Ahead of Print

Introduction

Topical antibiotic ointments are the current standard of care for many oculoplastic surgeons worldwide to reduce the risk of surgical site infection (SSI).¹ However, their regular use has been called into question. Concerns regarding antimicrobial resistance have grown worldwide promoting a culture of stringent antimicrobial stewardship.²

There is increasing evidence in non-oculoplastic surgical specialties to discourage the routine use of topical antibiotic ointments which has resulted in a decrease in their use.^3‑7 However, there is a paucity of literature specific to oculoplastic surgery and it may be difficult to extrapolate data from other surgical sites due to potential differences in: wound care, wound healing and infection rates, anatomy and outcomes following infection.^8-12

In addition to balancing the risk of SSI with antimicrobial resistance, there are other considerations in post-operative wound care, including adverse reactions to antibiotic ointments and cost. Topical antibiotic ointments available in different countries vary, and these include bacitracin, chloramphenicol, tobramycin, ciprofloxacin, erythromycin, and gentamicin, in addition to some combination ointments such as Kenacomb (gramicidin, neomycin, nystatin, triamcinolone acetonide).¹³ While there is a scarcity of literature with regard to specific patterns of use in oculoplastic surgery, topical chloramphenicol ointment has historically been utilised more frequently for wound care in Australia and the United Kingdom, and has been avoided in the United States due to the remote risk of aplastic anaemia.^14,15

The purpose of this study was to systematically review the literature to determine whether the use of topical antibiotic ointment reduces SSI in oculoplastic surgery, and to provide guidelines on the ongoing use of topical antibiotic ointment.

Methods

We performed a systematic review of the literature according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement.¹⁶ The protocol of this review was registered on PROSPERO with the ID: CRD420251008870.¹⁷

Studies were included if they: investigated patients undergoing oculoplastic procedures with primary wound closure and, compared topical antibiotic ointments with either an antibiotic-free ointment or no ointment. No restriction was placed on immune status of patients as long as they did not have active infections. Both randomised and non-randomised comparative studies were included. Examples of included oculoplastic procedures were blepharoplasty, browplasty, external transcutaneous dacryocystorhinostomy, ectropion repair, entropion repair, wedge excision, eyelid lesion removal, tarsorrhaphy, Mohs surgery, ptosis repair including anterior approach levator resection, and orbitotomy, including transcutaneous orbital surgery.

Studies were excluded if they: did not include explicit data for oculoplastic procedures (even if some oculoplastic procedures were included), investigated transconjunctival or corneal surgery, investigated cataract or other intra-ocular procedures, investigated wounds left to heal by secondary intention, investigated topical eye drops, compared topical antibiotic ointments with another antibiotic (either topical or systemic), did not contain any comparator or, investigated patients with active infections. Review articles, case-series and case-reports, as well as conference abstracts were also excluded.

Articles were sourced from OVID Medline, CINAHL, PubMed, SCOPUS, and Web of Science. The final searches were completed on 12 March 2025. The following search strategy was used: (oculoplastic OR oculofacial OR eyelid OR periorbital OR periocular) AND (surg* OR blepharoplasty OR browplasty OR dacryocystorhinostomy OR ectropion OR entropion OR wedge OR tarsorrhaphy OR orbitotomy OR Mohs OR ptosis) AND (topical) AND (antibiotic OR antimicrob* OR chloramphenicol OR ointment OR bacitracin) AND (infection). We searched for additional studies using the bibliographies of included and similar articles. The final search results were imported to Covidence^®, a systematic review management tool, where duplicates were removed.¹⁸

The article titles and abstracts were screened independently by two reviewers (AJS and SAS) conflicts were resolved through discussion. Full texts were screened independently by two reviewers (AJS and SAS) and conflicts were resolved through discussion. Final full texts were then collated for data extraction.

Included studies were assessed independently for risk of bias by two reviewers (AJS and SAS) using the Cochrane ROB-2 tool for RCTs and the Newcastle-Ottawa Scale for non-randomised studies.^19,20 Heterogeneity of the included studies precluded the aggregation of results for quantitative analysis. Thus, studies were analysed qualitatively according to the domains of the data-extraction tool.

Results

Description of included studies

As seen in the PRISMA flow chart (Figure 1), 603 non-duplicate studies were available for screening. 581 studies were excluded after the title/abstract screening process. 18 studies were excluded after full text review. The remaining four studies were included for analysis.

