The surgical management of overcorrection in myopic epikeratophakia.

Three patients underwent myopic epikeratophakia that resulted in overcorrection. The surgical management of these cases involved resuturing the myopic lenticule to flatten the peripheral curvature and reduce the amount of minus power. A reduction in the overcorrection was achieved in all cases.

Corneal endothelial and intraocular pressure changes after phacoemulsification with Amvisc Plus and Viscoat.

A prospective, randomized, observer-marked study was conducted to compare corneal endothelial and intraocular pressure (IOP) changes after cataract surgery with the viscoelastic agents Amvisc Plus and Viscoat. Forty-nine patients (50 eyes) who had uncomplicated phacoemulsification and implantation of a posterior chamber intraocular lens were randomly assigned to either Amvisc Plus (25 eyes) or Viscoat (25 eyes) groups. Surgical technique was rigidly standardized in all cases. No significant difference in endothelial parameters or postoperative IOPs measured at 24 hours, one week, and two months was detected by analysis of variance between the Amvisc Plus and the Viscoat groups. Visualization was difficult with Viscoat because of its tendency to retain bubbles. Phacoemulsification energy was related to a loss of endothelial density, regardless of the viscoelastic used. The postoperative beta blocker may have contributed to the lower average postoperative IOP than has been reported.

AMO array multifocal lens versus monofocal correction in cataract surgery.

PURPOSE: To compare the functional capabilities of 15 patients (30 eyes) who had implantation of the Allergan Medical Optics (AMO) Array multifocal intraocular lens (IOL) with those of 13 patients (26 eyes) with an AMO monofocal IOL. SETTING: Department of Ophthalmology, The University of Western Ontario, Canada. METHODS: The objective capabilities of both groups were analyzed through visual acuity measurements for distance, near, and depth of focus. Subjective functionality was assessed through the use of a questionnaire that included the previously validated VF-14 index of visual function, a global measure of overall satisfaction with visual acuity, and questions related to the frequency of spectacle wear. RESULTS: Both groups had excellent corrected and uncorrected distance visual acuity postoperatively. The multifocal group had better acuity than the monofocal group at near with distance correction in place (70% versus 43% achieved J3 or better). The multifocal group also had significantly better depth of focus. Subjectively, both groups indicated high levels of satisfaction with visual function. However, the multifocal group indicated higher levels of satisfaction during the day, at night, and overall without spectacles. This result translated into less spectacle wear for both near and distance in the multifocal group. CONCLUSIONS: The results of this study indicate high patient satisfaction with the Array multifocal IOL and greater functional independence from spectacle wear, by objective and subjective patient measures, than with the monofocal IOL.

Phacoemulsification with aspirated or retained Viscoat.

Endothelial cell counts, morphology, and 24-hour postoperative intraocular pressure (IOP) changes were measured in 55 consecutive patients (60 eyes) who had uncomplicated phacoemulsification and posterior chamber lens implantation with either aspirated (30 eyes) or retained (30 eyes) Viscoat (sodium chondroitin sulfate-sodium hyaluronate). The surgical technique was standardized in all cases. Endothelial cell loss was almost identical in the aspirated and in the retained groups (8.8% and 8.7%). Postoperative pleomorphism was significantly less in the retained Viscoat group than in the aspirated group, suggesting a possible protective effect of the retained viscoelastic. Corneal thickness increased significantly in the retained Viscoat group, but this was not significant clinically. The retained Viscoat group had more patients with a postoperative IOP greater than 30 mm Hg and a greater mean increase in postoperative IOP, although the difference between the groups was not significant. The IOP changes may have been caused by blockage of the trabecular meshwork by the retained Viscoat. The results suggest that Viscoat can be retained after cataract surgery if the surgeon is prepared for a greater 24-hour postoperative increase in IOP.

Four incision radial keratotomy.

Radial keratotomy is a constantly evolving procedure. This paper investigates the value of four incision radial keratotomy. The possible advantages of fewer incisions include increased corneal stability, lower risk of perforation, less potential of endothelial cell loss, decreased chance of overcorrection, and simplification of the procedure. We evaluated the results of four incision radial keratotomy in 55 eyes of 31 patients. Follow-up ranged from one to 18 months. Results in low myopia (-2.00 to -3.12 diopters) show 93% of the patients were 20/40 or better, 90% were within +/- 1 diopter of emmetropia, and no patients were overcorrected greater than 1 diopter. In moderate myopia (-3.25 to -4.37 diopters), 84% of the patients were 20/40 or better, 92% were within +/- 1 diopter of emmetropia, and no patients were overcorrected greater than 1 diopter. Regression analysis was performed and it was determined that the postoperative result was equal to .262 + [1.293 x preop spherical equivalent] - [1.166 x optical zone] + [0.56 x depth] + [.038 x age], R = .87.

Epikeratophakia: technique modifications and visual results compared to the national study.

