PURPOSE: To determine whether the routine use of vancomycin prophylaxis in elective cataract surgery promotes emerging resistance and provides effective protection against post-operative endophthalmitis.

METHODS: Critical review of the current scientific and clinical literature was undertaken including appropriate statistical analyses of published data.

RESULTS: Public health concerns for emergent vancomycin-resistant life-threatening “super bugs” are legitimate. Evaluation of the risk factors that are known to promote emerging vancomycin resistance (sick patients, hospital intensive care unit setting, methicillin-resistant Staphylococcus aureus (MRSA) clonal infections, prolonged systemic therapy, sub-therapeutic dosing, indwelling intravascular and drainage catheters, total kilogram usage and agricultural use) suggest that ophthalmic usage in routine cataract surgery is unlikely to be a significant factor in promoting emerging worldwide resistance. Clinical and scientific studies purporting to prove the value of vancomycin prophylaxis in cataract surgery contain substantial biases and design flaws that seriously undermine their validity. Issues of potential intraocular toxicity, increased costs, absence of medical-legal protection, and compliance with current Centers for Disease Control and Prevention (CDC) and American Academy of Ophthalmology guidelines (in hospital) mitigate against this practice.

CONCLUSIONS: Ophthalmologists who use vancomycin prophylaxis in routine cataract surgery are neither the villains nor heroes according to my interpretation of the currently available scientific data. Personal conscience and an ongoing critical review of the literature should guide each ophthalmologist’s choice in this controversy.