Acute unilateral corneal immunoprotein deposition in IgM monoclonal gammopathy.

A healthy 43-year-old officer of a merchant ship at sea developed pain, redness, and photophobia in his right eye. During the next 2 weeks, he noted the presence of a band of opacity spreading from his temporal limbus toward his central cornea. His episcleral vessels were engorged in a distribution contiguous with the peripheral, sectorial, fleck-like corneal opacities. The opacity had progressed during topical and systemic antibiotic therapy, but halted with use of topical corticosteroids. Systemic evaluation showed mild IgM monoclonal gammopathy. Transmission electron microscopy of a corneal biopsy specimen revealed electron-dense fibrils identified as immunoprotein. To our knowledge, this is the first report of a case of acute unilateral deposition of corneal immunoprotein in a patient with monoclonal gammopathy. Clinicians should begin with a broad differential diagnosis when evaluating patients with corneal opacity.

The iris cerclage suture for permanent mydriasis: a running suture technique.

Permanent mydriasis can be a disabling condition. The author describes an iris cerclage running suture technique for the treatment of permanent mydriasis caused by diffuse iris sphincter damage. A long, curved transchamber needle on 10-0 polypropylene is passed in and out of the anterior chamber through limbal paracentesis openings while weaving the needle through the iris near the pupillary margin to form the cerclage. The technique minimizes stretching and distortion of the iris and creates a pupil that is precisely sized and rather round.

Radial keratotomy clear zone diameter errors.

PURPOSE: To examine the variability of achieved clear zone diameters following radial keratotomy and to determine if refractive outcomes are correlated to clear zone diameter errors. METHODS: Twenty-six patients with radial keratotomy (51 eyes) were studied retrospectively. The central clear zone diameter for each radial incision meridian was measured using a slit-lamp and a photograph. The achieved clear zone diameters were statistically compared to the intended clear zone sizes and to the refractive outcomes. RESULTS: Twenty-nine of the 51 eyes met various exclusion criteria. Ninety individual slit-lamp clear zone measurements were obtained for the remaining 22 eyes. Sixty-two of 90 (69%) achieved clear zone diameters were more than 0.25 mm different than the intended clear zone size. A maximum difference of +/- 0.80 mm from the intended clear zone marker size was observed. The average clear zone diameter error did not statistically differ between the three refractive outcome groups (undercorrection, emmetropia, and overcorrection). CONCLUSIONS: In selected cases of centripetal radial keratotomy, the achieved clear zone diameter can vary widely from the intended clear zone size despite extensive surgeon experience.

Single wound, in situ tying technique for iris repair.

The authors describe a technique for placing and tying interrupted iris sutures in virtually any area of the iris using only a single limbal paracentesis wound. The tying is performed with conventional knot-forming techniques outside the eye before the throws are pulled into the anterior chamber and tightened with the desired 180 degrees tension on the suture ends. During suture tying, the iris stays in situ rather than being stretched and distorted.

Measurement of radial keratotomy clear zone diameters.

BACKGROUND: To compare the accuracy of photographic measurements to slit-lamp measurements of radial keratotomy clear zone diameters in order to develop an independent, objective, unbiased, and reproducible method of verifying clinical observations. METHODS: Twenty-five patients (48 eyes) following radial keratotomy had matched slit-lamp and photographic measurements of the diameter of the central clear cornea between the ends of opposite radial incision pairs. Matched slit-beam, photographic, and pathologic observations were compared statistically. RESULTS: Two hundred fifty-four slit-lamp clear zone diameter measurements were obtained. In twenty instances (8%), the radial incision end-point could not be identified on the photograph. For the remaining 234 measurements, the mean slit-lamp clear zone diameter was statistically smaller than the photographic measurement by 0.03 mm (t-test, p = 2.2 x 10(-5)). The slit-lamp and photographic clear zone measurements were strongly positively correlated (Pearson r = 0.99, p < 1.0 x 10(-15)). Matched slit-lamp, photographic, and pathologic clear zone measurements (N=8) in one excised corneal button were not statistically different. CONCLUSIONS: For radial keratotomy clear zone diameters, slit-beam measurements and photographic caliper measurements yield indistinguishable results that are highly concordant over a wide range of diameters. Both slit-beam and photographic measurements yield accurate and reliable results that reflect the true pathologic achieved clear zone diameter following radial keratotomy surgery.

Screening for glaucoma with stereo disc photography.

PURPOSE: To determine the value of taking simultaneous stereo photographs of the optic nerve head as a basis for identification of patients with glaucoma. METHODS: Two hundred fifty-eight patients received complete ophthalmological examinations and were ranked on a scale of 1-5 regarding the likelihood of their having glaucoma. Each eye was also photographed using the NIDEK camera, providing stereo pairs of the optic nerve head. The same patients were reclassified by two independent masked observers on the same scale of 1-5, based solely on examination of the photographs. RESULTS: Examination of stereo photographs alone provided maximum sensitivity of 75% and specificity of 95% in identification of glaucoma patients when photographic readings were compared with all available clinical information. CONCLUSIONS: Stereo photographs of the optic nerve head can be used for glaucoma detection with an accuracy that is significantly greater than simple tonometry and with a sensitivity that is equivalent to screening with computerized perimetry.

Increasing pharmacy productivity by expanding the role of pharmacy technicians.

Efforts to meet growing clinical and distributive demands without increasing pharmacy staff are described. Real and expected increases in demands for services led pharmacists at a cancer center to seek ways of accommodating those demands within budgetary limits. Growth in the distributive workload was interfering with clinical consultation work. Research studies by the medical staff were resulting in complex dosage calculations and time-consuming compounding. Increasing requests for clinical services had to be met without compromising distributive services and teaching responsibilities and without raising costs. A plan of action was approved that included the use of a written test and a training manual to allow the hiring and retaining of skilled pharmacy technicians qualified to assume greater responsibilities. Technicians were assigned to enter drug orders into the computer, check other technicians, and dispense certain drugs. Greater use was made of commercially prepared i.v. solutions, and the floor stock was expanded. A comprehensive quality control program was concurrently put in place. The larger role for technicians not only enabled the pharmacy department to increase its distributive workload dramatically but reduced pharmacy medication errors and provided more time for clinical pharmacy practice. The number of pharmacist and technician full-time equivalents increased by only 1.5 in each category between 1985 and 1990. By making more use of pharmacy technicians, a pharmacy department was able to meet escalating demands for services with only a minor increase in personnel.