CORRESPONDENCE
Prospective comparative evaluation
of povidoneiodine (10% for 5 minutes
versus 5% for 1 minute) as prophylaxis
for ophthalmic surgery
Christopher N. Ta, MD, Kuldev Singh, MD,
Peter R. Egbert, MD, Herminia Mino de Kaspar, PhD
Postoperative endophthalmitis is a rare but poten-
tially severe complication of intraocular surgery. The
incidence of endophthalmitis after cataract and glau-
coma surgery is 0.082% and 0.124%, respectively.1
The goal of antisepsis is to eliminate or greatly reduce
the number of microorganisms in the surgical field at
the time of surgery. The eyelids and conjunctiva are
considered the most common sources of bacteria lead-
ing to endophthalmitis.2,3 Decreasing the bacterial
load in the ocular region should reduce the risk for
postoperative endophthalmitis.
Povidoneiodine is an effective antiseptic agent.414
Studies demonstrate that povidoneiodine 5% is safe
and effective in reducing the number of bacteria on
the ocular surface at the time of surgery.4,15 In one
study,4 1 to 2 drops of povidoneiodine 5% placed
on the eye reduced the number of bacteria by 91%.
Two reports5,6 describe the safety of povidoneiodine
10% when used in the periorbital area. The goal of our
study was to determine whether povidoneiodine
10% applied for a longer time was relatively more
effective than povidoneiodine 5%.
PATIENTS AND METHODS
After approval for the prospective randomized study
was obtained from the Institutional Review Board at
Stanford University, appropriate informed consent
was obtained from each patient having a cataract,
glaucoma, or penetrating keratoplasty procedure.
Patients with active ocular infections were excluded.
Patients were randomized to 2 methods of povi-
doneiodine application. In the standard group, the
brow, upper and lower eyelids, eyelashes, and adja-
cent forehead, nose, cheek, and temporal orbital area
were scrubbed with povidoneiodine 5% for 1 minute.
In the intense povidoneiodine group, a gauze pad
soaked in povidoneiodine 10% was placed over the
closed eye for 5 minutes followed by the standard
povidoneiodine (povidoneiodine 5% scrub in the
periorbital area for 1 minute). In addition to the perior-
bital scrub, 2 drops of povidoneiodine 5% were
placed in the inferior fornix of all eyes in both groups.
All eyes also received topical ofloxacin 1 hour before
surgery.
Conjunctival cultures were obtained from the oper-
ated eye using a cotton swab moistened with thiogly-
colate broth and immediately inoculated into this
Q 2008 ASCRS and ESCRS
Published by Elsevier Inc.
medium. Cultures were then obtained at the following
times: baseline (before antibiotic or povidoneiodine
application), immediately before surgery (after
antibiotic or povidoneiodine application), and after
surgery (at the conclusion of the procedure).
Aqueous fluid was aspirated from the anterior
chamber using a blunt cannula via a paracentesis site
just before the conclusion of the surgical procedure.
The samples were immediately inoculated into aerobic
and anaerobic blood culture media. All cultures were
incubated at 37 C for at least 10 days.
To have a power of 80%, using a binomial sample-
size calculation with a difference in the proportion of
patients with positive cultures estimated to be 20%
and an a-error of 0.05, 19 patients were required.
RESULTS
Thirty-nine patients participated in the study. After
randomization, 20 patients were in the standard group
and 19 in the intense povidoneiodine group. Eleven
conjunctival samples from each group were positive
for bacteria at baseline, before the application of anti-
biotic or povidoneiodine (P Z .8880).
There was no significant between-group difference
in the percentage of eyes with positive bacterial
growth in the preoperative and postoperative
cultures. Before surgery, 7 eyes (35%) in the standard
group and 8 eyes (42%) in the intense povidoneiodine
group had positive cultures (P Z .8992). After surgery,
35% and 26%, respectively, had positive cultures
(P Z .8101). The results are summarized in Table 1.
