{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T11:56:19Z","timestamp":1790855779301,"version":"4.1.0"},"reference-count":37,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:00:00Z","timestamp":1790812800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:00:00Z","timestamp":1790812800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Acta Ophthalmologica"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>\n                    This systematic review and meta\u2010analysis aimed to compare aqueous chlorhexidine (AqCHX) with povidone\u2010iodine (PI) for ocular antisepsis in preventing post\u2010procedural endophthalmitis (primary outcome) and to evaluate antimicrobial efficacy and patient\u2010reported pain (secondary outcomes). A systematic search of PubMed, Embase and Web of Science was conducted on 26 November 2024 and updated on 25 June 2025. Randomised controlled trials (RCTs) and non\u2010randomised studies (NRS) comparing AqCHX with PI for ocular antisepsis were included. Risk of bias was assessed using RoB 2 for RCTs and ROBINS\u2010I for NRS. Meta\u2010analyses were conducted using random\u2010effects models. Endophthalmitis and microbiological culture positivity were reported as odds ratios (ORs), binary pain outcomes as risk ratios (RRs) and continuous pain outcomes as standardised mean differences (Hedges' g), each with 95% confidence intervals (CIs). The certainty of evidence was assessed using GRADE. Eight studies were included, comprising four RCTs and four NRS. Across three large NRS, endophthalmitis rates were low in both groups (0.024% with AqCHX vs. 0.025% with PI), with no statistically significant difference between AqCHX and PI (OR 0.80; 95% CI 0.54 to 1.19;\n                    <jats:italic>I<\/jats:italic>\n                    <jats:sup>2<\/jats:sup>\n                    \u2009=\u20090%). For microbiological culture positivity, pooled results from three RCTs and one NRS showed no significant difference between AqCHX and PI (OR 1.06; 95% CI 0.61 to 1.83;\n                    <jats:italic>I<\/jats:italic>\n                    <jats:sup>2<\/jats:sup>\n                    \u2009=\u20090%). The risk of pain or pain\u2010related ocular symptoms was lower with AqCHX than with PI (RR 0.22; 95% CI 0.14 to 0.33;\n                    <jats:italic>I<\/jats:italic>\n                    <jats:sup>2<\/jats:sup>\n                    \u2009=\u20090%) and pain intensity also favoured AqCHX, although heterogeneity was substantial (Hedges'\n                    <jats:italic>g<\/jats:italic>\n                    \u2009=\u2009\u22121.83; 95% CI \u22122.54 to \u22121.13;\n                    <jats:italic>I<\/jats:italic>\n                    <jats:sup>2<\/jats:sup>\n                    \u2009=\u200977.3%). Certainty of evidence was rated as moderate across all outcomes. AqCHX showed comparable effectiveness to PI for ocular antisepsis while being associated with better tolerability. However, conclusions regarding endophthalmitis are limited by the reliance on NRS and the very low event rate, leaving uncertainty about the magnitude of any difference between treatments. Further well\u2010designed, adequately powered studies are needed to clarify their comparative effectiveness and tolerability.\n                  <\/jats:p>","DOI":"10.1111\/aos.70242","type":"journal-article","created":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T11:07:06Z","timestamp":1790852826000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Aqueous chlorhexidine versus povidone\u2010iodine for ocular antisepsis: A systematic review and meta\u2010analysis"],"prefix":"10.1111","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0242-5451","authenticated-orcid":false,"given":"Hande","family":"Coskun","sequence":"first","affiliation":[{"name":"Department of Drug Design and Pharmacology University of Copenhagen  Copenhagen Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katrine Najah","family":"Mikha","sequence":"additional","affiliation":[{"name":"Department of Drug Design and Pharmacology University of Copenhagen  Copenhagen Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-3386-8607","authenticated-orcid":false,"given":"Christian","family":"Rasmussen","sequence":"additional","affiliation":[{"name":"Department of Drug Design and Pharmacology University of Copenhagen  