Small incision single-suture-loop pupilloplasty for postoperative atonic pupil

In this small incision technique to correct postoperative atonic pupil in the aphakic or pseudophakic eye, the pupil is sutured and constricted with a 10-0 polypropylene loop through 3 1.0 mm stab incisions. The surgery is easier to perform than previous methods, appears safe and reproducible, and requires little special equipment. Although the pupil's shape may become slightly irregular, its size is fairly easy to regulate. This new method should be useful in correcting postoperative atonic pupil, and the small incision technique will likely minimize surgical trauma and induced astigmatism.     

The effect of catalase inhibitor 3-amino-1,2,4-triazole on coupled oxidative phosphorylation and the state of adenyl system in liver mitochondria of albino rats

Blepharoptosis is a recognized complication of cataract extraction and other ocular procedures. A 6-month waiting period is recommended before repairing postcataract ptosis because most cases resolve during this time. We report the course of a patient who developed spontaneous recovery of eyelid function 11 months after cataract surgery. She had previously undergone successful ptosis repair 8 months after cataract extraction, but developed overcorrection 3 months later as her levator function returned to normal. We recommend at least a 1-year waiting period before repair of postcataract ptosis. If corrective surgery is undertaken earlier than 1 year due to visual obstruction or for aesthetic reasons, we suggest two guidelines. The levator should be plicated rather than resected and patients should be forewarned of the possibility for a revisionary procedure if spontaneous return of levator function occurs.     

Retinal detachment following congenital cataract surgery. I. Preoperative findings in 114 eyes

One hundred fourteen eyes of patients with retinal detachment occurring after congenital cataract surgery were studied. Retinal detachment was typified by high incidences of men, myopia, preference for the second and fourth decades of life, and a fairly long interval after cataract surgery. Frequently found were the following: (1) undetected retinal breaks, (2) high incidences of small oval or round holes in the upper nasal quadrant near the ora serrata, (3) retinal detachment in more than one quadrant, and (4) extensive vitreous and preretinal traction. Preoperative examination was often hampered by a small, bound-down pupil, nystagmus, extreme photophobia, and an inability to move the eye in desired directions. The major factor in the pathogenesis of retinal detachment after congenital cataract surgery appears to be chronic vitreoretinal traction in the anterior vitreous caused by cataract removal.     

Optical iridectomy for corneal opacities in Peter's anomaly

Three children were born with partial corneal opacity and anterior segment anomalies but no cataract (Peter's anomaly type 1). In each affected eye, the corneal scar was off center and encroached on the visual axis. Glaucoma (if present) was controlled medically or surgically, after which an optical iridectomy was performed in each eye (in lieu of a penetrating keratoplasty). After surgery, in all patients the pupil extended beyond the corneal opacity and the corneal opacity decreased slightly. All could fixate and follow around the opacity. Optical iridectomy should be considered in selected cases of congenital corneal opacities.     

Educating doctors to use drugs well

In the cryoextraction of a cataract associated with severe hypotension and narrow pupil, a new smooth iris double-forceps has been found useful for the grasping of the iris and the dilatation of the pupil. Thus, it will be possible to obtain a round pupil even in these rare cases.     

Clinical findings in Brown-McLean syndrome

The Brown-McLean syndrome is a clinical condition with corneal edema involving the peripheral 2 to 3 mm of the cornea. The edema typically starts inferiorly and progresses circumferentially, but spares the central portion of the cornea. Additionally, the edema is associated with a punctate orange-brown pigmentation on the endothelium underlying the edematous areas. Central cornea guttata is frequently seen. This condition occurs most frequently after intracapsular cataract extraction, but may also occur after extracapsular cataract extraction and phacoemulsification, or pars plana lensectomy and vitrectomy. Surgical complications and multiple intraocular procedures are frequently observed in these patients. Less frequently, the Brown-McLean syndrome can occur in eyes that have not had surgery. We studied the clinical characteristics of 43 affected eyes of 32 patients. New findings included Brown-McLean syndrome occurring in two eyes of a phakic patient with intermittent angle-closure glaucoma. Two eyes developed Brown-McLean syndrome after phacoemulsification and one eye developed peripheral edema after pars plana vitrectomy and lensectomy. Additionally, severe, infectious keratitis occurred after rupture of peripheral bullae in two eyes. Patients with this condition should be examined periodically and educated regarding the early clinical signs of corneal ulceration.     

