Use of Povidone-Iodine Solution for Intraoperative Antisepsis: A Systematic Review

Antisepsis is a critical aspect of ocular surgery, particularly in intraocular procedures, due to the high risk of postoperative infections. Povidone-iodine is widely recognized for its broad-spectrum antimicrobial properties. This systematic review evaluates the intraoperative use of povidone-iodine applied to the conjunctiva in ocular surgeries. A systematic literature search was conducted using PubMed, Scopus, and Google Scholar for randomized controlled trials (RCTs) published between 2009 and 2023 in English that involved individuals who had undergone an ophthalmological intervention. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a PRISMA flow diagram was used to illustrate the study selection process. Keywords used included the following: ("Povidone-iodine" OR "Betadine") AND ("Conjunctiva" OR "Ocular surgery"). Studies were selected based on predefined inclusion criteria focusing on the intraoperative antiseptic application of povidone-iodine in human ocular procedures, omitting conference abstracts or unpublished studies. Four RCTs met the inclusion criteria. The evidence base is limited by the small number of included RCTs, which restricts the statistical power and generalizability of the findings. This small sample increases susceptibility to methodological bias, reduces the reliability of pooled estimates, and limits the ability to explore heterogeneity. Furthermore, the potential for publication bias cannot be excluded, particularly given the limited number of studies, which may overestimate treatment effects. These studies compared povidone-iodine 5% to other concentrations or antibiotic agents such as povidone-iodine 1%, chloramphenicol 5%, netilmicin, commercial ozonized antiseptic solution (ozone), moxifloxacin 0.5%, and gatifloxacin. The application of all agents was topically on the conjunctiva just before the ophthalmological procedure started, and only gatifloxacin was applied for three days prior to the procedure. Across all included trials, povidone-iodine demonstrated superior antiseptic efficacy, significantly reducing conjunctival bacterial flora before surgery. The comparative agents showed minimal or less consistent antimicrobial effects. No serious or minor adverse effects related to povidone-iodine use were reported in any of the trials. Povidone-iodine remains a highly effective and safe antiseptic agent for intraoperative use in ocular surgery, while a need exists for additional high-quality independently conducted RCTs to confirm the observed effects and expand the evidence base. Its broad antimicrobial spectrum and favorable safety profile support its continued and widespread application for conjunctival antisepsis, outperforming several commonly used alternatives.