1. ASCRS 2011 San Diego (USA) Introduction Johann Sebastian Bach, considered to be the most famous sacred musician of all time died in 1750 eventually because of the consequences of endophthalmitis due to his unsuccessful cataract surgery 6,10,11,12,13,14. This study showed that intracameral cefuroxime administered at the time of surgery significantly reduced the risk for developing endophthalmitis after cataract surgery 1,5,7,8,15,17. Peter Barry 5 Johann Sebastian Bach (1685 – 1750) 16 Still today the risk of endophthalmitis in cataract surgery is not overcome completely even having modern surgical techniques and several antibiotics available 1,8. This poster wants to highlight the achievements in modern ophthalmic medicine that led to the ESCRS Guidelines for endophthalmitis prophylaxis presented by Peter Barry over the last two years 1,8. From Bach to Barry – endophthalmitis now and then Sibylle K. Scholtz, Gerd U. Auffarth International Vision Correction Research Centre (IVCRC), Dept. of Ophthalmology, University of Heidelberg, Germany No financial interests

2. Johann Sebastian Bach and his probably fatal cataract surgery In August 1748, Bach’s hand writing began to indicate that he had trouble with his eyes; it is likely that he suffered from cataract. There are no documents written by him after 1749, his wife or his son signed important documents on his behalf. At age 65, Bach decided to undergo cataract surgery in late March of 1750 by famous John Taylor. Taylor operated exclusively on the left eye of his patients, never mind which eye was worse affected by the cataract 2,6,9,10,11. Johann Sebastian Bach 1746 16 ASCRS 2011 San Diego (USA)

3. Johann Sebastian Bach and his probably fatal cataract surgery The method of “couching” Taylor used was very painful and dangerous: Proper anaesthesia (apart from alcohol and opiates) was not available, nobody knew about the importance of disinfecting eyes or surgical tools. Taylor prepared his patients for surgery with laxatives, bloodletting and eye drops made from pig’s blood, sugar and salt. Moreover, the surgery was not performed at a hospital, but on an “outpatient” basis (e.g. at inns) 2,3,4,6. Johann Sebastian Bach´s eyes, detail from the Haussmann painting 16 ASCRS 2011 San Diego (USA)

4. Johann Sebastian Bach and his probably fatal cataract surgery Bach had his first eye surgery between March 28 and 31, 1750. Shortly after the operation, the local newspaper published an article reporting that Bach’s vision had improved, which is not a very believable source, since Taylor often issued publications of such reports to advertise his business. Meanwhile, Taylor had moved on to treat other people’s cataract 2,3,4,6,10. When he came back to Leipzig, he performed another operation on Bach, between April 5 and 7, 1750. It is said that Bach went completely blind after the second surgery 2,3,6. Bach 1750 and his signature 16 ASCRS 2011 San Diego (USA)

5. Johann Sebastian Bach and his probably fatal cataract surgery We will never find out what exactly happened to him. If Bach was completely blind after the second surgery (app. 5. – 7. April 1750), and if Taylor had again just treated one eye, the cataract in the other eye must have been very advanced, so that the eye was blind or had extremely limited vision. Reports also indicate that Bach was suffering from severe pain in his eyes, which may have been caused by increasing ocular pressure or by a deteriorating eye infection 2,3,4,6. An eye infection could have caused blood poisoning, which would have been life threatening. Sources reporting that Bach had a high fever support this view 2,3,4,6. After weeks of suffering, Bach died on July 28, 1750, in Leipzig 10. Taylor had long departed Bach´s bust 19 ASCRS 2011 San Diego (USA)

6. The ESCRS endophthalmitis study The ESCRS study 1,8 aimed to answer two questions: Do perioperative antibiotics prevent endophthalmitis? Should antibiotics be administered intracamerally, topically, or both? The study’s objectives were the efficacy of the use of intracameral cefuroxime and intensive perioperative antibiotics versus placebo. Preoperative antibiotic drops were not used in the conventional sense 7. “…This was the largest study of an antibiotic in the history of medicine…” (Peter Barry 15 ) ASCRS 2011 San Diego (USA) ESCRS endophthalmitis study, study groups[1]

