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In a randomized study comprising 60 patients, six different prophylactic regimens were evaluated for their effectiveness in eradicating bacteria on the conjunctivas before surgery. Gentamicin sulfate ophthalmic solution was the only antibiotic able to eliminate bacteria in almost all of the examined patients. The other drugs (chloramphenicol solution, oxytetracycline-polymyxin B ointment, sulphamethizole, bacitracin-neomycin and ristocetin-polymyxin B solutions) were not effective, although most of the isolated strains were sensitive to the respective antibiotics, probably because of the short treatment period (18 h). The problem of prophylactic therapy of ophthalmology is discussed, and some guide lines are given.

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Twenty-two aphakic eyes in seven females and thirteen males were fitted with a new type of soft contact lens designed for continuous wear. Nine patients were operated on for unilateral traumatic cataract, and eleven patients were operated on for senile cataract. Sixteen patients terminated the study. In all cases the visual acuity with lens was almost equal to the acuity obtained with spectacles. The lenses were well tolerated without any special wearing schedule. No serious complications occurred. However, about one third of the patients developed conjunctivitis during the investigation period of eleven months. Four patients showed mild limbal vascular reaction, while only one patient had neovascularisation along the corneal scar caused by the original trauma. The new lens was found to be a good alternative to other contact lenses.

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In 499 patients operated on for cataract, the clinical postoperative signs of extraocular inflammation (conjunctival hyperaemia, chemosis, discharge and oedema of the lids), the number of infiltrates around the corneoscleral sutures, and the severity of intraocular inflammation in the anterior chamber (aqueous-flare) were assessed on the fourth postoperative day and correlated with the bacterial conjunctival flora examined both qualitatively and quantitatively on the same day. Patients with potential pathogens (Staphylococcus aureus, gram-negative bacilli and streptococci) on the conjunctiva following operation did not show any increased inflammatory reactions when compared with those without such pathogen. The quantity of bacteria, i.e. number of colonies, did not appear to play a role. The reasons are discussed. The clinical postoperative inflammatory signs were further correlated with the following factors: surgical complications, quality of suturing technique, use of alpha chymotrypsin, systemic disease, sex and age. A positive correlation was found between the severity of extraocular inflammation and retained lens material and hyphaema. Furthermore, extraocular reactions were more severe in males than in females. The incidence of infiltrates around corneoscleral sutures was found to vary with age, i.e. occurred more frequently in patients less than 60 years. No relationship was found between the severity of aqueous-flare and the above mentioned factors.

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The conjunctival flora of 499 patients operated for cataract was studied on the 4th and 7th postoperative days and compared with the flora examined previously on admission to the hospital and at the time of surgery (Fahmy et al. 1975b, c). Antibiotics had been administered approximately 18 hours before operation, at the conclusion of surgery, and then on the 4th postoperative day after the cultures had been taken. After a significant fall in incidence, including all kinds of bacteria at the time of surgery (Fahmy et al. 1975c), Staphylococcus albus showed an increase in incidence on the 4th postoperative day to the level found on admission. Corynebacteria and gram-negative bacilli likewise showed increasing incidence but not to the level of admission. The incidence of Staphylococcus aureus and streptococci remained unchanged. On the 7th postoperative day, S. aureus showed a fall in incidence while other bacteria had largely the same incidence as that of the 4th postoperative day. The origin of S. aureus isolated postoperatively from the conjunctiva was studied, and showed that the great majority of strains were similar to those found on the patient's own conjunctiva preoperatively. In a few instances, S. aureus could be traced to the patient's own nose or to the noses of some of the nurses. The air of the wards, eye drops or ophthalmic ointments used in the treatment of the patients apparently did not play any role as a source of S. aureus infection. Cultures obtained on the 4th postoperative day showed only a minor relationship to the flora of the wound site observed at the conclusion of surgery.

