Electroretinograms in autism: a pilot study of b-wave amplitudes.

The authors recorded electroretinograms for 27 autistic patients and 20 age- and sex-matched healthy volunteers. Thirteen (48%) of the autistic patients demonstrated subnormal b-wave amplitudes, which may indicate abnormal retinal function. One patient was tested serially at two sites; his low b-wave amplitude did not vary over time or between the two sites. If this retinal finding can be confirmed at other laboratories and in larger samples of autistic patients, it might provide a marker for a specific subtype of autism.

Intrascleral nerve loop mistakenly identified as a foreign body.

A 5-year-old boy had an excisional biopsy of a pigmented scleral lesion thought clinically to be a foreign body, probably graphite from a pencil. Histological study demonstrated that the pigmented lesion was an intrascleral nerve loop (Axenfeld).

Posterior scleritis. A cause of diagnostic confusion.

The referring diagnoses in seven women with posterior scleritis included intraocular neoplasm, retrobulbar tumor, choroiditis, and idiopathic central serous choroidopathy. In all cases, a localized area of intense posterior scleritis was responsible for the misdiagnosed ocular findings. Features that helped to correctly identify posterior scleritis were as follows: female sex; a history of anterior scleritis; a fundus mass the same color as normal adjacent pigment epithelium; choroidal folds; serous retinal detachment with cloudy fluid; early pinpoint leaking spots from fluorescein angiography; and thickening of the posterior coats of the eye, retrobulbar edema, and high internal reflectivity on ultrasonography. Corticosteroids given for retrobulbar or systemic effect provided effective treatment.

Crystallization on intraocular lens surfaces associated with the use of Healon GV.

OBJECTIVE: To describe a series of patients who had visually significant crystalline deposits on their intraocular lenses during cataract surgery with the use of Healon GV (a high concentration and high molecular-weight hyaluronate sodium). METHODS: Patients were examined for crystalline deposits on their intraocular lenses. These deposits were compared with intraocular lens type, viscoelastic solutions, any other intraocular substance used, type of surgery, and perioperative medications. RESULTS: In the 11 patients with documented changes (six photographically), the only consistent finding was the use of Healon GV. Furthermore, since we discontinued the use of Healon GV, we have not seen a recurrence of these deposits in more than 500 consecutive patients. The deposits could last a long time (at least 6 months) if sequestered by the posterior capsule, and they are believed to be visually significant at times (Snellen visual acuity of 20/40 or worse). CONCLUSION: Healon GV use is associated with a new clinical finding of crystalline deposits on intraocular lenses. These deposits can be clinically significant.

Peters' anomaly as a consequence of genetic and nongenetic syndromes.

A new syndrome includes Peters' anomaly and short-limbed dwarfism. A balanced chromosomal translocation in the brother (patient 1) appears to be coincidental to the physical abnormalities, because his sister (patient 2) has identical findings but normal fibroblast and lymphocyte karyotypes. Peters' anomaly, which includes corneal clouding, iris and/or lens adhesions to the cornea, and the absence of endothelium and Descemet's membrane, is often associated with systemic abnormalities. Since there are different genetic and nongenetic systemic conditions that include Peters' anomaly, and there are several ocular syndromes with features overlapping this disorder, we believe that Peters' anomaly is a morphologic finding rather than a distinct entity.

Phacoanaphylactic endophthalmitis associated with extracapsular cataract extraction and posterior chamber intraocular lens.

We describe the clinicopathologic findings in a patient who underwent extracapsular cataract extraction (ECCE) with insertion of a posterior chamber intraocular lens (IOL). The patient had a sterile hypopyon and anterior uveitis that temporarily subsided but recurred. The inflammation actually worsened after removal of the IOL, and the eye was enucleated. Histopathologic examination showed a pattern consistent with phacoanaphylactic endophthalmitis. We therefore postulate that the patient's complications were due to hypersensitivity to her own lens protein, which remained after the ECCE, rather than to the IOL itself.

Prevention of the rise in intraocular pressure following neodymium-YAG posterior capsulotomy using topical 1% apraclonidine.

