LAUSR

Dear Editor, We thank Lim and Tan for their valuable comments on our article BIntracameral cefuroxime in the prevention of postoperative endophthalmitis: an experience from Hong Kong^ [1]. We agree with them that currently, the optimal choice of antibiotic remains the subject of discussion and debate. Apart from cefuroxime, other options such as intracameral moxifloxacin have also been proven to reduce the endophthalmitis rate [2–4]. The choice of antibiotics ultimately depends on the cost, availability and the local pattern of causative micro-organisms encountered. One main aim of our study was to highlight the hurdles when implementing such a routine practice in a high-volume cataract surgery center setting, and to discuss how we tackle them. Lim and Tan pointed out that the visual outcome of cases of postoperative endophthalmitis before implementation of intracameral cefuroxime in our series seemed to be worse than other studies despite coagulase-negative Staphylococcus being the dominant organism. Although our series of endophthalmitis cases did have a poor visual outcome, our two cases with coagulase-negative Staphylococcus and the other culture-negative case had relatively better visual outcomes. On the other hand, among our four worse cases with no light perception, three were caused by Streptococcus species and one by Staphylococcus aureus. This is consistent with a recently published large series of acute-onset endophthalmitis after clear corneal cataract surgery, where Yannuzzi et al. reported that visual acuity outcomes were most favorable with coagulase-negative Staphylococcus (with 51% achieving 20/ 40 or better), while those with Staphylococcus aureus or Streptococcus species achieved less favorable visual outcomes (with 86% and 57% had with 5/200 or worse, respectively) [5]. Nevertheless, all these four culprits in our series were susceptible to penicillin, and this convinced us that intracameral cefuroxime would be an effective preventive measure in our locality. We agreed with Lim and Tan that it may be interesting to evaluate other risk factors that could have contributed to the postoperative endophthalmitis rates. However, since there were only eight cases, the sample size was inadequate to identify any specific factor responsible for poor visual outcome using linear regression. Our cataract population was mainly geriatric patients with a low social-economic background. Together with a long cataract waiting time, our cases generally had more advanced cataracts, which poses a significant risk of developing endophthalmitis and poorer outcome [6]. Among our 3 eviscerated cases, the average age was 83. Two of them also had multiple systemic co-morbidities, with diabetes and renal failure in one case, and the other case was on chronic systemic steroid therapy. These were known risk factors for poor outcome [3]. All phacoemulsification surgeries were performed with a clear corneal incision with one-piece acrylic intraocular lens insertion, while all extracapsular cataract extractions were also performed with a corneal wound approach with PMMA intraocular lens insertion. Thus, we could not comment on these two factors. * Kenneth Kai-Wang Li [email protected]