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The incidence of postoperative endophthalmitis in a series of 4,498 consecutive cataract operations, performed in a period of 10 years, was examined and found to equal 0.533%. Paracentesis of the anterior chamber was done in two cases and revealed Staphylococcus albus to be the causative organism in both instances. Conjunctival cultures were recovered in a further 17 cases, and showed S. albus in pure culture in eight cases and in combination with Pseudomonas aeruginosa and Proteous morgani in two cases. Streptococcus haemolyticus was isolated in pure culture in one case, while the cultures from six other patients were negative. The role of such factors as age, diabetes mellitus, chronic bronchitis, "weak ocular tissue", and persurgical complications which predisposed to postoperative infections was examined and found to have no significance on the occurrence of endophthalmitis in the present study. The visual end results were assessed and showed a better prognosis than generally expected. Of 24 cases, five achieved good visual acuity (6/6-6/12), 13 had a useful vision (6/18-6/60), while five remained actually blind (less than 6/60). In only one case was the eye enucleated. Methods of treatment and prophylaxis are described and discussed. A total suppression or elimination of all regional bacteria at the time of surgery seems to be the logical goal.

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The conjunctival flora of 499 patients was studied the day before cataract extraction, no antibiotics or chemotherapeutical agents had been used before admission. Staphylococcus albus was by far the most common micro-organism (95.4%), followed by corynebacteria (44%), Staphylococcus aureus (14.9%), gram-negative bacilli (7.8%) and pneumo-streptococci (4.4%). Corynebacteria was isolated more frequently in the presence of S. albus, while S. aureus and gram-negative bacilli were found more frequently in the absence of S. albus. No relationship could be demonstrated between the occurrence of pneumo-streptococci and S. albus. The flora of the nose and skin of the face were studied and compared with the conjunctival flora, and a similarity could be observed. Furthermore, strains of S. aureus isolated at the same time from the two or three regions, in most cases, showed the same bacterio-phage type complex. The conjunctival flora was further correlated with sex, age, season, and number of polymorphonuclear neutrophils recovered from the conjunctival fluid. The incidence of corynebacteria and gram-negative bacilli was found to be higher in males, while corynebacteria was the only organism to show seasonal variation, i.e. was isolated more frequently in the second and third quarters of the year. No correlation could be found between age or number of neutrophils.

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The peroperative flora of 499 patients undergoing cataract extraction was studied with local bacterial cultures taken at the beginning and end of surgery and compared with the preoperative flora examined previously (Fahmy et al. 1975 b) on admission the day prior to surgery. The local application of a single dose of oxytetracycline - polymyxin B, approximately 18 hours before surgery, significantly reduced the incidence of bacteria at the time of surgery. However, 92% of the conjunctivas examined immediately before operation proved to harbour one or more kinds of microorganisms. Futhermore, 61% of the wound sites were found to be contaminated with bacteria at the conclusion of surgery. The reasons are discussed. The origin of Staphylococcus aureus isolated peroperatively from the conjunctiva and wound site was studied. The great majority of strains could be traced to the patient's own conjunctiva preoperatively. In a few cases S. aureus was traced to the patient's own nose, skin of face or to the surgeon's nose. The air of the wards and operating theatre as well as the hands and gloves of surgeons and assistant nurses apparently did not play any role as a source of S. aureus infection.

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The methods used for obtaining bacterial cultures from the normal conjunctiva were reviewed. A comparison was made between four methods; a) platinum loop, b)calcium alginate swab c) dry, and d) wet cotton wool swab, using agar (all methods) and serum-bouillon (methods b, c, d) as culture media. The comparisons were based on the isolation rate of Staphylococcus albus and corynebacteria. At the same time, four topical anaesthetics (benoxinate, tetracaine, proparacaine, cocaine) and one vital stain (tetrazolium - alcian blue mixture) instilled into the conjunctiva immediately before taking samples, were studied for their effects on the isolation rate of Staphylococcus albus and corynebacteria. For isolating Staphylococcus albus, method d was found to be superior to the others when the methods were used in the above mentioned order, and when agar was the only culture medium used. On the other hand, after instillation of the above mentioned eyedrops, causing the so-called "washing-out" effect (Fahmy et al. 1974), method a was found better than the others, providing the methods were used in the a-b-c-d order and when agar only was used. When considering the growth of Staphylococcus albus in serum boullion as well, methods b, c, and d were found equal in effect, but somewhat superior to a. Corynebacteria showed nearly the same isolation rate with all the methods before as well as after the instillation of eye drops.

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