We studied apraclonidine hydrochloride (aplonidine hydrochloride or ALO 2145), an alpha-agonist, for its effect on the intraocular pressure (IOP) rise following neodymium-YAG posterior capsulotomy (YPC). In a prospective multicentered double-masked study, 63 eyes were pretreated with one drop of either 1% apraclonidine hydrochloride or placebo one hour before performing YPC and again following the laser treatment. The greatest IOP rise in the placebo-treated eyes occurred in the third hour after YPC, when the mean (+/- SD) IOP rose from a baseline pressure of 16.4 +/- 3.7 to 20.8 +/- 6.8 mm Hg. In apraclonidine-treated eyes, the IOP fell from a mean of 15.6 +/- 3.8 to 12.8 +/- 6.0 mm Hg three hours postoperatively. There were five times as many eyes that had an IOP rise greater than 10 mm Hg in the placebo-treated group compared with those treated with apraclonidine. Apraclonidine proved to be highly effective in preventing the rise in IOP following YPC.

Reduction of pupillary constriction during cataract surgery using suprofen.

The efficacy of a new nonsteroidal anti-inflammatory agent, suprofen, for reducing pupillary constriction during cataract surgery was ascertained in a double-masked, multicenter, clinical study. Prior to surgery 1.0% suprofen or a placebo was instilled; the surgeon's normal regimen of mydriatics and cycloplegics was used. Suprofen (209 patients) was far more effective than the placebo (203 patients) in maintaining a dilated pupil prior to intraocular lens (IOL) implantation (or instillation of a miotic). The mean pupillary area prior to IOL implantation was 6.3 sq mm larger (20% larger) in patients treated with suprofen than in patients receiving the placebo. The investigators' subjective evaluations of the adequacy of pupil size for IOL implantation and of the difficulty of IOL implantation favored patients treated with suprofen over those receiving the placebo.

Prospective randomized comparison of phacoemulsification cataract surgery with a 3.2-mm vs a 5.5-mm sutureless incision.

PURPOSE: To report sutureless cataract surgery by phacoemulsification with a 3.2-mm surgical incision compared with a 5.5-mm surgical incision. METHOD: In a prospective, randomized, masked clinical trial of phacoemulsification cataract surgery, 55 eyes (55 patients) had a 3.2-mm incision and 56 eyes (56 patients) had a 5.5-mm incision. All incisions were in the superior vertical meridian, commenced 1.5 mm posterior to the limbus, and extended into the cornea for a total length of 2.5 to 3.0 mm. In a masked fashion, astigmatism was monitored by keratometry, and logMAR visual acuity was determined both with and without best correction throughout a mean follow-up of 33.9 months. RESULTS: Statistically significant differences were seen in favor of the 3.2-mm incision group at the final examination for astigmatism (Cravy analysis) and uncorrected visual acuity (-0.18 vs -0.88 diopter, P < .001; logMAR, 0.14 vs 0.26, P = .04). CONCLUSIONS: Over the long term, phacoemulsification with a 3.2-mm incision is associated with significantly less astigmatic shift and better uncorrected visual acuity than is phacoemulsification with a 5.5-mm incision. A small incision with a foldable intraocular lens has long-term benefits.

Intraoperative crystallization on the intraocular lens surface.

PURPOSE: To report a physician survey, laboratory studies, and clinical observations of intraoperative crystallization on the surface of the intraocular lens (IOL). METHOD: We sent a survey to all ophthalmologists in the states of Wyoming, Idaho, Montana, Utah, and Colorado asking whether crystallization on the IOL surface had occurred in any of their patients and what viscoelastics, IOLs, and other solutions were used. All returned surveys were tabulated and analyzed by standard statistical means. A sample of crystallization from an IOL on a glass slide submitted by a physician was analyzed to ascertain the relative elemental composition. During in vitro laboratory studies, BSS Plus (Alcon Surgical, Fort Worth, Texas) and BSS (Alcon Surgical) were measured and analyzed for precipitation. Healon GV (Pharmacia/Upjohn, Kalamazoo, Michigan) and calcium chloride were combined in various solutions and examined for precipitate formation. Silicone IOLs and plate silicone were placed in different BSS and BSS Plus solutions with different viscoelastics and varying calcium concentrations. In seven patients, prominent crystallization on an IOL surface was examined, photographed, and followed for up to 3 years. RESULTS: Two hundred six surveyed ophthalmologists returned 181 surveys (88%) and reported 29,609 cataract surgeries, with IOL implantation with 22 eyes (0.07%) (22 patients) in which intraoperative crystallization was observed on the IOL surface during 1993. The survey indicated there was a correlation with BSS Plus (chi-square = 4.9, P = .0268) and silicone IOLs (chi-square = 6.8, P = .0093). The sample showed the cation to be calcium. CONCLUSION: Crystallization on the IOL surface during cataract surgery is a rare occurrence that may be associated with calcium as the cation related to an osmotic gradient around the IOL with increased calcium concentration. If encountered surgically, the lens should be exchanged in the operating theater after irrigating the anterior chamber with BSS and completely filling the capsular bag with a low molecular weight viscoelastic.