Aqueous samples were obtained from the anterior
chamber at the conclusion of surgery in 32 of the 39
patients. In 7 cases, the anterior chamber aspirate
had inadequate volume for culture. In the standard
group, 3 (18%) of the 17 available samples were posi-
tive for bacteria compared with 3 (20%) of the 15 avail-
able samples in the intense povidoneiodine group
(P Z .7767).
DISCUSSION
The most common sources of ocular bacterial contam-
ination leading to postoperative endophthalmitis are
eyelid, skin, and conjunctiva.2,3 Minimizing the num-
ber of bacteria on the eyelids and conjunctiva may re-
duce the risk for endophthalmitis. When placed on the
eye preoperatively, 1 to 2 drops of povidoneiodine
5% reduce bacterial counts by 91%.4 Despite the use
of povidoneiodine and prophylactic antibiotic
agents, up to 43% of eyes having anterior segment
surgical procedures develop aqueous humor contami-
nation.13,1621 One can postulate that a higher con-
centration of povidoneiodine or longer duration of
application may reduce the contamination rate of the
0886-3350/08/$dsee front matter 171
doi:10.1016/j.jcrs.2007.08.035
172 CORRESPONDENCE
Table 1. The proportion of patients with positive conjunctival
cultures.
Before After
Number Baseline, Surgery, Surgery,
Group of Patients n (%) n (%) n (%)
Standard PVI 20 11 (55) 7 (35) 7 (35)
Intense PVI 19 11 (58) 8 (42) 5 (26)
P value* d .8880 .8992 .8101
After Surgery Z at the conclusion of surgery; Baseline Z before applica-
tion of antibiotic agent or iodine; Before Surgery Z just before surgery
(after application of antibiotic agent or iodine); PVI Z povidoneiodine
*Comparison of control and study groups
conjunctiva and aqueous humor before surgery. We
designed a study to determine whether increasing the
concentration and duration of application of povi-
doneiodine would reduce conjunctival bacterial flora
and the rate of aqueous humor bacterial contamination.
In the current study population and in the setting of
using topical ofloxacin application, povidoneiodine
10% for 5 minutes was no better than povidoneiodine
5% for 1 minute. Results of conjunctival cultures re-
vealed no difference between the standard and intense
povidoneiodine groups. Furthermore, there was no
significant between-group difference in the rates of
aqueous humor contamination at the conclusion of
surgery.
Povidoneiodine at 5% concentration effectively
reduces the bacterial population of the conjunctiva in
preparation for intraocular surgery.4,711,14,15 Our
study suggests that when adjunctive ofloxacin is
used, a higher concentration of povidoneiodine
(10%) applied for a longer time does not result in
a greater reduction in bacteria than povidoneiodine
5%. Given the potential surface toxicity and additional
time required with the povidoneiodine 10% for
a 5-minute technique, the current study indicates that
using povidoneiodine 5% for a 1-minute technique is
quicker, less toxic, and equally effective.
