I fully agree with the authors that incision closure is probably the most important step surgeons take to decrease the odds of postoperative endophthalmitis (POE). In fact, in a multivariate analysis we published in 2005 regarding POE in the sutureless era, we found that a leaking incision on the first postoperative day increased the POE risk 44-fold ( P < .001). How this emphasis on incision closure intertwines with the different antibiotic approaches to POE prevention would only be an educated guess; however, it is not necessary to decide between being careful about incision closure and how you approach the antibiotic prophylaxis.

Calling a third group the Suturalists assumes that the best approach to incision closure is a suture. We all have seen sutured incisions still leaking, as well as subsequent suture complications such as localized ulcers, infectious scleritis, and even delayed acute POE in one case I remember. There are no studies I can find that strongly support sutures as the best approach. I am not saying they are a bad approach, just that we have little in the way of clinical studies to support this approach as superior. Certainly, a way to avoid later complications with sutures is to make sure they are removed no more than a couple of weeks after surgery.

Other approaches include the new liquid bandages, a sclerocorneal incision, and rigorous self-sealing incision creation with careful testing at the end of surgery to see if the incision is robust. Again, the debate is unlikely to convince advocates that one approach is superior. Our previously cited study did have 1500 patients with sclerocorneal incisions and no cases of POE, out of about 15 000 patients. However, this result did not reach statistical significance in our multivariable analysis. Clearly, the lack of significance could be merely a statistical power issue.

One of the few randomized clinical trials about incision closure looked at scleral vs corneal incisions and did find that a scleral approach resulted in a 4.6-fold decrease in the risk for POE ( P = .04). I can already imagine the arguments that this was an old study and the scleral approaches were superior while the corneal approach was temporal; and we have come a long way since then in understanding correct incision creation. Although the debate on incision closure best practices will continue, I expect almost all will agree that this debate is important. So I suggest calling the new group the Closuralists, with POE antibiotic prophylaxis an entirely independent consideration.