Twenty-eight epikeratophakia procedures have been performed at the University of Minnesota since December 1985. This report describes several technique modifications and compares the refractive and visual outcome of these cases with the national results. There have been 17 aphakic cases (13 adult and four pediatric), seven myopic procedures, and four keratoconus cases. Of the adult aphakic cases, 80% were within 3 diopters of emmetropia at six months, with four cases showing an undercorrection. In the myopic group, five cases showed an overcorrection at six months and all patients were within two Snellen lines or better than their preoperative best corrected vision. The major complications included one graft removal for failure to epithelialize, an interface hematoma, and a severe overcorrection to +9.37 diopters in a myopic patient. A no-keratectomy technique was used in the aphakic and myopic groups. A variation on centering the Hessburg-Barron trephine and removing the epithelium was performed and allowed for more accurate trephine placement.

Visual results following vitreous loss and primary lens implantation.

Implantation of an intraocular lens following vitreous loss at cataract surgery is a controversial decision. To address this issue, we retrospectively identified all cases performed at the University of Minnesota in the last three years that had either a posterior or an anterior chamber lens placed following anterior vitrectomy. Twenty patients had a posterior chamber lens implant; 14 had follow-up longer than six months. All these patients achieved 20/40 or better visual acuity, although one patient had a retinal detachment. Of the six patients with an anterior chamber lens implant, four achieved 20/40 or better acuity and two achieved 20/50 acuity with follow-up of six months; one patient had a retinal detachment. This review demonstrates that with a meticulous anterior vitrectomy, good visual results can be achieved, although the risk of retinal detachment is higher than in uncomplicated cases.

Effects of Healon vs. Viscoat on endothelial cell count and morphology after phacoemulsification and posterior chamber lens implantation.

The endothelial cell count and several morphologic characteristics of the cells were examined before and after surgery in 56 consecutive patients (60 eyes) who underwent phacoemulsification and implantation of a posterior chamber intraocular lens with either Healon (30 eyes) or Viscoat (30 eyes) as the viscoelastic material. In all cases the technique was the same, including removal of the viscoelastic from the anterior chamber at the end of the operation. The mean cell loss was greater in the Viscoat group than in the Healon group (9.27% +/- 2.52% vs. 2.71% +/- 2.53%), but not significantly so. There was a significantly greater reduction in polymegathism in the Healon group than in the Viscoat group (p less than 0.05). Although the results suggest that Healon has a greater protective effect on the corneal endothelium than Viscoat, the greater effort needed to remove Viscoat from the anterior chamber may have adversely affected the endothelium. Further studies in which Viscoat is left in the eye are warranted.

Diagnosis of congenital syphilis in adults presenting with interstitial keratitis.

In the antibiotic era the ophthalmologist has become less familiar with the diagnosis of congenital syphilis. The recognition of this disease is crucial, as neurosyphilis or cardiovascular syphilis will develop in a substantial number of patients with latent congenital syphilis without the appropriate treatment. We describe eight patients aged 60 years or more who presented with refractive problems in whom congenital syphilis was subsequently diagnosed for the first time. One patient was found to have neurosyphilis and the highest VDRL result ever recorded by the London Public Health Laboratory. Seven patients required extensive antibiotic therapy, and three subsequently underwent successful ocular surgery. These cases illustrate the importance of recognizing this treatable disease.

Corneal endothelial response to polymethylmethacrylate versus hydrogel lenses after phacoemulsification.

We performed a study to evaluate the corneal endothelial cell response in 26 patients who received a polymethylmethacrylate (PMMA) intraocular lens and 26 patients who received a soft, nonfolded poly-hydroxy-ethylmethacrylate (poly-HEMA) intraocular lens after posterior chamber phacoemulsification. Specular microscopy and pachymetry were done before surgery and a mean of 8 or more weeks after surgery. The mean percent cell loss was 8.2% in the PMMA group and 10.7% in the poly-HEMA group. There was no significant difference in the pachymetry values before or after surgery between the two groups; however, in the poly-HEMA group the postoperative value was significantly higher than the preoperative value (p = 0.027). The results suggest that the amount of perioperative corneal endothelial cell loss with poly-HEMA lenses is similar to that with PMMA lenses. Further study is needed to fully evaluate the long-term corneal effects of poly-HEMA lenses.

Ocular trauma: emergency care and management.

The emergency care and management of patients with ocular trauma can often be handled completely by the family physician, whose goal should be recognizing the nature and circumstance of the injury and subsequent decision making based on the initial management steps. Obtaining a careful and thorough patient history is vital, as unsuspected trauma may be looked for based on historical clues. The initial examination is similarly crucial for determining the extent of the injury and for formulating the treatment plan. Very often, early and effective first-aid care can prevent future complications, which could otherwise lead to subsequent deterioration of the eye.

Cataracts in systemic diseases and syndromes.

