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phocytes, but these nuclei had diameters roughly a third to half that of the larger “neoplastic” cells. The putative neoplastic lymphocytes would appear too large for centrocyte-like cells based on this comparison. Neither the hyperchromatic nucleus nor remaining cytoplasm of larger cells resembled centrocytes, nor did they have the appearance of monocytoid variants. Their dense nuclear chromatin was not consistent with that of larger immunoblasts, which populate extranodal marginal zone lymphoma. Given the challenges of lymphoma classification based on FNA cytology alone, the diagnosis of new lymphomas would benefit from documentation of monoclonal expansion with polymerase chain reaction and complete immunophenotype profiling. These comments are not meant to detract from the remarkable results the authors achieved with rituximab, but they might stimulate discussion about when to use ancillary laboratory studies.

Hakan Demirci, MD Victor M. Elner, MD, PhD Author Affiliations: Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor.

Curtis E. Margo, MD, MPH Author Affiliations: Department of Pathology and Cell Biology, Morsani College of Medicine, University of South Florida, Tampa; Department of Ophthalmology, Morsani College of Medicine, University of South Florida, Tampa.

Corresponding Author: Hakan Demirci, MD, Department of Ophthalmology and Visual Sciences, University of Michigan, 1000 Wall St, Ann Arbor, MI 48105 ([email protected]). Published Online: May 7, 2015. doi:10.1001/jamaophthalmol.2015.1167.

Corresponding Author: Curtis E. Margo, MD, MPH, Department of Ophthalmology, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC Box 21, Tampa, FL 33612 ([email protected] .edu).

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Published Online: May 7, 2015. doi:10.1001/jamaophthalmol.2015.1153.

Need for Antibiotic Prophylaxis for Pseudophakic Endophthalmitis

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Demirci H, Grant JS, Elner VM. Intralesional rituximab for primary iris lymphoma. JAMA Ophthalmol. 2015;133(1):104-105. 2. Swerdlow SH, Campo E, Harris NL, et al, eds. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4th ed. Lyon, France: International Agency for Research on Cancer; 2008. 3. Crapanzano JP, Lin O. Cytologic findings of marginal zone lymphoma. Cancer. 2003;99(5):301-309. 4. Schwock J, Geddie WR. Diagnosis of B-cell non-Hodgkin lymphomas with small-/intermediate-sized cells in cytopathology. Patholog Res Int. 2012;2012: 164934.

In Reply We thank Dr Margo for his comments concerning methods used to diagnose MALT lymphoma. The diagnosis of these lymphomas is usually made on the basis of morphology supported by immunohistochemical and flow cytometric studies. Polymerase chain reaction is rarely necessary. However, ophthalmic pathology biopsy specimens—particularly those of intraocular, optic nerve, or posterior orbital origin—may contain scant material, precluding flow cytometry. In such cases, the diagnosis is based on morphology and a limited number of immunohistochemical stains. The FNA biopsy performed in this case had the disadvantage of very limited available tissue, placing a premium on cytopathologic examination and a few immunohistochemical stains. When observed with the optical microscope, the nuclear details of the cells were discernible and the essential features are seen in the article’s Figure. When the images are enlarged, hyperchromatic, medium-sized malignant lymphocytes with regions of vesicular open chromatin, large 970

nucleoli, and chromocenters are found on the upper left of part D, as is a centrocyte-like cell on the lower right. In part F, “monocytoid” malignant lymphocytes with condensed nucleoli and abundant cytoplasm are easily observed. Many of the lymphocytes show a stippled nuclear pattern consistent with plasmacytoid differentiation that can be distinguished from the reactive T cell with condensed nuclei. In this sparse specimen, all of the features of MALT lymphoma were not visible in a single, high-power microscopic field. The predominant immunohistochemical CD20 staining of the malignant lymphocytes and CD3 staining of only scattered T cells strongly supported the diagnosis of this B-cell MALT lymphoma.

To the Editor We read with interest the article by Schimel et al,1 who provided a concise and informative overview on currently available and used methods for pseudophakic endophthalmitis prophylaxis. We agree on most of the reported information and analysis, and we certainly oppose the use of antibiotics in the irrigating solutions; however, we also strongly support the use of a bolus of antibiotic drugs administered intracamerally at the end of the surgical procedure. Although we also agree that we are witnessing a rapid evolution of practice patterns, novel recommendations should be based at least in part and with heavy emphasis on properly conducted trials. We are concerned in regard to the authors’ interpretation and recommendations, such as their statement that “[s]urgeons should carefully evaluate their own rates of endophthalmitis… before considering this practice [intraocular antibiotic administration].”1 We question the practicality of these recommendations. Do the authors recommend that a senior ophthalmologist might continue to not adopt antibiotic prophylaxis if her or his endophthalmitis rates are low, while a junior surgeon must inevitably adopt antibiotic prophylaxis for the rest of the junior surgeon’s career because of the lack of precise data from the junior surgeon’s own rates? Additionally, we were surprised that the authors were concerned about the cost implications when safety is at stake: treating a patient with endophthalmitis among many thousands undergoing cataract surgery will cost less than systematically treating all patients with antibiotic prophylaxis; is it ethical to deny a treatment to that patient? Nowadays, patients are undergoing cataract surgery even for minimally visually signifi-

