Intracameral Drugs in Cataract Surgery: Moxifloxacin, Cefuroxime, Adrenaline, Lignocaine and Mydrane, With Dilution Safety
Last updated: November 2026
Drugs injected into the anterior chamber reach the corneal endothelium and, through the pupil, the retina. They must be the right drug, the right dose, preservative-free and correctly diluted. Most serious problems with intracameral drugs come from preparation errors, not from the drug itself. This page covers antibiotics for endophthalmitis prophylaxis, drugs for pupil dilation and anaesthesia, and miotics.
Golden rules: use products made for intracameral use when available; otherwise preservative-free and (for adrenaline) bisulfite-free preparations only. One person prepares and labels, a second checks. Never draw intracameral drugs from multi-dose bottles. Discard leftovers.
Antibiotics for endophthalmitis prophylaxis
| Drug | Dose | How it is prepared | Notes |
|---|---|---|---|
| Cefuroxime | 1 mg in 0.1 mL | Commercial intracameral product (e.g. 50 mg vial reconstituted with 5 mL saline gives 10 mg/mL; inject 0.1 mL) | Used in the ESCRS study, which showed a large fall in endophthalmitis. Avoid in cephalosporin allergy. Overdose (e.g. 10× from a dilution error) causes macular oedema and retinal toxicity |
| Moxifloxacin | Commonly 100–500 µg (0.1 mL of 0.5% = 500 µg; diluted forms deliver about 150–250 µg) | Preservative-free 0.5% moxifloxacin (some use the ophthalmic drop formulation off-label; intracameral products are available in India) | Widely used in India (AIIMS and Aravind practice). Diluted forms are easier to dose safely in routine cases; higher doses may be chosen after posterior capsule rupture |
| Vancomycin | Not recommended | — | Linked to haemorrhagic occlusive retinal vasculitis (HORV), which can be blinding |
After posterior capsule rupture with vitreous loss, dosing still follows the same product limits; check your unit protocol before increasing the dose.
Drugs for pupil dilation and anaesthesia
| Preparation | Composition | Use |
|---|---|---|
| Preservative-free lignocaine 1% | 2% preservative-free lignocaine diluted 1:1 with BSS (0.5 mL + 0.5 mL) | Anaesthesia and some pupil dilation under topical anaesthesia; 0.1–0.5 mL in the chamber |
| Epi-Shugarcaine | 9 mL BSS Plus (or BSS) + 3 mL 4% preservative-free lignocaine + 4 mL 1:1000 preservative-free, bisulfite-free adrenaline | About 0.75% lignocaine with 1:4000 adrenaline; dilates a poorly dilated pupil and helps floppy iris (IFIS) |
| Adrenaline in the irrigating bottle | Preservative-free adrenaline added to the BSS bottle (unit protocol, e.g. 0.3–0.5 mL of 1:1000 in 500 mL) | Keeps the pupil dilated during surgery |
| Mydrane (Théa) | Tropicamide 0.02%, phenylephrine 0.31%, lidocaine 1%; 0.2 mL | Commercial intracameral mydriatic and anaesthetic at the start of surgery |
| Phenylephrine and ketorolac (Omidria) | Added to the irrigating solution | Maintains dilation and reduces pain; not widely available in India |
Adrenaline caution: bisulfite preservative is toxic to the endothelium. If only bisulfite-containing adrenaline is available, the ASCRS advises diluting it at least 1:4 with BSS (about 1:4000) or adding it only to the irrigating bottle. Do not use formulations labelled "not for ophthalmic use".
Miotics
| Drug | Use | Notes |
|---|---|---|
| Acetylcholine 1% (Miochol-E) | Rapid miosis within seconds; short acting | Reconstitute just before use |
| Carbachol 0.01% (Miostat) | Slower, longer miosis; also lowers early postoperative IOP | Use the intraocular product, never topical carbachol |
Other intracameral drugs
- Triamcinolone: a small amount of preservative-free triamcinolone stains vitreous in the chamber after capsule rupture. See dyes and triamcinolone.
- Trypan blue 0.06%: capsule staining in white or brunescent cataracts.
- Dexamethasone intracameral implants and steroid suspensions are used in some units to reduce postoperative drops.
When preparation goes wrong
| Problem | Typical cause | Result |
|---|---|---|
| Toxic anterior segment syndrome (TASS) | Wrong concentration, preservatives, detergent or endotoxin residue on instruments, wrong pH or osmolarity | Diffuse limbus-to-limbus corneal oedema and anterior chamber reaction within 12–24 hours, sterile |
| Toxic retinopathy and macular infarction | Antibiotic overdose (e.g. cefuroxime 10× from a dilution error) | Severe, sometimes permanent vision loss |
| HORV | Intracameral vancomycin | Retinal haemorrhages and vascular occlusion days later |
Safe preparation checklist
- Confirm the drug, strength and route on the label: "for intracameral use" or preservative-free.
- Use a fresh sterile syringe and filter needle as your protocol requires; prepare on a separate tray.
- Write the drug and dose on the syringe immediately.
- Second person reads the label and checks the calculation.
- Inject slowly at the end of surgery through the side port; check the wound seals.
- Record drug, dose, batch and time in the operation note.
Pearls
- Prepare intracameral drugs on a separate, clearly labelled tray, never next to the topical bottles.
- Cefuroxime is 1 mg in 0.1 mL: a ten-fold error is easy with home-made dilutions, so use commercial intracameral products.
- For adrenaline, preservative-free and bisulfite-free is the rule.
Common mistakes
- Drawing intracameral drugs from a multi-dose bottle.
- Using intracameral vancomycin.
- Using topical carbachol drops inside the eye.
Test yourself: flip cards
Quick quiz
Related: Sutures, Needles and Sterilisation in the Eye Theatre, Phacoemulsification Step by Step: A Beginner's Guide, Cataract Pre-operative Risk Checklist: Spot the Difficult Case, IOL Injectors and Cartridges for Residents: Alcon A, B, C, D, Preloaded Systems, J&J Unfolder, Zeiss, Medicel and Indian Lenses, Anaesthesia for Eye Surgery: Drops, Local Block, Sedation and General.
Key sources
- ESCRS Endophthalmitis Study Group. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study. J Cataract Refract Surg. 2007;33:978-988
- ASCRS Clinical Committee. Intraocular use of epinephrine to maintain mydriasis (December 2017)
- Haripriya A, et al. Intracameral moxifloxacin to prevent endophthalmitis after cataract surgery (Aravind). Ophthalmology. 2017;124:768-775
- Arshinoff SA. Intracameral moxifloxacin: should we dilute it? ESCRS 2024 poster PO409
- Witkin AJ, et al. Vancomycin-associated hemorrhagic occlusive retinal vasculitis. Ophthalmology. 2017;124:583-595
- Cataract Coach. Review: intracameral medications (2020)
📘 Want more exam-ready material? See Most Commons in Ophthalmology on Kindle, or browse all my books.
Looking for an eye specialist in Ahmedabad? Cataract surgery at Sadbhaav or book a consultation with Dr. Dhaval Patel.