This review attempts to interpret the basic science and more esoteric aspects of diseases associated with cataract, in the context of practical management and diagnostic implications. In the past year, the large epidemiologic Beaver Dam Eye Study has dismissed many putative relationships between cataract and cardiovascular risk factors. However, glycated hemoglobin and high density lipoprotein cholesterol levels still have an association. Cataract continues to be associated with a number of systemic diseases and syndromes such as atherosclerosis, diabetes mellitus, atopy, juvenile rheumatoid arthritis, Marfan's syndrome, and the Cronkhite-Canada syndrome. The unifying role of oxidative stress in the formation of these, as well as iatrogenically induced laser cataracts, is presented, together with a biochemical update on the pathogenesis. Finally, to bridge the gap between the basic science and clinical significance, recent controversial and practical management issues have been highlighted.

Cataracts in systemic diseases and syndromes.

A comprehensive review of the ophthalmic literature on cataracts during the past year is presented. Topics covered include new epidemiologic associations, diabetic cataracts, and syndromes involving cataracts. Data from the Beaver Dam Eye Study suggest the presence of a recessive gene for nuclear sclerosis. Estrogen exposure may decrease the risk of nuclear sclerosis. The effects of amiodarone, propranolol, and lovastatin on the lens are discussed. Electron microscopy studies have furthered our understanding of diabetic cataracts and the rare Christmas tree cataract. Two new studies support the adverse effect of extracapsular cataract extraction on diabetic retinopathy. New associations between neurofibromatosis 2 and the lens will aid in the diagnosis of this condition. Other ocular and systemic syndromes are discussed.

Pituitary apoplexy presenting with light-near dissociation of the pupils.

We describe a patient with pituitary apoplexy causing sudden visual loss and light-near dissociation of the pupils but minimal ophthalmoplegia. Good visual recovery occurred despite an 8-day delay in neurosurgical treatment.

Cataracts in systemic diseases and syndromes.

In the past year, harmony has developed among diverse areas of research in cataractogenesis. A number of epidemiologic studies have identified new, or strengthened the role of previous, risk factors in the development of cataract. Age, tobacco smoking, alcohol consumption, and inhaled corticosteroids have been implicated. Clinical observation of cataract in diseases such as cystic fibrosis, atopic dermatitis, Alzheimer's disease, and mitochondrial cytopathy have led to hypotheses of formation. The basic science research has, in some cases, given support to the clinical hypotheses, especially with respect to the role of estrogens and protein condensation in cataract as well as other systemic diseases. Although oxidative stress continues to be the leading proposed mechanism of cataractogenesis, genetic mechanisms are gaining increasing popularity. Finally, the results of previously contraindicated surgical management of cataract in the setting of advanced diabetic ocular disease and age-related macular disease are highlighted.

Neodymium:YAG laser zonulysis for treatment of lens subluxation.

Nine eyes with lens subluxation in seven patients (6 patients with Marfan's syndrome, 1 with idiopathic lens subluxation) were treated by neodymium:YAG (Nd:YAG) laser zonulysis. The procedure uses an Nd:YAG laser to lyse the zonules to obtain a clear aphakic visual axis. Pretreatment best-corrected visual acuity was 20/60 or worse in eight eyes (6 eyes less than or equal to 20/200). Movement of the crystalline lens was achieved after zonulysis in all cases (100%), and a clear aphakic visual axis, sufficient to maintain aphakic correction without diplopia or glare, was obtained in eight eyes (88.9%). The procedure was combined with optical iridotomy in three cases (33.3%). Five cases (55.6%) required more than one zonulysis treatment. Visual acuity improved two or more Snellen lines in all but one eye (7 eyes greater than or equal to 20/60). Four cases had complications which included: increased intraocular pressure (IOP), mild iritis, recurrent migration of the lens into the visual axis, and crystalline lens damage. The final two complications necessitated eventual surgical removal of the lens. These results suggest that Nd:YAG laser zonulysis may be of benefit as an alternative treatment modality for selected patients with lens subluxation.

Complications of Nadbath facial nerve block and a review of the literature.

In a retrospective study of complications resulting from the Nadbath facial nerve block, we identified three patients (0.25%) over a 2-year period. Complications included dysphonia, laryngospasm, unilateral vocal cord paralysis, and a sensation of the inability to breathe. As it exits the stylomastoid foramen, the facial nerve lies close to the vagus, glossopharyngeal, and accessory nerves. Particular care must be taken, therefore, when giving Nadbath blocks in very thin individuals. The use of hyaluronidase, which enhances effusion of the anesthetic agent, should probably be withheld.

Implantation of a posterior chamber lens without capsular support during penetrating keratoplasty or as a secondary lens implant.

We have devised a technique to fixate a posterior chamber lens in the ciliary sulcus when no posterior capsular support exists. Our short-term follow-up of 22 eyes with lenses thus fixated has shown these eyes to be quiet and to have good pupillary motility after at least 3 months. We believe this new technique is a significant advancement in corneal and anterior segment surgery.