Secondary intraocular lens implantation after cataract surgery in children

PURPOSE: To report results of secondary intraocular lens implantation after cataract surgery in children. METHODS: We reviewed clinical records for a 5-year period of patients who had cataract surgery in childhood and received a secondary intraocular lens implant. We studied indications for secondary intraocular lens placement; surgical procedures for intraocular lens implantation; preoperative and postoperative visual acuity, refractive error, and binocular status; and complications of the procedure. RESULTS: A secondary intraocular lens was placed in 28 eyes of 25 patients who had cataract surgery in childhood. In 20 eyes, the lenses were placed in the ciliary sulcus. The other eight eyes had insufficient capsular support for an intraocular lens; in two, the intraocular lens was placed in the anterior chamber and, in six, in the posterior chamber with suture fixation to the sclera. Twenty of 28 eyes (71%) had measurable improvement in visual acuity; only one eye had a decrease in visual acuity of 2 lines. Fifteen patients (54%) had a final refraction within 1.50 diopters of the fellow eye; 21 (75%) were within 3.00 diopters. During follow-up, two eyes developed glaucoma. One had transient pressure elevation; one required two filtration procedures. Three patients required Nd:YAG capsulotomy. Six patients demonstrated Worth fusion at distance and near; three demonstrated 200 seconds of arc or better stereo visual acuity. CONCLUSION: Secondary placement of an intraocular lens in the posterior chamber appears to be a safe, effective alternative for correction of aphakia in the contact lens- or spectacles-intolerant child or young adult.     

Effect of phosphorylation on activities of Rap1A to interact with Raf-1 and to suppress Ras-dependent Raf-1 activation

OBJECTIVE: To develop a method for the detection of bilateral Horner's syndrome in patients with bilateral interruption of the cervical sympathetic pathway or widespread autonomic neuropathy. METHODS: Darkness pupil diameters and redilatation times during light reflexes have been recorded with infrared TV pupillometry in 65 healthy subjects, 47 patients with unilateral Horner's syndrome, and 20 patients with bilateral Horner's syndrome. The aetiologies of the last group were diabetic autonomic neuropathy (three cases), amyloidosis (four), pure autonomic failure (PAF) (four), dopamine-beta-hydroxylase deficiency (two), and one case each of hereditary sensory and autonomic neuropathy (HSAN) type III, carcinomatous sympathetic neuropathy, familial dysautonomia, multiple system atrophy, Anderson-Fabry disease, and anterior spinal artery thrombosis at C5,6 and one had had bilateral cervical sympathectomies. RESULTS: Darkness diameters on the affected side were below normal in 12 patients with unilateral Horner's syndrome, the measurement yielding only 26% sensitivity for detection of the condition. By contrast, the time taken to reach three quarter recovery in the light reflex (T3/4) was abnormally prolonged (redilatation lag) in 33 of the same eyes. The measurement yielded 70% sensitivity and 95% specificity for detection of the condition. In 20 cases, diagnosed on clinical grounds as having bilateral Horner's syndrome of various aetiologies, pupil diameters were abnormally small on both sides in five and on one side in three patients. Fourteen of these patients had significant redilatation lag in both eyes, five patients in one eye, and one patient had it in neither eye. Measurement of redilatation lag was therefore a more sensitive diagnostic test than pupil diameter in both unilateral and bilateral Horner's syndrome. CONCLUSIONS: Provided that the pupils are not tonic, bilateral Horner's syndrome can be diagnosed on the basis of redilatation lag. It occurs clinically in some generalised autonomic neuropathies and with interruption of the local sympathetic nerve supplies to the two eyes.     