Copenhagen Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4114-0267","authenticated-orcid":false,"given":"Jens","family":"Rovelt","sequence":"additional","affiliation":[{"name":"Department of Drug Design and Pharmacology University of Copenhagen  Copenhagen Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gianni","family":"Virgili","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA) University of Florence and Careggi University Hospital  Florence Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8697-0734","authenticated-orcid":false,"given":"Miriam","family":"Kolko","sequence":"additional","affiliation":[{"name":"Department of Drug Design and Pharmacology University of Copenhagen  Copenhagen Denmark"},{"name":"Department of Ophthalmology Rigshospitalet  Glostrup Denmark"},{"name":"Department of Ophthalmology Aalborg University Hospital  Aalborg Denmark"},{"name":"Eye Hospital, Your Eye Doctors  Rungsted Kyst Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,10,1]]},"reference":[{"key":"e_1_2_9_2_1","doi-asserted-by":"crossref","first-page":"788","DOI":"10.1016\/j.oret.2020.11.008","article-title":"Aqueous chlorhexidine compared with povidone\u2010iodine as ocular antisepsis before intravitreal injection: a randomized clinical trial","volume":"5","author":"Ali F.S.","year":"2021","journal-title":"Ophthalmology Retina"},{"key":"e_1_2_9_3_1","unstructured":"Barry P. Cordov\u00e9s L.&Gardner S.(2013)ESCRS guidelines for prevention and treatment of endopthalmiyis following catarct surgery: data dilemmas and conclusions."},{"key":"e_1_2_9_4_1","doi-asserted-by":"crossref","first-page":"928","DOI":"10.1016\/j.oret.2025.03.022","article-title":"Endophthalmitis incidence after intravitreal injection of anti\u2010VEGF agents with povidone\u2010iodine versus aqueous chlorhexidine antisepsis","volume":"9","author":"Bates B.","year":"2025","journal-title":"Ophthalmology Retina"},{"key":"e_1_2_9_5_1","doi-asserted-by":"crossref","DOI":"10.1186\/s12348-024-00404-2","article-title":"Comparing the in\u00a0vitro efficacy of chlorhexidine and povidone\u2010iodine in the prevention of post\u2010surgical endophthalmitis","volume":"14","author":"Batista C.S.P.","year":"2024","journal-title":"Journal of Ophthalmic Inflammation and Infection"},{"key":"e_1_2_9_6_1","doi-asserted-by":"crossref","first-page":"581","DOI":"10.1089\/jop.2024.0071","article-title":"Long\u2010term stability, sterility, and cost\u2010effectiveness of 0.05% chlorhexidine gluconate as antisepsis for intravitreal injection","volume":"40","author":"Durrani A.F.","year":"2024","journal-title":"Journal of Ocular Pharmacology and Therapeutics"},{"key":"e_1_2_9_7_1","doi-asserted-by":"crossref","first-page":"1383","DOI":"10.1007\/s15010-026-02763-5","article-title":"Microbiological etiology of endogenous and exogenous postprocedural endophthalmitis: a 5\u2010year German federal state study","volume":"54","author":"Englisch C.N.","year":"2026","journal-title":"Infection"},{"key":"e_1_2_9_8_1","doi-asserted-by":"crossref","first-page":"1386","DOI":"10.1080\/09273948.2022.2152699","article-title":"Exogenous endophthalmitis","volume":"31","author":"Fabiani C.","year":"2023","journal-title":"Ocular Immunology and Inflammation"},{"key":"e_1_2_9_9_1","doi-asserted-by":"crossref","first-page":"e215","DOI":"10.1111\/aos.15732","article-title":"Antimicrobials and antiseptics: lowering effect on ocular surface bacterial flora \u2013 a systematic review","volume":"102","author":"Ferrara M.","year":"2024","journal-title":"Acta Ophthalmologica"},{"key":"e_1_2_9_10_1","doi-asserted-by":"crossref","DOI":"10.1186\/s12886-018-0844-9","article-title":"Preoperative preparation of eye with chlorhexidine solution significantly reduces bacterial load prior to 23\u2010gauge vitrectomy in Swedish health care","volume":"18","author":"Gili N.J.","year":"2018","journal-title":"BMC Ophthalmology"},{"key":"e_1_2_9_11_1","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1159\/000486145","article-title":"2018 update on intravitreal injections: Euretina expert consensus recommendations","volume":"239","author":"Grzybowski A.","year":"2018","journal-title":"Ophthalmologica"},{"key":"e_1_2_9_12_1","doi-asserted-by":"crossref","first-page":"1283","DOI":"10.1016\/j.jclinepi.2011.01.012","article-title":"GRADE guidelines 6. 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