I read with interest the article by Olson ; however, I believe that some discussion of the paper is needed.

It was shown in several studies that the similar endophthalmitis rate could be achieved with different approaches, including topical or intracameral antibiotics (IA). For example, a study from Bascom Palmer Eye Institute in which no patients were treated with IA reported a rate of 0.028% in 28 568 surgeries.

There are also several studies reporting no benefit of IA when topical antibiotics (TA) were used, or no benefit of TA use when IA were used, including the only randomized controlled trial (RCT) study available (ie, the ESCRS Study).

The situation is complicated by problems with the choice of IA. Cefuroxime was used in the only RCT study and in the majority of retrospective case series, and its safety is well established. On the other hand, its limitations are well known and they include their complete lack of activity against enterococci, Pseudomonas species, and Enterobacteriaceae species enterococci; low activity against methicillin-resistant Staphylococcus aureus (MRSA) and S epidermidis (MRSE); and increasing resistance of coagulase-negative staphylococci. It was shown that enterococci and coagulase-negative staphylococci are responsible for the majority of endophthalmitis cases; in a Swedish prospective epidemiologic study based on 464 996 operations they were responsible for 57% of endophthalmitis cases. This was recently confirmed in a retrospective review of 692 786 surgeries.

It was also recently suggested that these infections occur as a result of selection after cefuroxime intracameral use, when the sensitive strains are killed by the prophylaxis, whereas the resistant strains remain and proliferate. The same National Cataract Registry reveals that the practice in same-day bilateral surgery in Sweden is to add 100 μg of ampicillin to the 1 mg cefuroxime dose, because of its activity against enterococci.

It is well known that intracameral vancomycin is potent against these organisms and most other gram-positive bacteria, and because of its activity is used by 52% of American surgeons. The use of intracameral vancomycin, however, is associated with specific concerns. The US Centers for Disease Control’s Hospital Infection Control Practices Advisory Committee has recommended that “the use of vancomycin should be discouraged” in situations including “routine prophylaxis other than in a patient who has a life-threatening allergy to beta-lactam antibiotics.” The use in prophylaxis of this potent and indispensable antibiotic against multiresistant strains might lead to loss of its activity. Moreover, it was shown recently that postoperative hemorrhagic occlusive vasculitis has been associated with intracameral vancomycin.

Moxifloxacin has a broader spectrum of efficacy than cefuroxime, and its intracameral use was shown to decrease the rate of endophthalmitis. Data from the Swedish National Cataract Registry indicated, however, no advantage with moxifloxacin as compared with cefuroxime. Moreover, moxifloxacin is used on an off-label basis with all potential legal consequences.

It seems that all these unanswered questions and problems should be addressed before the consensus between Intracameralists and Topicalists can be achieved.