Alcohol and poor compliance as factors in Wernicke''s encephalopathy diagnosed 13 years after gastric bypass

OBJECTIVE: The aim was to study the relationship between aqueous humour betaxolol concentration and intraocular pressure (IOP). METHODS: In this double-blind, randomized study, we administered betaxolol (a) or placebo (b) ocularly to 131 patients scheduled for cataract surgery. The patients were randomly divided into ten groups. In groups 1a and 1b, the drug was scheduled to be instilled 1-2 h, in groups 2a and 2b 12 h, in groups 3a and 3b 24 h, and in groups 4a and 4b 48 h before surgery. The pupil was dilated in all eyes prior to surgery. The IOP was measured with Perkins' applanation tonometer before the instillation of the drug and just before the peribulbar block. Twenty microlitres of 0.5% betaxolol or placebo solution was instilled into the eye. IOP was also measured before instillation of the drug and after 1 2 h in undilated eyes of 20 patients, whose contralateral eye was to be operated on, to rule out the effect of pupil dilation on IOP (groups 5a and 5b). Aqueous humour betaxolol concentrations were analysed using a radioreceptor assay. RESULTS: Betaxolol did not decrease IOP significantly in eyes with pupillary dilation. Both betaxolol and placebo decreased IOP significantly in patients without pupillary dilation, the effect of betaxolol being slightly more pronounced. The betaxolol concentration in aqueous humour was 731 ng m-1 in group la, 2.4 h after drug instillation. Measurable concentrations of betaxolol were also detected in aqueous humour in group 4a 47.7 h after drug administration. CONCLUSION: No correlation between aqueous humour concentration of betaxolol and the effect on IOP was found in eyes where the pupil was dilated before surgery. A single betaxolol dose did not decrease IOP significantly in patients undergoing cataract surgery, but the IOP decreasing effect was, however, clearly seen in patients who did not receive mydriatic drugs. The routine use of topical betaxolol prior to cataract surgery to decrease IOP is not recommended.     

Influence of systemic diseases and environmental factors on age at appearance, location and type of acquired cataract

We studied 257 patients scheduled for cataract surgery for possible correlation with systemic diseases, blood chemistry, and environmental exposure. We found that posterior subcapsular cataract appeared in patients 10 years younger on average than those with other types of cataract. Nuclear cataract patients had higher blood levels of uric acid and creatinine and lower blood levels of calcium. We suggest capsular insult as a possible pathophysiological explanation for cataract formation in young age groups (as well as diabetes) and a toxic effect of blood metabolites in patients with renal failure, resulting in earlier and more prevalent sclerosis of lens fibers. No effect of smoking or of exposure to sunlight on the distribution of various types of cataracts was noted.     

Bladder biofeedback for the treatment of refractory sensory urgency in adults

PURPOSE: Constriction of the pupil during phacoemulsification and intraocular lens (IOL) implantation in patients with diabetes mellitus was studied. METHODS: Before surgery a combination of 0.75% cyclopentolate and 2.5% phenylephrine was applied topically to the eyes of 32 patients with diabetes mellitus and 25 age-matched controls. Epinephrine was mixed with buffered saline solution and used during the surgery. The surgical procedure included capsulorhexis, phacoemulsification in the posterior chamber and implantation into the capsular bag of a heparine surface-modified poly(methyl metacrylate) IOL with an optic diameter of 5.0 mm. The durations of phacoemulsification and the whole surgical procedure were recorded. Measurements of the horizontal pupillary diameter were taken before surgery, after phacoemulsification and at the end of the surgery. RESULTS: There was no significant difference in pupil size between controls and the diabetic group before the operation. Surgically induced miosis after phacoemulsification and at the end of operation were significantly more pronounced in the diabetic group than in controls (p < 0.05) (p < 0.05). Phacoemulsification and the entire surgical procedure took significantly longer time when performed in the diabetic eyes (p < 0.05) (p < 0.05). CONCLUSION: We conclude from these data that constriction of the pupil during cataract surgery is more pronounced in diabetic eyes as compared to controls.     

Use of a preanesthetic video for facilitation of parental education and anxiolysis before pediatric ambulatory surgery

PURPOSE: To find out whether there is a "hidden" group of patients with posterior capsule opacification (PCO) 5 years after cataract surgery and to establish the incidence of PCO. SETTING: Department of Ophthalmology, Sahlgrenska University Hospital, Gothenburg, Sweden. METHODS: A random sample (n = 164) was selected among patients who had extracapsular cataract extraction (ECCE) with intraocular lens implantation in 1991 (N = 1672). All surgically treated cases that required neodymium:YAG (Nd:YAG) laser capsulotomy (n = 37) within the first 5 years after surgery were recorded. Patients still alive 5 years after surgery who had not had Nd:YAG treatment were offered an eye examination to determine whether PCO requiring capsulotomy existed. RESULTS: Thirty-seven of 110 patients (34%) alive 5 years after surgery had an Nd:YAG capsulotomy during the first 5 postoperative years. Follow-up was possible in 51 of 73 untreated patients (70%). Clinically significant PCO according to specified criteria was found in 7 cases (14%). Half of them would benefit from treatment; the other half had visual impairment from other eye disease. CONCLUSIONS: The estimated incidence of PCO 5 years after ECCE was 43%. Five years after surgery, there was an untreated group with clinically significant PCO, approximately 9% of the surgically treated population. This hidden group must be considered in PCO studies.     

