Results of bilateral cataract extraction with posterior chamber intraocular lens implantation in children.

OBJECTIVE: A retrospective study was undertaken to evaluate long-term anatomic and visual outcomes in eyes of children who underwent bilateral intraocular lens implantation. DESIGN: The study design was a review of medical records of 24 children operated on for bilateral cataracts and posterior chamber-intraocular lenses. PARTICIPANTS: Twenty-four children operated on for bilateral cataracts by 1 surgeon between February 1980 and February 1995 were studied. INTERVENTION: Cataract extraction with bilateral posterior chamber-intraocular lens implantation was performed. MAIN OUTCOME MEASURES: Best-corrected visual acuity, visual acuity without correction, intraocular pressure, manifest refraction, and any intraoperative or postoperative complications were measured. RESULTS: At last follow-up (mean follow-up, 50.8 months; range, 10-149 months), the intraocular lens was in good position and the intraocular pressure was normal without medication in all eyes. Four years after surgery, 79.2% (19 of 24) of first eyes achieved a best-corrected visual acuity of 20/40 or better compared to 66.7% (16 of 24) of second eyes. No eye had any loss in best-corrected visual acuity. In first eyes of 3- to 8-year olds at the time of surgery, 73.3% (11 of 15) achieved a spherical equivalent within 2 diopters of the intended at 4 years after surgery compared to 80% of second eyes. In the 9- to 18-year-old group, 88.9% (8 of 9) of first eyes and 100% of second eyes achieved a spherical equivalent within 2 diopters of the intended at 4 years after surgery. Intraoperative and postoperative complications were minimal. CONCLUSIONS: Long-term anatomic and visual results have been gratifying in this series of patients with bilateral implants.

Anterior chamber fluid cultures following phacoemulsification and posterior chamber lens implantation.

BACKGROUND AND OBJECTIVE: A randomized, prospective study was undertaken to evaluate the incidence of positive cultures in the anterior chamber following cataract surgery when using intracameral gentamicin compared with no antibiotic. PATIENTS AND METHODS: A total of 97 patients were enrolled-- 48 receiving gentamicin in the irrigating solution and 49 receiving no intracameral antibiotics (control group). Each cataract extraction was accomplished by phacoemulsification followed by intraocular lens implantation. At the end of surgery, o.1 ml of anterior chamber fluid from each case was collected and cultured. RESULTS: All cultures were negative in the group receiving gentamicin. However, one positive culture occurred in the control group. There was no significant difference in the positive culture rate between the two groups (P = .52). CONCLUSION: This study suggests that cataract extraction with phacoemulsification and intraocular lens implantation has greatly reduced the incidence of bacterial contamination of anterior chamber fluid, with or without the use of intracameral antibiotic.

Effects of wound architecture and suture technique on postoperative astigmatism.

BACKGROUND AND OBJECTIVE: A prospective randomized investigation was performed to evaluate the effects of wound architecture and suture techniques on postoperative astigmatism after phacoemulsification and intraocular lens implantation. PATIENTS AND METHODS: Two hundred eyes with preexisting with-the-rule astigmatism were randomized into four groups: (1) sutureless scleral tunnel frown incision, (2) scleral tunnel frown incision with a horizontal suture, (3) scleral tunnel frown incision with both a horizontal and a running suture, and (4) posterior limbal acute beveled cataract incision with a running suture. All the incisions were placed in the vertical steep meridian. RESULTS: Data were analyzed from 128 cases with 1-year follow-up. The results revealed that at the 2-month postoperative visit, preexisting astigmatism was significantly reduced in group 1 (P = .029) and significantly increased in groups 3 (P = .020) and 4 (P = .005). There was no significant change in group 2 (P = .06). By the 1-year postoperative visit, there was no significant difference in astigmatism from preoperative levels for all four groups. Vector analysis revealed no significant difference in the mean surgically induced cylinder at 1 year in all four groups. The number of eyes with induced against-the-rule astigmatism, however, was significantly higher than the number of eyes with induced with-the-rule astigmatism in all four groups (P <.01). CONCLUSION: The authors found that sutured wounds placed in the vertical steep meridian may initially increase with-the-rule astigmatism, whereas nonsutured wounds placed in the vertical steep meridian may initially reduce with-the-rule astigmatism. By 1 year, however, a mean flattening of the vertical steep meridian was observed in the three groups with sutures as well as in the group without sutures.

Intraocular pressure response to combined phacoemulsification and trabeculotomy ab externo versus phacoemulsification alone in primary open-angle glaucoma.

