Postcataract ptosis. A randomized, double-masked comparison of peribulbar and retrobulbar anesthesia.

PURPOSE: A randomized, double-masked study of 317 patients was conducted to determine if the incidence of postcataract ptosis is greater with retrobulbar or two-injection peribulbar injection anesthesia. METHODS: Surgery consisted of a planned extracapsular extraction with posterior chamber lens implantation, and no superior rectus bridle suture was used. Ptosis was quantitatively documented preoperatively and postoperatively at 1, 2, 5, and 90 days by the surgeon, photographically at 90 days by a masked observer, and subjectively by the patients. Postcataract ptosis was defined as a drop in the lid margin of 2 mm or greater after correcting for any change in the fellow eye. RESULTS: The incidence of ptosis at 90 days in patients given peribulbar anesthesia was 5.8% and in patients given retrobulbar anesthesia 5.5%, and this difference was not statistically significant (P = 0.90). Eighteen percent of patients in both groups reported a change in the appearance of their eyelids. There was a moderate, positive correlation among patients who reported a change in their lid position and objective measurements of ptosis. Preoperative clinical measurements of vertical lid fissure width and levator function, and the appearance of the lid crease or superior sulcus were not predictive for the development of postoperative ptosis at 90 days; the best predictor was the presence of ptosis in the immediate postoperative period. CONCLUSION: The incidence of postcataract ptosis is the same whether two injection peribulbar or retrobulbar anesthesia is used.

Anisocoria in the pigmentary dispersion syndrome.

We studied four patients with anisocoria and the pigmentary dispersion syndrome. In all patients, the larger pupil was on the side of the greater iris transillumination. The amount of anisocoria was between 0.5 and 1.5 mm and was the same in both the light and dark. There was no blepharoptosis, and all pupils dilated normally with cocaine. All of the patients were young men with myopia, and one patient had increased intraocular pressure.

Traumatic air blast injury with intracranial, bilateral orbital, and mediastinal air.

Air at 75 lbs/sq in from an air compressor hose struck a 19-year-old man in his right eye. Injected through a superior conjunctival laceration, the air entered subcutaneous, mediastinal, and bilateral orbital and intracranial spaces. High-resolution computed tomography scanning of the head and orbits revealed air adjacent to the right optic nerve throughout the orbit. We hypothesize that air was injected intracranially, but extradurally, through the superior orbital fissure. The patient suffered no visual loss.

Robert E. Wright and the development of facial nerve akinesia.

The name of Auguste Van Lint is linked with the development of facial nerve akinesia for ophthalmic surgery. Less well known is Robert Ernest Wright (1884-1977) who described techniques to block the facial nerve in the same manner as later published by Atkinson and Nadbath. This paper reviews Wright's life as an ophthalmologist and ophthalmic bacteriologist and pathologist in British India, and his role in the evolution of facial nerve akinesia.

Modification of the bent needle technique for anterior capsulotomy.

A simple modification of the bent needle cystitome allows a more precise and regular anterior capsulotomy in extracapsular cataract surgery.

Current concepts in retrobulbar anesthesia.

Recently there have been major advances in the field of retrobulbar anesthesia. New agents which allow prolonged anesthesia and akinesia have been introduced. Several new techniques to administer retrobulbar anesthesia have been developed. The toxicity of local anesthetics and the complications arising from such injections have been studied, and ways to avoid and manage them have been expanded.

John Vetch and the Egyptian ophthalmia.

During the Napoleonic Wars from 1798-1815, severe epidemics of keratoconjunctivitis affected the military and civilian populations of Western Europe. This disease was known as the Egyptian ophthalmia because it was first described in troops stationed in Egypt. Most physicians believed this condition was not infectious, but caused by various climatological factors. John Vetch, a British physician, emphasized that this disease was spread by direct conveyance of pus from the diseased to the healthy eye. His insistence that the ophthalmia was contagious, and his suggestions for prevention and treatment were milestones in the history of ophthalmology.

Edward J. Curran and the concept of relative pupillary block.

The historical development of the concept of relative pupillary block and its role in the pathogenesis of angle-closure glaucoma is reviewed. Prior to 1920, the mechanism of action of iridectomy in glaucoma was not understood, its indications unclear, and its technique unsatisfactory. Edward J. Curran's original statement of this concept, and its cure by peripheral iridotomy, were outstanding contributions to the treatment of glaucoma. The controversial responses of other ophthalmologists are related.

Diagnostic ultrasonography.

Ultrasonography and the more recently developed technique of computerized tomography (see the preceding chapter) should be used concurrently in the evaluation and diagnosis of suspected orbital pathology. Ultrasonography is easily performed and safe; it has no known complications or contraindications. Unique information concerning the position and acoustical quality of tumors can be obtained. However, the interpretation of the ultrasonogram can be quite difficult; highly sophisticated equipment is needed to obtain the finer resolution required to make tissue diagnosis.