Persistent and hyperplastic primary vitreous syndrome. Clinical and therapeutic aspects

PURPOSE: Persistent hyperplastic primary vitreous (PHPV) is a rare developmental malformation of the eye. This anomaly is usually unilateral and unassociated with other disease. PHPV may have clinical variations: an anterior and/or a posterior one. Diagnosis and treatment are exposed in our paper. METHODS: We study 38 eyes in 34 patients. All patients had an anterior form of PHPV. Nine of them associated a posterior form. Eighteen eyes underwent surgery, the mean postoperative follow-up is 4.7 years. Treatment is discussed, depending on the initial form of PHPV. We report the evolution of the surgical eyes and the untreated eyes. RESULTS: Slit lamp examination and echographic findings (A-scan and B-scan) support the diagnosis. In some cases computed tomography or RMN can be useful. If the cataract is mild in the anterior form of PHPV, treatment of amblyopia and frequent clinical examination can be sufficient. If the cataract is dense, a lensectomy must to be performed. The surgical technique can be difficult. For the eyes with posterior PHPV, the surgical treatment is to be avoided, because of high risk of retinal detachment. CONCLUSION: PHPV may have clinical variations, mostly with cataract as major sign. In purely anterior presentation, in absence of marked microphthalmos, lensectomy can be useful.     

Exfoliative syndrome and phacoemulsification

PURPOSE: Exfoliation syndrome (ES) is often considered as a poor indication for phacoemulsification because of zonular weakness, capsular weakness and poor pupil dilatation. METHODS: We evaluated from January 1992 to December 1992 a series of 107 consecutive eyes with ES and undergoing cataract surgery or combined cataract-glaucoma surgery. The pupil was surgically enlarged if the diameter was < or = 5 mm. RESULTS: During surgery, only one case of zonular dialysis without vitreous loss was observed. The incidence of postoperative complications was low (6 hyphemas and 8 inflammatory reactions) and visual results were satisfactory. CONCLUSION: Phacoemulsification can be used routinely in eyes with ES if a careful peroperative protocol is followed: pupillary dilatation, wide capsulorhexis, total nucleus hydrodisection.     

Sequence analysis suggests the presence of an IG-like domain in the N-terminal region of alpha-dystroglycan which was crystallized after mutation of a protease susceptible site (Arg168-->His)

PURPOSE: Retinal detachment after Nd: YAG laser vitreolysis is rarely reported. The pathogenic role of Nd: YAG laser is analyzed from 3 cases of severe retinal detachment. METHODS: Three men aged (40 to 59 years old) had one or more risk factors for retinal detachment: myopia, complicated cataract surgery, personal or family history of retinal detachment. Nd: YAG laser treatment onto vitreous strand was performed because of: retinal traction, repeated vitreous hemorrhage, anterior vitreous strand in a aphakic patient with cystoid macular edema. Within six weeks following Nd: YAG laser vitreolysis, severe retinal detachment with several tears occurred, complicated with proliferative vitreoretinopathy in two patients, and with choroidal hemorrhage in one. In two cases, several surgical procedures with silicon oil were required and visual acuity remained under 20/1000. In the last case retinal reattachment was obtained with scleral buckling and cryopexy, the patient recovered a visual acuity of 20/100 with a macular pucker. DISCUSSION: Retinal detachment occurred shortly after laser YAG vitreolysis. We assumed Nd: YAG laser was possibly responsible and investigated the possible mechanisms: direct retinal tear, vitreous strand traction, side effect of intraocular shock wave. CONCLUSION: Nd: YAG laser vitreolysis seems to be able to cause retinal detachment. Its use is therefore not recommended, particularly in patients at risk, especially since the efficacy of this treatment has not been proved.     

