendations-for-cataract-surgery-2024-executive-summary.pdf)
8. [Mydrane SmPC (Summary of Product Characteristics)](https://www.medicines.org.uk/emc/product/7254/smpc)
9. [Systematic review of clinical practice guidelines for post-cataract surgery endophthalmitis prophylaxis](https://www.dovepress.com/systematic-review-of-clinical-practice-guidelines-forpost-cataract-sur-peer-reviewed-fulltext-article-OPTH)
10. [Kazuki Matsuura and colleagues (2012). Bag and chamber flushing: a new method of using intracameral moxifloxacin to irrigate the anterior chamber and the area behind the intraocular lens. Graefe s Archive for Clinical and Experimental Ophthalmology.](https://doi.org/10.1007/s00417-012-2098-1)
11. [Steve A. Arshinoff, Milad Modabber (2016). Dose and administration of intracameral moxifloxacin for prophylaxis of postoperative endophthalmitis. Journal of Cataract & Refractive Surgery.](https://doi.org/10.1016/j.jcrs.2016.10.017)
12. [Neal H. Shorstein, Susanne Gardner (2019). Injection volume and intracameral moxifloxacin dose. Journal of Cataract & Refractive Surgery.](https://doi.org/10.1016/j.jcrs.2019.04.020)
13. [Factors Influencing Adoption: Intracameral Antibiotics and Steroids (CRST Europe)](https://crstodayeurope.com/topics/general/factors-influencing-adoption-intracameral-antibiotics-and-steroids/47551/)
14. [Prophylactic intracameral cefuroxime (Journal of Cataract & Refractive Surgery, 2002)](https://doi.org/10.1016/s0886-3350%2801%2901269-x)
15. [ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study](https://europepmc.org/article/MED/16631047)
16. [Intraocular antibiotics during cataract surgery: Risks and benefits (Srinivasan, J Cataract Refract Surg 2016 editorial)](https://www.ovid.com/jnls/jcrs/fulltext/10.1016/j.jcrs.2016.11.007~intraocular-antibiotics-during-cataract-surgery-risks-and)
17. [Marc Labetoulle and colleagues (2015). Evaluation of the efficacy and safety of a standardised intracameral combination of mydriatics and anaesthetics for cataract surgery. British Journal of Ophthalmology.](https://doi.org/10.1136/bjophthalmol-2015-307587)
18. [David F. Chang, John R. Campbell (2005). Intraoperative floppy iris syndrome associated with tamsulosin. Journal of Cataract & Refractive Surgery.](https://doi.org/10.1016/j.jcrs.2005.02.027)
19. [Aravind Haripriya and colleagues (2015). Efficacy of Intracameral Moxifloxacin Endophthalmitis Prophylaxis at Aravind Eye Hospital. Ophthalmology.](https://doi.org/10.1016/j.ophtha.2015.09.037)
20. [Intracameral antibiotic prophylaxis: Where do we stand?](https://www.healio.com/news/ophthalmology/20241120/intracameral-antibiotic-prophylaxis-where-do-we-stand)
21. [The Anterior Chamber Injection of Moxifloxacin Injection to Prevent Endophthalmitis after Cataract Surgery: A Meta-analysis](https://onlinelibrary.wiley.com/doi/10.1155/2020/7242969)
22. [Randy C Bowen and colleagues (2018). Comparative analysis of the safety and efficacy of intracameral cefuroxime, moxifloxacin and vancomycin at the end of cataract surgery: a meta-analysis. British Journal of Ophthalmology.](https://doi.org/10.1136/bjophthalmol-2017-311051)
23. [Prophylactic Intracameral Antibiotics and Endophthalmitis After Cataract Surgery](https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2820065)
24. [Intracameral antibiotic prophylaxis and surgical expertise: key determinants in endophthalmitis after cataract surgery](https://link.springer.com/article/10.1186/s40942-026-00845-y)
25. [Nick Mamalis and colleagues (2006). Toxic anterior segment syndrome. Journal of Cataract & Refractive Surgery.](https://doi.org/10.1016/j.jcrs.2006.01.065)
26. [A double-blind, randomized controlled pilot study comparing the safety of intracameral levofloxacin and intracameral cefazolin in patients undergoing cataract surgery](https://www.nature.com/articles/s41598-025-17553-6)
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*Topic: Encyclopedia › Life and health › Human health and medicine › Clinical assessment and procedures › Surgery and surgical specialties › Ophthalmic surgery procedures*
*Initially written Sep 29, 2026 · Edited: Oct 15, 2026; Oct 21, 2026*
*Copyright 2026 EdgeChat AI, a subsidiary of Biostate AI.*
License: Edgepedia Community License 1.0, https://www.edgepedia.org/edgepedia/license