Editor,—We would like to comment on the paper by Bainbridge et al.1

The aim of their study was to investigate the possible association between the use of three piece foldable silicone polypropylene intraocular lenses and increased risk of endophthalmitis, and indeed the investigators have met this goal and proved this association in an elegant study.

In addition, the authors have supplied the reader in their article with very important information (Table 1) that was not discussed. All of the seven cases had a medical history of one or more systematic diseases that may affect the immunological conditions of the patients and contribute to the development of postoperative endophthalmitis.2 In fact, one patient with plastic anaemia was excluded from the statistical analysis.

Comparing the patients with endophthalmitis with control subjects in a random fashion, even in small series, may reveal additional risk factors such as medical history. The addition of a controlled group of patients undergoing the same surgery who did not develop endophthalmitis could add a lot to the strength of the study.

We believe that endophthalmitis develops when several risk factors are present. We are obliged to take all these factors into consideration before, during, and after surgical procedure, especially in debilitated and immunosuppressed patients. In this kind of patient prophylactic considerations must be borne in mind, including adequate preparation of the patient and surgical field, antibiotics, experienced surgeon, safer instruments, and IOLs.