We investigated trabeculotomy ab externo as a means of optimizing intraocular pressure (IOP) control in glaucoma patients having phacoemulsification and implantation of an intraocular lens (IOL). A prospective, randomized, controlled study was performed to evaluate the effect on IOP and the incidence of complications associated with combined phacoemulsification and trabeculotomy ab externo. The study group had the combined procedure, while the control group had only phacoemulsification with IOL implantation. A total of 106 patients were randomized, and the IOP for each group was compared at 3, 6, 12, and 24 months. At two years, the mean IOP reduction was 6.1 mm Hg in the study group and 3.8 mm Hg in the control group (P = .001). There were no complications in the control group. Two complications (2/53 or 3.8%) occurred in the study group: a small tear in Descemet's membrane and a postoperative microhyphema. There was no increase in medication in either the study or control group. Combined phacoemulsification and trabeculotomy ab externo represents an option to lower IOP and potentially reduce the need for pressure-lowering medications in patients with primary open-angle glaucoma and visually significant cataracts.

Recognition and management of internal wound gape.

We describe a method for recognizing and managing wound gape of the internal aspect of a scleral tunnel incision. The apposition of the cataract internal incision can be adequately assessed with the use of a gonioprism during and after surgery. With self-sealing tunnel incisions, even though the external incision may be well sealed either with or without the use of a suture, the internal incision may be inconspicuously gaping. When an internal incision gapes open, it takes on the appearance of an elongated oval opening by gonioscopy, a process we have termed fishmouthing. Often fishmouthing can be closed by rapidly deepening the anterior chamber with balanced salt solution through the paracentesis incision; if this is unsuccessful, a limbal suture may be required. Assessment of the internal incision with a gonioprism and management of internal incision fishmouthing is an important method to ensure wound stability and minimize surgically induced astigmatism.

Comparison of laser and manual removal of corneal epithelium for photorefractive keratectomy.

BACKGROUND: Photorefractive keratectomy relies on precise ablation of cornea stromal tissue to achieve a desired change in refraction. The routine technique for photorefractive keratectomy has been manual debridement of the epithelium prior to performing excimer laser ablation. We investigated whether laser ablation versus manual debridement of the corneal epithelium influences the refractive result. METHODS: A retrospective matched controlled study analyzing the refractive outcome of 46 eyes after excimer laser photorefractive keratectomy was performed. Half of the eyes had the corneal epithelium ablated with the excimer laser, while the other half had mechanical removal. Topical postoperative corticosteroid dosing was different in the two groups. All photorefractive keratectomies were performed by the same surgeon (H.V.G.). The two groups were analyzed for statistical differences in refractive outcomes and corneal haze after 6 months. RESULTS: The mean preoperative spherical equivalent refraction in the laser removal group was -5.11 diopters (D), and -5.09 D in the manual group. At 6 months postoperatively, the mean spherical equivalent refraction in the laser group was +0.03 D and -0.40 D for the manual group (p = .21). At no point postoperatively was there any significant difference in the mean refractive outcome or variance of the refractive results between the two groups, although there was a trend toward greater correction with laser ablation of epithelium. There was no statistical difference in the amount of stromal haze by slit-lamp microscopy in the two different debridement groups. There was no significant difference in final uncorrected visual acuity, rate of reepithelialization, or reported incidence of halos or glare between the two groups. CONCLUSION: There was a tendency toward greater refractive correction at 6 months using the laser for corneal epithelial removal than manual debridement, although the difference was not statistically significant. The trend toward slightly higher correction emphasizes the need for care when removing epithelium with the laser to prevent concomitant stromal ablation.

Posterior capsulorhexis with optic capture: maintaining a clear visual axis after pediatric cataract surgery.

We describe a technique for preventing secondary membrane formation after pediatric cataract extraction. This technique involves capture of an intraocular lens (IOL) optic through a posterior curvilinear capsulorhexis opening in an attempt to maintain a clear visual axis in children after cataract surgery. This maneuver ensures centration of the posterior chamber IOL because the haptics remain in the capsular bag and the optic is captured in the posterior capsular opening. Also, the need for an anterior vitrectomy may be eliminated. Apposition of the anterior and posterior capsule leaflets anterior to the optic may limit the migration of Elschnig pearls, reducing the incidence of secondary membranes and the need for additional procedures.

Aqueous flare increase after light exposure in age-related macular degeneration.

