2. Faulkner HW. Association between clear corneal cataract inci-

sions and endophthalmitis [letter]. J Cataract Refract Surg 2006;

33:562

REPLY: In his letter, Spencer explores the value ofpostoperative patching as a strategy to reduce the inci-dence of infection after surgery. This question was, insome fashion, also raised by Faulkner.1 He suggests byallowing the patient to fully blink after surgery, topicalanesthesia might contribute to a greater risk for in-fection, as lid ‘‘squeezing’’ might be associated withemptying the anterior chamber, subsequent ocular hy-potony, and resultant influx of surface microbes intothe anterior chamber. Faulkner suggests that we con-sider returning to injection anesthesia to avoid theabove sequence of events.

Conversely, Spencer suggests that 24 hours of patch-ing might obviate the need to consider injection anes-thesia. A study by Wallin et al.2 suggests a statisticalrelationship between the use of an eye patch and thereduced likelihood of postoperative endophthalmitis.Could this be true?

Would eye patching and/or use of injection anes-thesia by themselves protect against infection? I thinknot. However, consider the following scenario: Topicalanesthesia allows the patient to blink, making it poten-tially more difficult to properly retract the eyelids andcarefully drape the lid margins in preparation for sur-gery. It has been well established that the lid marginsand eyelash follicles are the sources of the microbesthat cause sporadic endophthalmitis in most cases,3

underscoring the need for careful draping. Further-more, a patch is generally applied following injectionanesthesia but not topical anesthesia. Hence, poordraping may be associated with the use of topical an-esthesia, which, in turn, requires no patch. Conversely,injection anesthesia generally requires an eye patchbut allows more careful draping.

In a guest editorial about the Wallin study,4 Iobserved that it was unfortunate that the study did notconsider the relationship between the anesthesia typeand the risk for postoperative infection. Nevertheless,in my view, the central issues are to establish amethodof appropriate draping, irrespective of anesthesia type,and to create a clear corneal incision that is physicallystable and will resist deformation in the early postop-erative period. Toward that end, Belani and I5 investi-gated incisional stability in the early postoperativeperiod. We demonstrated that clear corneal incisionsthat are square in their surface architecture and notdistorted during surgery are physically stable, do notleak, and are not associated with ocular hypotony inthe early postoperative period. It is my firm beliefthat incisional architecture and appropriate handlingof the incisional tissue are the key elements in

preventing microbial influx early postoperatively. Aneye patch will not prevent eyelid squeezing unlessthe patient has also been subjected to injection anesthe-sia. Furthermore, use of a patch will not allow the pa-tient to apply topical antibiotic and antiinflammatoryagents during the crucial initial postoperative period.

I appreciate the comments of Spencer and Faulkner.However, I submit that rates of infection are, at best,only indirectly related to injection anesthesia and eyepatching.dSamuel Masket, MD

REFERENCES1. Faulkner HW. Association between clear corneal cataract inci-

sions and endophthalmitis [letter]. J Cataract Refract Surg

2007; 33:562

2. Wallin T, Parker J, Jin Y, et al. Cohort study of 27 cases of

endophthalmitis at a single institution. J Cataract Refract Surg

2005; 31:735–741

3. Speaker MG, Milch FA, Shah MK, et al. Role of external bacterial

flora in the pathogenesis of acute postoperative endophthalmitis.

Ophthalmology 1991; 98:639–649; discussion by J Baum, 650

4. Masket S. Is there a relationship between clear corneal cataract

incisions and endophthalmitis? [guest editorial]. J Cataract

Refract Surg 2005; 31:643–645

5. Masket S, Belani S. Proper wound construction to prevent short-

term ocular hypotony after clear corneal incision cataract surgery.

J Cataract Refract Surg 2007; 33:383–386

1673LETTERS

J CATARACT REFRACT SURG

Effect of stromal hydration on clear cornealincisions

In their recent article,1 Vasavada et al. looked atwhether stromal hydration can theoretically reducethe risk for endophthalmitis, the most serious postop-erative complication of cataract surgery. In the study,the surgeons performed all cataract surgery through2.2 mm temporal incisions and recommended thatstromal hydration be done because ingress of trypanblue in the anterior chamber was significantly lowerin the stromal hydration group.

It would be interesting to know whether the authorscompared the levelof trypanblue ingress in superiorver-sus temporal clear corneal incisions; in a recent study,2

the incidence of postoperative endophthalmitis washigher in patients who had cataract surgery performedthrough a temporal incision. It would also be interestingto know whether the authors can compare the effect ofwound hydration on bimanual phacoemulsification(1.2mm incision) and standard coaxial phacoemulsifica-tion (2.75 to 3.2 mm incision), both of which have beenshown to have higher spontaneous wound leakage3

than themicroincisionphacoemulsification (2.2mminci-sion) performed by the surgeons in the study.

