LETTERS

REFERENCES
1. McLeod SD, Vargas LG, Portney V, Ting A. Synchrony dual-optic accommodating intraocular lens. Part 1: optical and biomechanical principles and design considerations. J Cataract Refract Surg 2007; 33:3746 2. Ossma IL, Galvis A, Vargas LG, et al. Synchrony dual-optic accommodating intraocular lens. Part 2: pilot clinical evaluation. J Cataract Refract Surg 2007; 33:4752 3. Sergienko NM, Tutchenko NN. Depth of focus: clinical manifestation. Eur J Ophthalmol 2007; 17:836840 4. Green DG, Powers MK, Banks MS. Depth of focus, eye size and visual acuity. Vision Res 1980; 20:827835 hrig B, Grolmus R. Reading ability with tz WH, Eckhardt HB, Ro 5. Hu 3 multifocal intraocular lens models. J Cataract Refract Surg 2006; 32:20152021 6. Marchini G, Pedrotti E, Sartori P, Tosi R. Ultrasound biomicroscopic changes during accommodation in eyes with accommodating intraocular lenses; pilot study and hypothesis for the mechanism of accommodation. J Cataract Refract Surg 2004; 30:24762482 7. Findl O, Kiss B, Petternel V, et al. Intraocular lens movement caused by ciliary muscle contraction. J Cataract Refract Surg 2003; 29:669676 8. Hancox J, Spalton D, Heatley C, et al. Objective measurement of intraocular lens movement and dioptric change with a focus shift accommodating intraocular lens. J Cataract Refract Surg 2006; 32:10981103

The author raises an important question regarding the force balance between the capsular bag tension and the spring force of the lens and suggests further studies documenting measurement of optic displacement. These studies are underway, and preliminary results that confirm anterior displacement of the front optic by pharmacological and near-target stimulation have been reported (A. Galvis, MD, et al., How the Synchrony Dual-Optic Accommodating IOL Works: In Vivo Ultrasound Biomicroscopy, presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Washington, DC, USA, May 2005).dStephen D. McLeod, MD, Michelle J. Trager, MD, Luis G. Vargas, MD, Val Portney, PhD

Prophylactic cefuroxime and endophthalmitis in Tanzania, East Africa

In our view, there is little if any controversy about the use of intracameral cefuroxime for the prophylaxis of endophthalmitis.1 Our unit in Dar es Salaam, Tanzania, had an unacceptably high level of postoperative endophthalmitis. We now perform 7000 intraocular cases annually, mainly cataract extractions with intraocular lenses using both small and large incisions. Additionally, we perform pars plana vitrectomy and a multitude of other types of cases. Nothing is more disheartening for patient, surgeon, and institution than the development of endophthalmitis after routine surgery. Despite using preoperative topical antibiotic agents as well as changing our sterilization practice, including the use of vacuum sterilizers, we continued to have a high rate of endophthalmitis of at least 1 case a month. We introduced intracameral cefuroxime (1 mg) in December 2003 and have not looked back. Our endophthalmitis rate has decreased from approximately 1 case a month to none as of this date, 3 and one-half years later. This effectively translates to a decrease from 12 cases of endophthalmitis in 5000 cases (0.24%) in 2003 to no cases in 2004, 2005, and 2006 (0%) despite an increase in surgical volume to 7000 cases annually. The medication is prepared by us at our unit, and we have not documented any adverse reactions to intracameral cefuroxime over the past 3 years. Although our observation and experience do not hold the value of a randomized controlled study, in our view the usefulness of intracameral cefuroxime is unquestionable, certainly in our environment where risks are high. Based on our positive experience, we have encouraged all hospitals in our network in East Africa to adopt this practice. For reasons that are not altogether clear, there has been some reluctance on the part of our colleagues but we are pleased that adoption of this practice is slowly occurring, with a commensurate reduction in endophthalmitis. For

REPLY: To perform accurate defocus curve testing, we wished to select patients in the control group without eye pathology and with good corrected visual acuity so we established BCVA of at least 20/20 as a criterion. In reporting our data for patients who had implantation of the dual-optic IOL, we presented uncorrected distance acuity in terms of 20/40 or better; for consistency, we reported best corrected acuity similarly. A review of the raw data confirms that, in fact, all patients in whom the dual-optic IOL was implanted did have a best corrected distance acuity of at least 20/20 at the 3, 6, and 12 month postoperative examinations, which renders them reasonably comparable to the control group in that respect. While we do not have the U.S. Air Force Grid Projections data on hand, we have conducted numerous studies comparing contrast sensitivity in dual-optic IOLs and in single-optic monofocal and multifocal IOLs and found no significant difference (I.L. Ossma, MD, A. Galvis, MD, Visual Function in Daily Tasks: A Comparative Study Between Multifocal and Dual-Optic Accommodating Intraocular Lenses, presented at the annual meeting of the American Academy of Ophthalmology, Las Vegas, Nevada, USA, November 2006; I.L. Ossma, MD, A. Galvis, MD, Quality of Vision with a Dual-Optic Accommodating Intraocular Lens, presented at the XXIV Congress of the European Society of Cataract & Refractive Surgeons, London, United Kingdom, September 2006).

J CATARACT REFRACT SURG - VOL 34, JANUARY 2008