 

Figure 1 Outline of study selection

 

Of the four included studies, one was a randomised controlled trial (RCT) and three were observational studies. Table 1 provides a description of the included studies.

 

Table 1. Description of included studies.

 

Risk of bias

Randomised studies

The Cochrane ROB-2 tool was used to assess risk of bias in the single RCT (Figure 2).^19,21 This study had some concerns for risk of bias for three reasons. Firstly, there were potential deviations from intended investigations. Neither participants nor people delivering interventions were blinded and no information regarding compliance was made available. Secondly, there was some concern for bias in measurement of outcomes. Investigators were not blinded and, although unlikely given reasonably clear definition of SSI, knowledge of intervention could have affected judgement. Thirdly, multiple choices were available to surgeons regarding antibiotic and non-antibiotic ointments, introducing potential for confounding.

 

Figure 2. Risk of bias summary for RCTs using the Cochrane RoB 2 tool¹⁹

 

Non-randomised studies

The Newcastle-Ottawa Scale was used to assess risk of bias for the three non-randomised studies (Table 2).^20,22‑24 Overall, the non-randomised studies were fair to good quality. The primary concern for all three studies was in the comparability between the two groups. Dupré et al used different ointments by country, with tobramycin, ciprofloxacin and vitamin A ointment only being used in France, while oxytetracycline with dexamethasone was used for all cases in Egypt and Tunisia.²² In the study by Alford, the differing time frames for each group may have led to confounding due to differences in surgeons as well as hospital protocols.²⁴ Likewise, in the study by Hunt et al there was a statistically significant difference in the seniority of the operating surgeon between groups.²³ This could produce bias in either direction—trainee-led cases might carry a higher risk of SSIs, or the predominance of trainees in the non-antibiotic group could reflect a simpler caseload with inherently lower SSI risk.

 

Table 2. Risk of bias for non-randomised studies using Newcastle-Ottawa Scale²⁰

 

Outcome measures

Table 3 describes the results of the included studies. Notably, all studies demonstrated lower rates of SSI in the topical antibiotic ointment group, with two studies demonstrating statistically significant differences between the two groups.

In the multicentre prospective cohort study on SSI in bilateral blepharoplasties by Alford, each patient for 15 months received topical bacitracin ointment twice daily for 7 days and then each patient for the subsequent 9 months received a non-antibiotic ocular ointment at the same dosage and duration.²⁴ The study was discontinued at this point due to high incidence of SSI in the non-antibiotic group (0.26% vs 6.33%, p-value<0.0001). Of the patients who developed SSI, all cultures grew Staphylococcus Aureus. All infections resolved with oral antibiotics but resulted in hypertrophic scarring along the incision. However, this result may be subject to bias as post-operative scar appearance was not assessed for all patients in a standardised manner. The authors were contacted but no correspondence was received regarding rates of adverse reactions to non-antibiotic ointment.

In the single-centre RCT by Ashraf et al there were no SSIs in the antibiotic ointment group while five patients developed SSI in the non-antibiotic ointment group.²¹ Of the five SSIs, four completely resolved following oral or topical antibiotics with favourable outcomes. One patient developed hypertrophic scarring which required two further surgeries. However, this result may be subject to bias as post-operative scar appearance was not assessed for all patients in a standardised manner. No statistically significant difference was seen regarding wound dehiscence or adverse reactions.

In the multinational retrospective cohort study by Dupré et al there was no statistically significant difference between the two groups regarding SSI.²² Additionally, all cases of SSI resolved following administration of systemic antibiotics with favourable outcomes. While subgroup-analysis, excluding the 83 patients who received intra-operative systemic antibiotics, was performed for the primary outcome of SSI, the same was not performed for secondary outcomes. Nonetheless, wound dehiscence was less likely in patients treated with antibiotic ointment compared to those treated with non-antibiotic ointment with statistical significance (1.46% versus 5.45%, p-value <0.001). No statistically significant difference was seen regarding adverse reactions.

In the single-centre retrospective cohort study by Hunt et al there was no statistically significant difference between the two groups regarding SSI.²³ This study compared patients who received Chloramphenicol ointment with those who received an appropriate dressing and no ointment. This was the only study in which the comparison group were not treated with an ointment post-operatively. Neither wound dehiscence nor adverse reactions were investigated in this study.

