I spent about thirty minutes on the telephone today
with a physician from MGH, Dr. Molly Durand,
who is on the staff of the infectious disease unit
at the Infirmary. She was very open and gracious,
and responded to my questions about an unidentified 
patient in an almost enthusiastic manner.

I conclude from this conversation that I was in error
concerning intraocular lens implantation as a risk
factor for endophthalmitis. Dr. Durand agreed with me
that there are no recent statistics in the literature 
concerning the absolute incidence of post-operative 
endophthalmitis, and certainly no statistics on the
consequence of intra-ocular lens implantation. She
quoted to me Henry Allen's publications in the 1960's
and early 1970's as citing an incidence of 1:1000
or 0.1%. She was unfamiliar with my figure of 1:200,
which I now remember I gleaned not from a medical
publication but from the Boston Globe. Dr. Durand
stated that the incidence of postoperative endoph-
thalmitis at the Infirmary, which she interpreted
not as metastatic but as consequence of accidental
operative contamination, was somewhat less than
1:1000. She stated that the late and chronic end-
ophthalmitis which concerned me was extremely rare;
that metastatic endophthalmitis affected eyes with
and without lens implants equally, and was seem
primarily in association with bacterial endocarditis.
She told me that antibiotic perioperative prophylaxis,
both topical and systemic, was discretionary with the
surgeon, but that no association between distant foci
of infection and endophthalmitis had been observed,
and that prophylactic administration of antibiotics
for infections such as dental abscesses was not warranted.
"It's not like having a heart valve", she said.

I then telephoned Peter Lou, who would know about endoph-
thalmitis from a retinal surgeon's perspective. He confirmed
Dr. Durand's opinion, and added that the presence of an
intraocular lens had the additional benefit of providing
mechanical stability of the vitreous and decreasing the
incidence of retinal detachment. I believe this last
statement is open to question, inasmuch as after extra-
capsular extraction, the posterior lens capsule forms a
membrane which in my observation stabilizes the vitreous
independent of the presence of an intraocular lens.

My conclusion, as a result of this additional information,
is that I should change my mind and ask Dr. Boulris to
implant a lens. If you wanted to talk with Dr. Durand
yourself, I have the impression she would be pleased to
talk to you; I don't think, however, that we would obtain
any addition information. 

The surgery, as you know, is scheduled for 9:00 a.m. on
March 13. I have not yet received the medical history
forms for you to complete; I expect to get them next
Wednesday. Please remember to get us multiple copies
of living will forms.