We have anecdotally observed that removal of thespeculum following phacoemulsification should bedone gently as it can cause a drop in intraocular

- VOL 33, OCTOBER 2007

Laser-assisted subepithelial keratectomy withMMC to treat post-LASIK myopic regression

Cagıl et al.1 evaluated laser-assisted subepithelialkeratectomy (LASEK) in the treatment of post-laserin situ keratomileusis (LASIK) residual refraction. Sur-face ablation could theoretically be the ideal procedurein cases of post-LASIK regression when in-the-bed en-hancement is not advisable, but it has been associatedwith the development of dense haze.2 Although laterreports did not find a high incidence of haze,3,4 thestudy by Cagıl et al.1 shows that it is an important is-sue. The authors found haze when ablations greaterthan �2.00 diopters (D) were performed and sug-gested that the use of mitomycin-C (MMC) could pos-sibly avoid this complication.

We have treated 4 eyes with post-LASIK regressionusing LASEK andMMC 0.02% for 30 seconds over theablated stroma, programming an undercorrection of10% of the intended correction. The ablation was per-formed with the Esiris excimer laser (Schwind EyeTech Solutions) using a photorefractive keratectomy

1674 LETTERS

pressure, leading to spontaneous inflow of ocular sur-face fluid into the anterior chamber by the suction ef-fect of the wound.

Vikas Sharma, MD, MRCD(Ed), MRCOphthShreyasi Sharma, MBBS

Sugato Paul, FRCSBhaskar Gupta, M.S., MRCophthWigan, Lancashire, United Kingdom

REFERENCES1. Vasavada AR, Praveen MR, Pandita D, et al. Effect of stromal hy-

dration of clear corneal incisions: quantifying ingress of trypan

blue into the anterior chamber after phacoemulsification. J Cata-

ract Refract Surg 2007; 33:623–627

2. Lundstrom M, Wejde G, Stenevi U, et al. Endophthalmitis after

cataract surgery; a nationwide prospective study evaluating inci-

dence in relation to incision type and location. Ophthalmology

2007; 114:866–870

3. Berdahl JP, DeStafeno JJ, Kim T. Corneal wound architecture

and integrity after phacoemulsification; evaluation of coaxial,

microincision coaxial, and microincision bimanual techniques.

J Cataract Refract Surg 2007; 33:510–515

REPLY: We appreciate the comments of Sharmaet al. Over a period of time, we have adopted the pro-cedure of phacoemulsification through temporal clearcorneal incisions. We found that in our hands, per-forming phacoemulsification through a superior inci-sion was difficult and also produced severe stress onthe incision during emulsification. Therefore, we didnot attempt to address this question in our paper,but we agree that the study suggested by Sharmaet al. comparing superior and temporal incisionswould be interesting.

In reference to comparing the effect of woundhydration onbimanual (1.2mm) andmicrocoaxial pha-coemulsification (2.2mm),weperformedarandomizedclinical trial and found that ingress of trypan blue intothe anterior chamber after phacoemulsification (trypanblue was used as a tracer) was significantly more withbimanual than with microcoaxial and attained statisti-cal significance (P!.001) (V.A. Vasavada, MD, ‘‘Com-parative Quantification of Ingress of Trypan Blue intothe Anterior Chamber After Bimanual or MicrocoaxialPhacoemulsification,’’ presented at the ASCRS Sympo-sium on Cataract, IOL and Refractive Surgery, SanDiego, California, USA, April 2007).

We totally agree with the observation about carefulremoval of the speculum after phacoemulsification.We clearly demonstrated the phenomenon of sponta-neous ingress of trypan blue in our ASCRS presen-tation.dAbhay R. Vasavada, MS, FRCS, MamidipudR. Praveeni, DO, Deepak Pandita, MS, DevarshiU. Gajjar, PhD, Vaishali A. Vasavada, MS, VirajA. Vasavada, MS, Shetal M. Raj, DO, Kaid Johar, MPhil,PhD

nomogram and a conventional ablation. The opticalzone was 6.0 mm with a transition zone of 1.0 mm.

Case 1 A 35-year-old woman had uneventful LASIKusing a 6.0mmoptical zone to correct refractive defects(right eye, C0.50 �1.75 � 180; left eye, �0.75 �2.00 �10). The preoperative central corneal thickness (CCT)was 503 mm in both eyes. Six months postoperatively,there was regression, with no signs of ectasia (righteye, C0.50 �1.00 � 180; left eye, �0.25 �1.00 � 15).The patient had LASEKCMMC in both eyes. Sixmonths postoperatively, there was an overcorrectionin the left eye (right eye, �0.50 D; left eye, C1.00 D).No haze was detected.

Case 2 A 45-year-old woman came to our clinic be-cause of regression of the myopic defect in the lefteye after LASIK performed at another center. Shehad no data regarding the initial surgery. Refractionin the left eye was �1.25 D, and the CCT was 394 mm.Topography showed no signs of corneal ectasia. Threemonths after LASEKCMMC, the left eye appearedconsiderably overcorrected: C2.75 D.

Case 3 A 55-year-old man had successful LASIK us-ing a 6.0 mm optical zone to correct a myopic defect(right eye, �5.25 �1.75 � 165). The preoperative CCTwas 505 mm. One year postoperatively, the patientshowed regression (�1.00 sphere), with normal topog-raphy and a clear lens. Three months after LASEKCMMC, therewas anovercorrection:C2.50�0.50� 155.

There are 2 possible causes of our unpredictable re-sults, which seem to contradict the results obtained by

J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007