The Rising Importance of Antiseptics in Ophthalmology: From Endophthalmitis Prevention to Treatment of Ocular Infections

Postoperative endophthalmitis (POE) is a rare but severe intraocular infection that can lead to irreversible vision loss if not promptly and adequately treated. This condition occurs when infecting organisms enter the eye through direct inoculation, such as during intraocular surgery, penetrating trauma, or contiguous spread from adjacent tissues. The risk of infection has also increased with the growing use of intravitreal pharmacotherapy, such as treatments with antivascular endothelial growth factor agents. Sources of infection in POE include bacteria colonized on the patient's eyelid margin and conjunctiva, healthcare personnel, surgical instruments, solutions, and intraocular lenses. Microbial trends indicate that Staphylococcus epidermidis (S. epidermidis) and unspecified coagulase-negative Staphylococci (CoNS) are the most prevalent pathogens. Fungal endophthalmitis, commonly caused by Candida albicans, primarily affects patients who are immunocompromised, including those with human immunodeficiency virus (HIV), malignancies, diabetes mellitus, immunosuppressive medication or intravenous drug use, solid organ transplantation, lung disease, and renal insufficiency. The management of POE relies on the prompt initiation of appropriate empirical antibiotic therapy targeting the most common causative organisms. However, antimicrobial resistance (AMR) has become one of the most pressing global health challenges, with the World Health Organization (WHO) recognizing AMR as one of the top ten global public health threats. The goal is to ensure the judicious use of antibiotics while preventing AMR development. A critical preventive strategy in ophthalmology is the use of antiseptics before interventional eye procedures. Studies have shown that the application of effective antiseptic agents—such as povidone-iodine (PVP-I), chlorhexidine (CHX), hypochlorous acid (HOCl), polyhexamethylene biguanide (PHMB), and picloxydine dihydrochloride can significantly reduce the incidence of postoperative infections, thereby minimizing the risk of endophthalmitis. This article reviews the importance, effectiveness, and benefits of preoperative antiseptic use in ophthalmology, emphasizing their role in preventing infections without encouraging antibiotic resistance. In addition to their preventive role, it also examines the potential therapeutic applications of these same agents in the management of ocular infections.