Anterior lens capsule rupture caused by air bag trauma.

PURPOSE: To report a child with anterior lens capsule rupture caused by air bag inflation. METHODS: A 10-year-old girl sustained a rupture of the right anterior lens capsule secondary to air bag deployment during a minor automobile accident. The evaluation included orbital ultrasound and orbital computed tomography. RESULT: The right eye underwent lens aspiration with intraocular lens placement. Postoperatively, the patient did well with 20/25 best-corrected visual acuity. CONCLUSION: Our case, in which the patient's lens capsule was ruptured by air bag inflation, illustrates that air bag deployment, even in minor low-speed accidents, can cause severe blunt trauma to the eye.

A limited comparison of apraclonidine's dose response in subjects with normal or increased intraocular pressure.

We performed a multicentered, placebo-controlled, randomized, crossover study comparing the efficacy of 0.5% and 1.0% apraclonidine hydrochloride in 15 normal volunteers and 17 subjects with increased intraocular pressure. Apraclonidine 1% produced a maximum 30.4% +/- 14.0% (4.7 +/- 2.4 mm Hg) decrease in mean intraocular pressure in normal eyes and a 31.3% +/- 16.5% (7.6 +/- 4.2 mm Hg) decrease in eyes with increased pressure. Apraclonidine 0.5% produced a maximum 25.8% +/- 9.7% (4.0 +/- 1.7 mm Hg) decrease in mean intraocular pressure in normal eyes and a 27.4% +/- 16.0% (6.8 +/- 4.5 mm Hg) decrease in eyes with increased pressure. There was no statistically significant difference in mean percent intraocular pressure lowering effect between the 0.5% and 1.0% apraclonidine concentrations. Most subjects treated with apraclonidine had a greater than or equal to 20% reduction in intraocular pressure from baseline. Twelve hours after instillation of apraclonidine, nine of the normal volunteers had an intraocular pressure of 10 mm Hg or less. Apraclonidine produced the same percent intraocular pressure decrease regardless of the initial level of intraocular pressure.

Hyperopic shift induced by high altitude after radial keratotomy.

BACKGROUND: The collagen fibrils embedded in the ground substance of the stromal lamellae provide the structural support for the cornea. When the stromal lamellae are cut in a radial keratotomy surgical procedure, the remaining uncut lamellae carry the tensile forces. METHODS: We studied two expert climbers who had bilateral radial keratotomy before participating in six climbs of extreme altitude, including Mount McKinley and above 7500 m (24,606 ft) on Mount Everest. RESULTS: Whenever either climber was exposed to altitudes greater than approximately 5000 m (16,405 ft) for more than a day, their refraction would become +3.00 D or more hyperopic and remain so al long as they were at or above this altitude. Visual acuity slowly returned to normal after descent. CONCLUSION: It appears that in the presence of significantly reduced atmospheric pressure and/or oxygen there is a greater effect of radial keratotomy in some patients, making the cornea more vulnerable to changes in shape. The cornea appears to respond by further flattening, exacerbating the intended surgical effect and producing a refractive shift toward hyperopia.

Ab externo scleral fixation of the Cionni modified capsular tension ring.

The Cionni modified capsular tension ring (CTR) allows for scleral fixation in cases of significant zonular dialysis, providing long-term centration of in-the-bag foldable intraocular lenses. Previous techniques of suture placement require placement of the primary incision along the axis of zonular weakness or enlarging and/or distorting the primary incision to attain proper positioning. They also use blind passes of the needle under the iris to approximate the ciliary sulcus. We describe an external closed-system approach for preplacing 10-0 polypropylene sutures in the ciliary sulcus for a Cionni modified CTR under topical anesthesia. This technique does not use blind passes of the suture needle and results in accurate placement of the sutures in the ciliary sulcus under a closed and stable system.

Comparison of energy required for phaco-chop and divide and conquer phacoemulsification.

PURPOSE: To evaluate the safety and usefulness of phaco-chop cataract extraction. SETTING: A university-associated, multispecialty ophthalmology practice. METHODS: Fifty-three patients in a university-associated ophthalmology practice had cataract extraction, 32 by the phaco-chop technique and 21 by four-quadrant divide and conquer phacoemulsification. Phacoemulsification energy and complication rates were compared. RESULTS: Mean phacoemulsification energy was significantly lower in the phaco-chop group (mean 782 J +/- 446 [SD]) than in the divide and conquer group (mean 3264 +/- 1218 J)(P < .00001). No complications occurred in either group. CONCLUSION: The phaco-chop technique provided safe, effective cataract extraction with significantly less energy than that required for divide and conquer phacoemulsification.

