culturing appropriately? Many of my ophthalmic colleagues donot observe the high rate reported in the control group in thisstudy.

The relative decrease in the incidence of endophthalmitiswith the use of intracameral cefuroxime in this study plus otherstudies is strong evidence that this may become the standard ofcare.4

I would like the authors to comment further on these issues.

GEORGE M. BOHIGIAN, MDSt. Louis, Missouri, USA

REFERENCES

1. Barry P, Seal DV, Gettinby G, et al. ESCRS study of prophylaxis of post-

operative endophthalmitis after cataract surgery: preliminary report of

principal results from a European multicenter study. J Cataract Refract

Surg 2006; 32:407–410

2. Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for

cataract surgery: an evidence-based update. Ophthalmology 2002;

109:13–24; questions for review and CME credit request, 25–26

3. Bohigian GM. A study of the incidence of culture-positive endophthal-

mitis after cataract surgery in an ambulatory care center. Ophthalmic

Surg Lasers 1999; 30:295–298

4. Montan PG, Wejde G, Koranyi G, Rylander M. Prophylactic intracameral

celfuroxine; efficiency in preventing endophthalmitis after cataract sur-

gery. J Cataract Refract Surg 2002; 28:977–981

implantation (PEA–IOL) in eyes with acute angle closure oreyes with prior laser iridotomy for acute angle closure. One ofthe findings in this study was a significant decrease in intraocularpressure (IOP) after PEA–IOL alone (Group 1).

In Group 1, the preoperative IOP was 48.9 mm Hg G13.9 (SD). All eyes in this group received IOP-lowering medicaltherapy consisting of acetazolamide, pilocarpine, mannitol, anda b-blocker before PEA–IOL. However, the authors did not spec-ify whether the preoperative IOP measurement was before or afterthe IOP-lowering medical therapy. If this was the IOP level at pre-sentation (ie, before any IOP-lowering medical therapy), the re-ported significant IOP lowering effect of PEA–IOL ‘‘alone’’could be misleading. Maybe the authors could clarify this point,thus allowing a more meaningful evaluation of the effect ofPEA–IOL on IOP in the acute stage of an angle-closure attack.

While there is good evidence from this study and others2,3

that PEA–IOL can reduce IOP and the glaucoma medication re-quirement in patients with primary angle-closure glaucoma(ACG), the role and optimum timing of PEA–IOL in the acutestages of an ACG attack remain to be determined.

THOMAS C. HO, MRCOPHTH

Hong Kong, China

REFERENCES

1. Imaizumi M, Takaki Y, Yamashita H. Phacoemulsification and intraocu-

lar lens implantation for acute angle closure not treated or previously

treated by laser iridotomy. J Cataract Refract Surg 2006; 32:85–90

2. Harasymowycz PJ, Papamatheakis DG, Ahmed I, et al. Phacoemulsifica-

tion and goniosynechialysis in the management of unresponsive pri-

mary angle closure. J Glaucoma 2005; 3:186–189

3. Lai JS, Tham CC, Chan JC. The clinical outcomes of cataract extraction

by phacoemulsification in eyes with primary angle-closure glaucoma

(PACG) and co-existing cataract: a prospective case series. J Glaucoma

2006; 1:47–52

Reply: Ho states that we did not specify whether the preop-erative IOP data were obtained before or after the IOP-loweringmedical therapy and, thus, the significant IOP-lowering effect ofPEA–IOL alone could be misleading if the preoperative IOP datawere obtained before the IOP-lowering medical therapy. Wemeasured the preoperative IOP in Group 1 after the IOP-loweringmedical therapy. However, the exact time of the measurementswas not fixed and thus the preoperative IOP does not necessarilyreflect the maximum effect of the medical therapy. To be moreexact, we should have said that the reported IOP-lowering effectwas mostly due to PEA–IOL and partially due to the medicaltherapy.

We also compared (1) the postoperative IOP in Group 1and the preoperative IOP in Group 2 and (2) the postoperativeIOPs in Group 1, Group 2, and the control group. The compar-ison of the postoperative and preoperative IOP in Group 1 wasone of the comparisons. The results showed that the post-

LETTERS

Reply: First, I would point out that patients in the study didnot receive preoperative antibiotic drops. The 2 treatments undertest were perioperative topical levofloxacin eyedrops and anintracameral injection of cefuroxime during surgery. In the levo-floxacin group, each patient received a drop of either topicallevofloxacin or placebo saline 60 to 30 minutes before surgery,a second drop 30 to 10 minutes before, a further drop at theend of the case, a further drop 5 minutes postoperatively, andthe last drop 10 minutes postoperatively. While technically thiscomprises preoperative treatment, it does not comprise preoper-ative antibiotics in the conventional sense.

We also are surprised at the incidence of postoperative en-dophthalmitis in the groups not receiving intracameral cefurox-ime. All patients received preoperative povidone–iodine andpostoperative levofloxacin drops for 6 days. Lower incidencesreported in many retrospective studies may have the weaknessof underreporting bias, and the use of numerous different pro-phylactic regimens makes it difficult to define and identifya true underlying background rate. Also, the use of polymerasechain reaction to demonstrate infection in cases that are Gramstain and culture negative leads to a higher but truer rate.

We are analyzing our data in detail following the publicationof our preliminary report and hope to be able to answer theseand other questions in greater detail in future publications.dPeter Barry, FRCS

Phacoemulsification and intraocular lensimplantation for acute angle closure

The study by Imaizumi et al.1 sought to determine the effectof phacoemulsification, aspiration, and intraocular lens

operative IOP in Group 1 was significantly lower than thepre-operative IOP in Group 2 and that there were no signifi-cant between-group differences in the postoperative IOPs.These findings indicate that PEA–IOL can reduce IOP and pre-serve the low IOP in the postoperative period as well as cata-ract surgery in eyes without other ophthalmic diseases (controlgroup).dMasamoto Imaizumi, MD, PhD

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