Variability in digital assessment of cortical and posterior subcapsular cataract

To identify validity of the standardised Nidek EAS-1000 retroillumination image analysis, images of 450 consecutive patients were analysed for the standard 6.5 mm and for the maximal pupil size. The software allows for separation of cortical and posterior subcapsular opacities and defines threshold for cataract automatically at 12% below the brightest point of the histogram of pixel luminescence. The results were compared with clinical Wilmer cataract grading. Correlation between clinical and digital assessment was 0.48* for cortical opacities in maximal pupil size, 0. 47* in 6.5 mm pupil size analyses, and 0.71* for posterior subcapsular opacities (*p < 0.001). In 24.6% of maximal pupil size analyses and in 11.7% of standard pupil size analyses standardisation revealed confounding features, such as other opacities of media, refractive shadows etc., that masqueraded as cataract and interfered with the cortical opacity measurements. Automatic standardized analysis has reduced many sources of observer variation (level of illumination, pupil size and threshold adjustment), but the revealed range of confounding opacities and artifacts still requires observer interpretation.     

Effect of capsulorhexis diameter on glare disability

PURPOSE: To determine whether the diameter of the anterior capsulorhexis has an effect on postoperative glare. SETTING: Sapir Medical Center, Meir Hospital, Kfar Saba, Israel. METHODS: Forty patients had extracapsular cataract extraction (manual or phacoemulsification) through an intact continuous curvilinear capsulorhexis (CCC) of various sizes. The CCC diameter was measured and the opacity of the anterior and posterior capsules was evaluated before and after dilation of the pupils. Glare test (Miller-Nadler glare tester) was performed with the eyelid in a normal position and after lid elevation. RESULTS: The diameter of the CCC ranged from 3.50 to 7.00 mm (mean 4.87 mm). The anterior capsule was always opaque in the area of contact with the IOL material. None was graded clear; 60% were graded as +3. Mean glare disability prior to pupil dilation was 12.1 +/- 8.8 (SD) and after dilation, 17.3 +/- 9.7. There was no correlation between glare disability and the diameter of the capsulorhexis, the width of the exposed opacified capsular ring, or the grading of capsule opacification (anterior and posterior). Dilation of the pupil significantly increased glare disability (P = .016), unrelated to CCC diameter. CONCLUSION: A CCC larger than 3.5 mm does not induce significant glare.     

Lives on hold: evaluation of a caregiver''s support program

BACKGROUND: With the increasing number of surgeons using phacoemulsification techniques combined with sutureless scleral tunnel and clear corneal incisions for cataract surgery, the majority of patients will undergo an uncomplicated course of visual rehabilitation requiring no more than standard topical antibiotic and steroid regimen. Occasionally--even with an uneventful surgical course--postoperative complications arise. Many of these postoperative complications can be managed medically, without surgical intervention. Topical and oral glaucoma and nonsteroidal anti-inflammatory agents play an important role in the management of postoperative cataract complications. METHODS: A review of the common postoperative complications and their medical management using topical and oral pharmaceutical agents are presented. Emphasis is placed on current trends in treatment following contemporary cataract surgery. CONCLUSION: Although the complication rate is reduced with modern cataract surgery techniques, the primary care clinician should be prepared to identify and manage the most common clinical conditions. Armed with the proper knowledge of ophthalmic medications and their possible ocular and systemic interactions, optometrists can successfully manage and co-manage many postoperative cataract complications. Common postoperative complications are reviewed, along with current treatment regiments and dosage forms.     

Can tropicamide eye drop response differentiate patients with progressive supranuclear palsy and Alzheimer's disease from healthy control subjects?

Pupillary dilation in response to dilute tropicamide eye drops has been proposed as a noninvasive diagnostic test to identify patients with Alzheimer's disease (AD). We examined 14 patients with progressive supranuclear palsy (PSP), another related neurodegenerative disorder characterized by severe widespread cholinergic deficits and known central hypersensitivity to cholinergic blockade, to determine whether they also showed a marked pupil dilation after administration of dilute tropicamide eye drops. Both PSP patients and healthy age-matched control subjects had a similar pupillary response comparable with that previously reported in AD patients. Given its lack of specificity, physicians should be very cautious in using this test for identification of patients with AD.