Combined phacoemulsification, intraocular lens implantation, and trabeculectomy.

PURPOSE: To analyze the results of phacoemulsification and posterior chamber intraocular lens (IOL) implantation combined with trabeculectomy. SETTING: John Moran Eye Center, University of Utah, Salt Lake City. METHODS: Two hundred twelve eyes of 174 patients with glaucoma and cataracts were analyzed retrospectively after cataract removal by phacoemulsification with posterior chamber IOL implantation combined with trabeculectomy. RESULTS: With an average follow-up of 26 months, patients had a significant improvement in visual acuity. The preoperative mean intraocular pressure (IOP) of 23.1 mm Hg decreased postoperatively to 15.9 mm Hg. Mean number of glaucoma medications decreased from 1.85 preoperatively to 0.41 postoperatively. Twenty-one patients (10% had a postoperative IOP of greater than 21 mm Hg, and seven required trabeculectomy revisions. CONCLUSION: Combined phacoemulsification, posterior chamber IOL implantation, and trabeculectomy yielded excellent results in the treatment of patients with both cataract and glaucoma.

Astigmatic decay following small incision, self-sealing cataract surgery.

A series of 22 consecutive patients had phacoemulsification using a small (3.5 to 4.0 mm), self-sealing incision. Preoperative keratometric analysis was performed using the EyeSys photokeratoscope. Results of this analysis were compared with keratometric data obtained at one week and at one month postoperatively. These comparisons were evaluated for surgery-induced cylinder and astigmatic decay at the 3, 5, and 7 mm corneal zones. At one week postoperatively, there was only mild against-the-rule change in cylinder at each corneal zone, and these changes showed minimal decay at the one month follow-up visit.

Cataract surgery complications in 1 year at an academic institution.

PURPOSE: To delineate all complication rates of cataract surgery and define normative rates, trends, and outliers as part of continuous quality management. SETTING: John A. Moran Eye Center, University of Utah Health Sciences Center, Salt Lake City, Utah, USA. METHODS: All cataract surgeries done at the John A. Moran Eye Center from July 1, 1996, to June 30, 1997 (1 complete academic year) were reviewed for intraoperative complications using operative reports. Cases with documented preoperative zonular dehiscence, traumatic capsule breakage, previous vitreous in the anterior chamber, or an accompanying major secondary procedure (e.g., trabeculectomy, corneal transplantation) were eliminated from the study. Over this year, 1729 cataract surgeries were performed by 12 attending physicians, 3 fellows, and 4 residents. Cases of cataract removal with intraocular lens implantation ranged from 18 to 510 per surgeon. RESULTS: There were 44 cases (2.54%) of posterior capsule rupture, with 29 (1.68%) requiring vitrectomy. Most capsule breakages occurred during phacoemulsification. The Student t test showed no statistically significant difference in the incidence of capsule breakage among surgeons (incidence from 0% to 6.25%). All cases were started as phacoemulsification, with 6 conversions (0.35%) to planned extracapsular cataract extraction. CONCLUSIONS: In evaluating continuous quality management, no outliers were found within our center. Phacoemulsification was the part of cataract surgery most likely to cause posterior capsule rupture.

Progressive constriction of the anterior capsular opening following intact capsulorhexis.

The continuous curvilinear capsulorhexis has rapidly increased in popularity as the procedure of choice when using phacoemulsification for cataract extraction. Only recently, however, have complications of this technique been reported. We review the complications of a continuous curvilinear capsulorhexis and present three cases involving progressive constriction of the postoperative anterior capsular opening. One patient had a history of myotonic muscular dystrophy, another had pars planitis, and the third had high myopia. A review of ocular findings in myotonic dystrophy and pars planitis is also presented, and the possible pathophysiology of this progressive constriction is explored.

Astigmatic decay following small incision, self-sealing cataract surgery: one-year follow-up.

Twenty patients who had phacoemulsification using a small, self-sealing incision were evaluated one year after surgery for astigmatic changes. Keratometric analysis was performed using the EyeSys photokeratoscope, and data for the 3 mm corneal zone for each patient were recorded. Results were compared with those reported for the one-week and one-month postoperative periods. From one month to one year, a minimal amount of additional against-the-rule change in cylinder occurred. Because the range of changes was broad, it was difficult to predict the direction of astigmatic change (i.e., against the rule versus with the rule) that would occur over time for a given patient.