LAUSR

Comparison of Recent Studies of Postoperative Endophthalmitis From the Same National Database To the Editor We were fascinated to read the article on the prevention of postoperative endophthalmitis (POE) following cataract surgery by Daien et al,1 and we congratulate them on the size of the study. However, because the study was retrospective and dependent on the acquisition of medical records, it may not have been inclusive of all eligible patients. It is unclear whether patients with POE were customarily treated in an outpatient setting, possibly without their diagnosis being entered into a database, as occurred in Australia in the 2000s.2 The authors acknowledge that there was no proven causeand-effect relationship between the injection of intracameral cefuroxime and POE. It could be argued that there should be no compulsion to administer intracameral cefuroxime at the conclusion of cataract surgery when the relationship is unproven. Given that the washout effect of 350 mL of balanced salt solution used during the course of surgery is sufficient to washout an average anterior chamber volume of 0.25 mL 1400 times over, we believe it unlikely that organisms would remain in the eye at the end of the surgery. Thus, the effect of intracameral cefuroxime is questioned. Cefuroxime is effectively eliminated from the anterior chamber 4 to 5 hours after surgery.3 However, organisms can enter the anterior chamber through nonsutured incisions at any time in the first few postoperative days.4 Organisms causing endophthalmitis can enter the eye postoperatively from the eyelids and the environment, and they can proliferate and cause POE.2,4 Suturing of incisions has been recommended to eliminate the ingress of periocular organisms postoperatively. Could the authors clarify what proportion of patients with sutured wounds and intact posterior capsules in this study developed POE? If not, could they comment on the limitations imposed by the absence of this information? The possibility of anaphylaxis and retinal toxicity, as well as the potential for errors in dilution or preparation,5 may mitigate against the safe use of prophylactic intracameral antibiosis. The authors state that code BELB001 indicates an injection of an organic or inert substance into the anterior chamber, and they assume this to be cefuroxime.1 Were other substances specifically identified and excluded, such as cholinergic substances or phenylephrine? If not, could the authors comment on the limitations that this may pose? Would a prospective, randomized clinical trial on POE, comparing sutured wound closure with prophylactic intracameral antibiosis, be useful in the further exploration of this issue?