Discussion

Multiple previous systematic reviews and meta-analyses in other surgical specialities have been conducted regarding the use of topical antibiotic ointments after primary closure of wounds for prevention of SSI.^3,4,6,7 These have led to a shift in practice away from antibiotic ointments in low-risk surgery, with evidence either demonstrating no difference or a small, clinically insignificant difference between antibiotic ointment and non-antibiotic options. To our knowledge, this is the first systematic review to compare topical antibiotic ointments with non-antibiotic options in oculoplastic surgery. Due to the paucity and low quality of available literature, in addition to the heterogeneity of included studies, we were unable to provide universal guidelines similar to those for dermatologic surgery. Hence, a more nuanced approach is required, considering the factors favouring and opposing the use of antibiotic ointments, and applying these to individual cases.

Favouring topical antibiotic ointment use for post-operative wound care

In the present evaluation, all included studies demonstrated lower rates of SSI for the antibiotic ointment group, but only two studies demonstrated this effect with statistical significance. There are multiple aspects of oculoplastic surgery which may translate to a potential modest benefit of topical antibiotic ointments.

Firstly, while the NICE Guidelines discourage the use of topical antibiotic ointment for post-operative wound care, they recommend an “appropriate interactive dressing” for 48 hours post-surgery to prevent SSI.¹² In oculoplastic surgery, especially bilateral cases, this is often impractical due to vision loss. Wounds are typically left exposed, subject to blinking movements and contact. Secondly, eyelash and eyebrow hairs have been shown to harbour bacteria which could theoretically underlie a benefit seen with topical antibiotics.^25,26 Thirdly, multiple oculoplastic procedures include conjunctival defects. In the study by Hunt et al 12 of the 17 eyes which developed SSI had conjunctival breaches during the operation.²³ However, no information was provided regarding relative risk or statistical significance so this indication would need to be explored further. It is unknown to what extent surgical antiseptic preparation used for skin was also applied to the conjunctival surfaces.

Favouring non-antibiotic options for post-operative wound care

While the included studies did demonstrate lower rates of SSI for the antibiotic ointment group, there are multiple caveats that require consideration when translating this to clinical practice.

The findings presented by Alford warrant careful consideration.²⁴ The substantial increase in infection rate following a shift to non-antibiotic ointment is not observed in other studies included in this evaluation nor in broader literature. This raises the possibility that the results may be influenced by a confounding factor and may represent an outlier. Carefully considering the other included studies, the modest statistical benefit of antibiotic ointment may not correspond with a substantial clinical benefit as the difference was small and almost all SSIs resolved easily with either topical or systemic antibiotics.^21-23 This is in keeping with previous literature in other surgical specialities.^3,4,6,7

The risk of adverse reactions, including allergic and contact dermatitis, has contributed to the hesitancy in prescribing topical antibiotic ointments in other surgical specialities. The rate of allergic contact dermatitis following bacitracin ointment has been reported at approximately 8%.²⁷ Allergic contact dermatitis following chloramphenicol is reportedly lower; however, it has been associated with rare but severe adverse effects such as aplastic anaemia.^15,27 There is limited literature on adverse effects specifically related to the ophthalmic use of topical antibiotic ointments. Among the included studies that reported on this outcome, the incidence of allergic contact dermatitis was low, with no statistically significant difference between groups.^21,22

Additionally, there are increasing concerns for antimicrobial resistance to topical antibiotics, particularly in developing countries.^28,29 Bessa et al explored Staphylococcus aureus resistance patterns to topical antibiotics and found high levels of resistance to neomycin and bacitracin (42.6% and 100% respectively).²⁹ Comparatively, the Bale et al review demonstrated chloramphenicol resistance was frequently less than 20% for bacteria implicated in ocular infection.²⁸

Further considerations

There are multiple other considerations in appropriately managing post-operative periocular wounds. The use of a topical ointment, regardless of antibiotic content, may be beneficial in providing a moist wound healing environment. Additional benefits include ocular surface lubrication (where this may be considered favourable, such as following ptosis repair), reduced crusting and aiding suture removal. Cost may be another important factor when working in the resource-limited healthcare system. Chloramphenicol topical ointment is the most frequently used antibiotic ointment in our institution and is relatively inexpensive in comparison to a similar non-antibiotic product.

Strengths/limitations

This systematic review was conducted with a robust methodology, utilising a sensitive search strategy across multiple databases, with study selection, risk of bias assessment, and data extraction completed by two independent reviewers.

Limitations of this review are due to the included studies being heterogenous with concerns for bias. This made direct comparisons difficult and weakened recommendations. This is due to the diverse range of study settings, available antibiotic and non-antibiotic options, and procedures included in oculoplastic surgery. Secondly, the heterogeneity of included studies precluded the use of quantitative meta-analysis. Thirdly, this review lacked individual patient data. In addition to lacking granularity, this increased the difficulty of addressing confounding factors.