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cant lens opacities; would any of them accept a marked visual deterioration related to pseudophakic endophthalmitis if they knew that some proven measures of prophylaxis were not used? In light of these considerations, if antibiotic prophylaxis in cataract surgery is to be avoided, it should be a joint decision by the ophthalmologist and patient, at least until an adequate trial or other evidence might demonstrate that antibiotic prophylaxis does not reduce the risk of pseudophakic endophthalmitis. Gianluca Carifi, MD Vasiliki Zygoura, MD, FEBO Nikolaos Kopsachilis, MD Author Affiliations: Moorfields Eye Hospital, London, England. Corresponding Author: Gianluca Carifi, MD, Moorfields Eye Hospital, 162 City Rd, London EC1V 2PD, England ([email protected]).

in light of the questionable benefit of such prophylactic measures. In 1995, the Centers for Disease Control and Prevention made recommendations that vancomycin should not be used as a prophylactic agent.6 Complications from intravitreous vancomycin include toxic anterior segment syndrome, cystoid macular edema, and hemorrhagic occlusive retinal vasculitis, which can be associated with moderate to severe vision loss. Therefore, safety is not compromised when intracameral antibiotics are avoided. We believe that modern cataract surgery is safer for the patient with a shorter duration than in past decades. However, the individual surgeon must evaluate the existing body of knowledge and determine the suitability of intracameral antibiotics in his or her own clinical practice. Andrew M. Schimel, MD Eduardo Alfonso, MD Harry W. Flynn Jr, MD

Published Online: May 28, 2015. doi:10.1001/jamaophthalmol.2015.1438. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Author Affiliations: Center For Excellence in Eye Care, Miami, Florida (Schimel); Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida (Alfonso, Flynn).

1. Schimel AM, Alfonso EC, Flynn HW Jr. Endophthalmitis prophylaxis for cataract surgery: are intracameral antibiotics necessary? JAMA Ophthalmol. 2014;132(11):1269-1270.

Corresponding Author: Harry W. Flynn Jr, MD, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th St, Miami, FL 33136 ([email protected]). Published Online: May 28, 2015. doi:10.1001/jamaophthalmol.2015.1506.

In Reply The European Society of Cataract and Refractive Surgeons reported in 2007 that the use of intracameral cefuroxime at the conclusion of cataract surgery was associated with a significantly lower rate of acute-onset postoperative endophthalmitis when compared with a control group.1 However, there was a markedly increased rate of endophthalmitis in the control group, which was much higher than contemporary rates. A subsequent survey of European countries regarding the European Society of Cataract and Refractive Surgeons guidelines indicated that this treatment was not universally followed even in Europe.2 Reasons for not using intracameral cefuroxime include potential contamination, rare anaphylaxis, and increased resistance among Staphylococcus species.3 A recent study (2015) reevaluating intracameral cefuroxime for endophthalmitis prophylaxis after cataract surgery was not able to identify a difference between this treatment (n = 7366 eyes) given from 2010 to 2012 (incidence = 0.108%) and a group treated similarly from 2006 to 2010 (n = 7756 eyes) before intracameral cefuroxime sodium was given at the conclusion of cataract surgery (incidence = 0.155%).4 Moxifloxacin is ineffective in approximately 40% of coagulase-negative Staphylococcus isolates. Therefore, we disagree with Carifi and colleagues, who “strongly support the use of a bolus of antibiotic drugs administered intracamerally at the end of the surgical procedure.”5 In the United States, it is estimated that at least 2.2 million cataract operations are performed each year. The cost in terms of drug expense and personnel for mixing correct doses of antibiotics is high. Cost must be a consideration, especially

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Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Flynn reported receiving grants from the National Eye Institute, Research to Prevent Blindness, and the Department of Defense. No other disclosures were reported. 1. Endophthalmitis Study Group, European Society of Cataract and Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33(6):978-988. 2. Beselga D, Campos A, Castro M, et al. Postcataract surgery endophthalmitis after introduction of the ESCRS protocol: a 5-year study. Eur J Ophthalmol. 2014;24(4):516-519. 3. Villada JR, Vicente U, Javaloy J, Alió JL. Severe anaphylactic reaction after intracameral antibiotic administration during cataract surgery. J Cataract Refract Surg. 2005;31(3):620-621. 4. Sharma S, Sahu SK, Dhillon V, Das S, Rath S. Reevaluating intracameral cefuroxime as a prophylaxis against endophthalmitis after cataract surgery in India. J Cataract Refract Surg. 2015;41(2):393-399. 5. Carifi G, Zygoura V, Kopsachilis N. Need for antibiotic prophylaxis for pseudophakic endophthalmitis [published online May 28, 2015]. JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2015.1438. 6. CDC issues recommendations for preventing spread of vancomycin resistance. Am J Health Syst Pharm. 1995;52(12):1272-1274.

CORRECTION Error in Table: In the Reply Letter titled “Postoperative Visual Acuity Should Be Reported in Studies of Binocular Summation—Reply” published online April 30, 2015, in JAMA Ophthalmology (doi:10.1001/jamaophthalmol.2015.0944), incorrect information appeared in the Table. For 2.5% low-contrast acuity in the better eye, the mean (SD) letter scores should have been 61 (13) preoperatively and 60 (12) postoperatively. For 1.25% low-contrast acuity in the better eye, the mean (SD) letter scores should have been 62 (12) preoperatively and 59 (12) postoperatively. This article was corrected online.

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Need for Antibiotic Prophylaxis for Pseudophakic Endophthalmitis.

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