7. Of 15,971 patients enrolled from 23 clinics across nine European countries, half received 1mg of intracameral cefuroxime in 0.1ml of normal saline solution. All patients received povidone-iodine preoperatively and also were randomized to receive either topical levofloxacin or placebo drops 7,17. Postoperatively, all patients received topical levofloxacin drops four times a day for 6 days starting on postoperative day one 7,17. The ESCRS study reasonably and accurately defined the true ratio of endophthalmitis and unequivocally demonstrated the effect of cefuroxime. If cefuroxime was commercially available in a single, sterile, ophthalmic unit dose, it would become the gold standard of endophthalmitis prevention 7. The ESCRS endophthalmitis study ASCRS 2011 San Diego (USA) Results of analysis of total endophthalmitis cases 1

8. The ESCRS endophthalmitis study Potential risk factors for endophthalmitis identified by the study included the use of a silicone IOL and clear corneal incisions 1,5,7,8,15,17. ASCRS 2011 San Diego (USA) Significant risk factors for presumed endophthalmitis[7] “…I would therefore appeal wholeheartedly to the industry to provide us with a single sterile unit dose of cefuroxime for the many millions of cataract procedures that are performed annually worldwide…” (Peter Barry) 15

9. Conclusions The celebrated British eye surgeon John Taylor performed surgery on Bach twice visiting Leipzig in March/April 1750. Bach died July 28th 1750, aged 65. Contemporary newspapers reported on Bach’s death as "from the unhappy con- sequences of the very unsuccessful eye opera- tion“ 2,3,4,6. Today’s view is that Bach died finally because of endophthalmitis. At that time a successful cataract surgeon achieved about 80 - 90% surviving eyes 4,6. We do not know the exact number of endophthalmitis cases at that time, however, over the last two centuries it dropped down to below 0.1 to 0.01%. Barry’s ESCRS study results represent today’s best proven ways of prophylaxis 1,8,18. Bach statue in Leipzig (D) 16 ASCRS 2011 San Diego (USA)

10. References: [1]Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie C for the ESCRS Endophthalmitis Study Group, ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery, Preliminary report of principal results from a European multicenter study, J Cataract Refract Surg 2006; 32:407–410, [2] Zegers, R.A., The Eyes of Johann Sebastian Bach, Arch Ophthalmol, Vol. 123, Oct. 2005, [3] Kubba, A.K., Young, M., Johann Sebastian Bach´s disastrous operation, IJCP, July/August 1997, [4] Glaukom-aktuell, Sekundärglaukom, Endophthalmitis, Sepsis – das lange Sterben des Johann Sebastian Bach, Glaukom-aktuell, 1/2006, [5] Barry, P., ESCRS study on antibiotic prophylaxis of endophthalmitis yields positive result, Editorial, EuroTimes 03/2006, [6] Scholtz, S., Augenblick, Saarbrücken 2007, [7] Barry, P., Endophthalmitis: Recommendations Based on the ESCRS Study, J Cataract Refract Surg Today, 04/2007, 63 – 65, [8] Seal D, Barry P, Gettinby G, et al. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: case for a European multicentre study. J Cataract Refract Surg 2006;32:396-406, [9] Toellner, R., Illustrierte Geschichte der Medizin, Vaduz 1992, [10] Korff, M., Johann Sebastian Bach, München 2000, [11] Geck, M., Bach. Leben und Werk, Reinbek 2001, [12] Wolff, C., Johann Sebastian Bach, Frankfurt 2005, [13] www.bach.de, [14] http://www.npj.com/thefaceofbach/index.html, [15] Barry P, Endophthalmitis following cataract surgery is preventable, EuroTimes 03/2006, [16] http://de.wikipedia.org/wiki/Johann_Sebastian_Bach, [17] Barry P, Lessons From the ESCRS Study on Endophthalmitis Prophylaxis, Cataract & Refractive Surgery Today Europe, 9/2008, 54 – 56, [18] Leitlinie zur Prophylaxe und Therapie von Endophthalmitiden, Deutschsprachige Gesellschaft für Intraokularlinsen-Implantation und refraktive Chirurgie (DGII), August 2005, [19] http://www.lastfm.de/music/Johann+Sebastian+Bach/+images/40791525. At Bach´s time cataract surgery was a very dangerous treatment due to infections because of a bad hygienic situation then. This is today not the fact anymore. There are antibiotics available as well as modern surgical techniques. Peter Barry’s ESCRS study results provide a fundamental under- standing of endophthalmitis today. Peter Barry giving Ridley Medal Lecture 15 Results ASCRS 2011 San Diego (USA)