An increase in anterior chamber flare is associated with many ocular conditions, including retinal diseases. We assessed anterior chamber flare in 18 patients (19 eyes) with exudative age-related macular degeneration using the Kowa flare-cell meter immediately before and 1 hour after exposure to 40 light flashes at a flash intensity of 300 W/s delivered with a Topcon fundus camera. Fourteen eyes showed a significant increase in flare 1 hour after light exposure (T = -3.452, p < 0.003, t-test). A second measurement in a subgroup of 10 patients exposed to 40 light flashes at a flash intensity of 36 W/s showed no significant change in flare 1 hour after light exposure. Multiple analysis of variance (two-way interaction) showed a highly significant difference between the two groups (F[1,27] = 8.66, p < 0.0066). We discuss possible mechanisms that may have produced these changes as well as implications of light exposure in various diagnostic and therapeutic settings.

Surgical results of penetrating keratoplasty in essential iris atrophy.

BACKGROUND: Results of penetrating keratoplasty in iridocorneal endothelial syndrome have been considered favorable based on past studies; however, documented results in eyes specifically with essential iris atrophy are lacking. METHODS: A retrospective study was performed to evaluate all patients at the University of Pittsburgh with essential iris atrophy who had undergone penetrating keratoplasty for corneal decompensation over 21 years (1971-1992). RESULTS: Penetrating keratoplasty had been performed on six eyes with essential iris atrophy for corneal decompensation. All eyes postoperatively had evidence of persistent anterior uveitis resistant to corticosteroid treatment with one or more episodes of graft reaction. Five of the six eyes (83.3%) ultimately went on to graft failure. Two of the six eyes (33.3%) rejected grafts on two separate occasions. CONCLUSIONS: Penetrating keratoplasty in essential iris atrophy was frequently associated with chronic anterior uveitis and immunologic graft failure.

Clinical characteristics of corneal foreign bodies and their associated culture results.

A prospective study was performed to investigate the clinical characteristics of corneal foreign bodies and to determine if these characteristics were related to the culture results of the foreign body. The clinical characteristics included the type of foreign body, the mechanism of injury, the time present in the cornea, and the presence of a rust ring or an infiltrate. Sixty-three foreign bodies were removed from corneas and cultured for bacteria, and 14.3% cultured positive for bacteria. The major pathogen was coagulase-negative Staphylococcus. The majority of foreign bodies were metallic, and mechanisms of injury were similar for both culture-positive and culture-negative groups. There was no significant correlation between the mean time present in the cornea and the culture results. The presence of a rust ring or an infiltrate was not found to be significant when predicting culture results. No clinical features readily distinguished culture-negative foreign bodies from culture-positive foreign bodies.

Effects of cycloplegia and iris pigmentation on postoperative intraocular inflammation.

Using the Kowa laser flare cell meter, we investigated the relation between anterior chamber inflammation following phacoemulsification and posterior chamber intraocular lens implantation, and (1) iris color and (2) the use of 1% cyclopentolate hydrochloride for 1 week postoperatively. One hundred sixty eyes, randomized into either a cycloplegic or noncycloplegic group, and classified into four different iris color groups--blue, brown, green, and hazel--were studied. Eyes with brown irides had significantly more intense flare 2 weeks postoperatively than eyes with blue irides. Overall, postoperative flare tended to be related to the degree of iris pigmentation. Use of 1% cyclopentolate hydrochloride for 1 week postoperatively failed to decrease anterior chamber inflammation in any of the eyes.

Aqueous flare and cell number in healthy eyes of Caucasians.

A prospective study was conducted using the laser flare-cell meter to determine aqueous flare intensity and cell counts in normal Caucasian eyes and to investigate factors which may have an effect on these measurements. The factors included age, iris color, pupillary size and pharmacologic dilation. We also compared the measurements of flare and cells in the right versus left eyes of the same individual to determine whether any difference exists between the aqueous protein concentration or cell count of two normal eyes. Ninety-two healthy Caucasians (184 eyes) whose ages ranged from 21 to 79 years were enrolled in the study. We found that there was no significant difference between the flare and cell measurements of the right and left eyes. The flare intensity range in this study population was between 1.3 and 7.6 photon count/ms. Flare increased significantly with aging (r = 0.562, P = 0.000). The baseline anterior chamber cell number did not vary significantly by age in the 3rd to 7th decades. Only in the 8th decade did a significant increase in cell number occur. No correlation between the undilated pupil size and the amount of flare or cells was found. After pharmacological pupillary dilation, anterior chamber flare significantly decreased and cell number significantly increased. The flare-cell meter is a sophisticated and sensitive instrument used to assess the condition of the blood aqueous barrier, but for accurate evaluations, the patient's age and the pharmacologic dilation of the pupil must be taken into consideration.

Migraine associated with periorbital ecchymosis.

Two patients are reported who developed periorbital ecchymosis in association with migraine. The association is rare, having only been reported in the literature almost a century ago. The possible mechanism of the occurrence of periorbital ecchymosis in migraine is discussed.