REFERENCES
1. Aaberg TM Jr, Flynn HW Jr, Schiffman J, Newton J. Nosocomial
acute-onset postoperative endophthalmitis survey; a 10-year
review of incidence and outcomes. Ophthalmology 1998;
105:10041010
2. Bannerman TL, Rhoden DL, McAllister SK, et al. The source of
coagulase-negative staphylococci in the Endophthalmitis Vitrec-
tomy Study; a comparison of eyelid and intraocular isolates
using pulsed-field gel electrophoresis; the Endophthalmitis
Vitrectomy Study Group. Arch Ophthalmol 1997; 115:357361
3. Speaker MG, Milch FA, Shah MK, et al. Role of external bacterial
flora in the pathogenesis of acute postoperative endophthalmi-
tis. Ophthalmology 1991; 98:639649; discussion by J Baum,
650
J CATARACT REFRACT SURG - VOL 34, JANUARY 2008
4. Apt L, Isenberg S, Yoshimori R, Paez JH. Chemical preparation
of the eye in ophthalmic surgery. III: effect of povidone-iodine on
the conjunctiva. Arch Ophthalmol 1984; 102:728729
5. Binder CA, Mino de Kaspar H, Engelbert M, et al. Bakterielle
Keimbesiedelung der Konjunktiva mit Propionibacterium
acnes vor und nach Polyvidon-Jod-Applikation vor intraokula-
ren Eingriffen. [Colonization of the conjunctiva with Propioni-
bacterium acnes before and after application of povidone
iodine before intraocular surgery.] Ophthalmologe 1988;
95:438441
6. Binder C, Mino de Kaspar H, Klau V, Kampik A. Praoperative
Infektionsprophylaxe mit 1%iger Polyvidon-Jod-Losung am Bei-
spiel von konjunktivalen Staphylokokken. [Preoperative infec-
tion prophylaxis with 1% polyvidone-iodine solution based on
the example of conjunctival staphylococci.] Ophthalmologe
1999; 96:663667
7. Caldwell DR, Kastl PR, Cook J, Simon J. Povidone-iodine: its
efficacy as a preoperative conjunctival and periocular prepara-
tion. Ann Ophthalmol 1984; 16:577, 580
8. Dereklis DL, Bufidis TA, Tsiakiri EP, Palassopoulos SI. Preoper-
ative ocular disinfection by the use of povidone-iodine 5%. Acta
Ophthalmol (Copenh) 1994; 72:627630
9. Grimes SR, Mein CE, Trevino S. Preoperative antibiotic and
povidone-iodine preparation of the eye. Ann Ophthalmol 1991;
23:263266
10. Hale LM. Povidone-iodine in ophthalmic surgery. Ophthalmic
Surg 1970; 1(5):913
11. Isenberg SJ, Apt L, Yoshimori R, Khwarg S. Chemical prepara-
tion of the eye in ophthalmic surgery. IV. Comparison of povi-
done-iodine on the conjunctiva with a prophylactic antibiotic.
Arch Ophthalmol 1985; 103:13401342
12. Rodeheaver G, Bellamy W, Kody M, et al. Bactericidal activity
and toxicity of iodine-containing solutions in wounds. Arch
Surg 1982; 117:181186
13. Mendvil Soto A, Mendvil MP. The effect of topical povidone-
iodine, intraocular vancomycin, or both on aqueous humor
cultures at the time of cataract surgery. Am J Ophthalmol
2001; 131:293300
14. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with
topical povidone-iodine. Ophthalmology 1991; 98:17691775
15. Mino de Kaspar H, Chang RT, Singh K, et al. Prospective
randomized comparison of 2 different methods of 5% povi-
done-iodine applications for anterior segment intraocular
surgery. Arch Ophthalmol 2005; 123:161165
16. Dickey JB, Thompson KD, Jay WM. Anterior chamber aspirate
cultures after uncomplicated cataract surgery. Am J Ophthalmol
1991; 112:278282
17. John T, Sims M, Hoffmann C. Intraocular bacterial contamina-
tion during sutureless, small incision, single-port phacoemulsifi-
cation. J Cataract Refract Surg 2000; 26:17861791
18. Mistlberger A, Ruckhofer J, Raithel E, et al. Anterior chamber
contamination during cataract surgery with intraocular lens
implantation. J Cataract Refract Surg 1997; 23:10641069
19. Ariyasu RG, Nakamura T, Trousdale MD, Smith RE. Intrao-
perative bacterial contamination of the aqueous humor. Oph-
thalmic Surg 1993; 24:367373; commentary by J Baum,
373374
20. Samad A, Solomon LD, Miller MA, Mendelson J. Anterior cham-
ber contamination after uncomplicated phacoemulsification and
intraocular lens implantation. Am J Ophthalmol 1995; 120:
143150
21. Tervo T, Ljungberg P, Kautiaimen T, et al. Prospective evalua-
tion of external ocular microbial growth and aqueous humor con-
tamination during cataract surgery. J Cataract Refract Surg
1999; 25:6571