Recommendations

With rising concerns for antimicrobial resistance, stringent antibiotic prescribing is increasingly important. The present evaluation demonstrates that topical antibiotic ointments may have a modest statistical benefit in decreasing SSI. However, this difference may not be clinically significant. Non-antibiotic options, either petroleum-based ointments or appropriate dressings, are a reasonable choice for surgeons. However, there may still be a role for topical antibiotic ointments for wounds with granulating surfaces and potentially those with conjunctival defects, patients at high risk of SSI, or for patients in whom the sequelae of SSI would be unacceptable (such as patients with poor vision in the non-operated eye). Ultimately, this study highlights the paucity of high-quality literature specific to topical antibiotic ointments in oculoplastic surgery. Further research is required in the form of a high-quality, well powered RCT with a uniform antibiotic ointment and non-antibiotic options to minimise confounding.

Conclusions

This review systematically surveyed the literature to compare antibiotic ointments with non-antibiotic options in oculoplastic surgery. The present evaluation demonstrates that topical antibiotic ointments may have a modest statistical benefit in decreasing SSI. However, in translating this to clinical practice, it is necessary to consider individual patient and procedural factors, as well as the increasing concern for antimicrobial resistance. Both antibiotic ointments and non-antibiotic options may be appropriate in the right patient cohort. Given the paucity of high-quality literature, the authors encourage further research in the form of a well powered, methodologically robust RCT.

Author contribution

AJS: Writing (original draft), resources, project administration, methodology, investigation, formal analysis, data curation, conceptualisation.
SAS: Writing (original draft), data curation.
AJ: Writing (review & editing), supervision.
TGH: Writing (review & editing), supervision, conceptualisation

Conflict of interest

The authors declare no conflicts of interest

Ethics statement

An ethics statement is not applicable

Funding

The authors received no funding for this study

Author(s)

Alexander J Savage*¹, Simon A Savage², Angela James³, Thomas G Hardy^4-6
1Department of Surgery, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
²Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
³Department of Pharmacy, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
⁴Orbital, Plastic and Lacrimal Unit, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
⁵Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
⁶Centre for Eye Research Australia, East Melbourne, Victoria, Australia

*Corresponding author email alexsavage12@icloud.com

References

1. Fay A, Nallasamy N, Bernardini F, et al. Multinational comparison of prophylactic antibiotic use for eyelid surgery. JAMA Ophthalmology. 2015;133(7):778–784. doi:10.1001/jamaophthalmol.2015.0789
2. Aslam B, Khurshid M, Arshad MI, et al. Antibiotic resistance: one health one world outlook. Front Cell Infect Microbiol. 2021;11:771510. doi:10.3389/fcimb.2021.771510
3. Saco M, Howe N, Nathoo R, Cherpelis B. Topical antibiotic prophylaxis for prevention of surgical wound infections from dermatologic procedures: a systematic review and meta-analysis. J Dermatolog Treat. 2015;26(2):151–158. doi:10.3109/09546634.2014.906547
4. Chen PJ, Hua YM, Toh HS, Lee MC. Topical antibiotic prophylaxis for surgical wound infections in clean and clean-contaminated surgery: a systematic review and meta-analysis. BJS Open. 2021;5(6): zrab125. doi:10.1093/bjsopen/zrab125
5. Levender MM, Davis SA, Kwatra SG, Williford PM, Feldman SR. Use of topical antibiotics as prophylaxis in clean dermatologic procedures. J Am Acad Dermatol. 2012;66(3):445–451. doi:10.1016/j.jaad.2011.02.005
6. Tong QJ, Hammer KD, Johnson EM, Zegarra M, Goto M, Lo TS. A systematic review and meta-analysis on the use of prophylactic topical antibiotics for the prevention of uncomplicated wound infections. Infect Drug Resist. 2018;11:417–425. doi:10.2147/idr.S151293
7. Heal CF, Banks JL, Lepper P, Kontopantelis E, van Driel ML. Meta-analysis of randomized and quasi-randomized clinical trials of topical antibiotics after primary closure for the prevention of surgical-site infection. Br J Surg. 2017;104(9):1123–1130. doi:10.1002/bjs.10588
8. de Keizer ROB, Kozdras G, Wubbels R, Van den Bosch WA, Paridaens D. Retrospective study in 608 cases on the rate of surgical site infections after orbital surgery without prophylactic systemic antibiotics. Br J Ophthalmol. 2019;103(10):1466–1468. doi:10.1136/bjophthalmol-2018-312232
9. Doucet V, McKenzie M, Lee-Wing M, Bellan L. Infection rate following elective oculoplastic surgery in a minor procedure setting: a single-centre retrospective study. Can J Ophthalmol. 2023;58(1):34–38. doi:10.1016/j.jcjo.2021.07.003
10. Lee EW, Holtebeck AC, Harrison AR. Infection rates in outpatient eyelid surgery. Ophthalmic Plast Reconstr Surg. 2009;25(2):109–10. doi:10.1097/IOP.0b013e3181994124
11. Dulku S, Akinmade A, Durrani OM. Postoperative infection rate after dacryocystorhinostomy without the use of systemic antibiotic prophylaxis. Orbit. 2012;31(1):44–47. doi:10.3109/01676830.2011.569630
12. National Institute for Health and Care Excellence: Clinical Guidelines. Surgical site infections: prevention and treatment. National Institute for Health and Care Excellence; 2020.
13. Kenacomb Ointment. NPS MedicineWise. https://www.nps.org.au/medicine-finder/kenacomb-ointment#4.3-contraindications
14. Heal CF, Buettner PG, Cruickshank R, et al. Does single application of topical chloramphenicol to high risk sutured wounds reduce incidence of wound infection after minor surgery? Prospective randomised placebo controlled double blind trial. BMJ. 2009;338:a2812. doi:10.1136/bmj.a2812
15. Flach AJ. Fatal aplastic anemia following topical administration of ophthalmic chloramphenicol. Am J Ophthalmol. 1982;94(3):420–422. doi:10.1016/0002-9394(82)90378-6
16. Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. doi:10.1186/2046-4053-4-1
17. Schiavo JH. PROSPERO: An International Register of Systematic Review Protocols. Medical Reference Services Quarterly. 2019;38(2):171–180. doi:10.1080/02763869.2019.1588072
18. Covidence Systematic Review Software. Veritas Health Innovation, Melbourne, Australia. 2026. www.covidence.org
19. Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. doi:10.1136/bmj.l4898
20. Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
21. Ashraf DC, Idowu OO, Wang Q, et al. The role of topical antibiotic prophylaxis in oculofacial plastic surgery: a randomized controlled study. Ophthalmology. 2020;127(12):1747–1754. doi:10.1016/j.ophtha.2020.07.032
22. Dupré R, Baillif S, Lotte R, et al. Is topical antibiotic use necessary to prevent surgical site infection following oculoplastic surgery? Graefes Arch Clin Exp Ophthalmol. 2024;262(10):3331–3343. doi:10.1007/s00417-024-06489-8
23. Hunt S, Garrott H, Ford R. Bringing eyelid surgery in line with international guidelines regarding peri-operative antibiotic agents: a pilot study. Surg Infect (Larchmt). 2022;23(9):834–840. doi:10.1089/sur.2022.217
24. Alford M. Infection rates comparing topical antibiotic versus antibiotic-free ointment in blepharoplasty surgery. Am J Cosmetic Surg. 2015;32(3):149–153. doi:10.5992/ajcs-d-15-00013.1
25. Nattis A, Perry HD, Rosenberg ED, Donnenfeld ED. Influence of bacterial burden on meibomian gland dysfunction and ocular surface disease. Clin Ophthalmol. 2019;13:1225–1234. doi:10.2147/opth.S215071
26. Zhu M, Cheng C, Yi H, Lin L, Wu K. Quantitative analysis of the bacteria in blepharitis with demodex infestation. Front Microbiol. 2018;9:1719. doi:10.3389/fmicb.2018.01719
27. Gehrig KA, Warshaw EM. Allergic contact dermatitis to topical antibiotics: Epidemiology, responsible allergens, and management. J Am Acad Dermatol. 2008;58(1):1–21. doi: 10.1016/j.jaad.2007.07.050
28. Bale BI, Elebesunu EE, Manikavasagar P, et al. Antibiotic resistance in ocular bacterial infections: an integrative review of ophthalmic chloramphenicol. Trop Med Health. 2023;51(1):15. doi:10.1186/s41182-023-00496-x
29. Bessa GR, Quinto VP, Machado DC, et al. Staphylococcus aureus resistance to topical antimicrobials in atopic dermatitis. An Bras Dermatol. 2016;91(5):604–610. doi:10.1590/abd1806-4841.20164860