Corneal endothelial damage associated with phacoemulsification

Ergonovine maleate (EM) is a powerful stimulant of human tubal motility. It has been therefore thought that EM could interfere with normal ovum transport and serve as a contraceptive. The tube activating effects of EM and methyl EM were evaluated in 14 women and results confirmed that both are powerful stimulants of the human Fallopian tube. EM immediately post coitus significantly reduces the conception rate.     

Intraoperative miotics and posterior capsular opacification following phacoemulsification with intraocular lens insertion

BACKGROUND AND OBJECTIVES: Posterior capsular opacification (PCO) is a frequent complication following phacoemulsification with intraocular lens (IOL) implantation. A series of consecutive patients receiving capsular bag-fixated, silicone IOL implants were assessed for both incidence of PCO and the administration of intraoperative miotics. PATIENTS AND METHODS: During a 5-year period, 477 consecutive eyes were retrospectively evaluated. Surgeries were grouped according to intraoperative miotic agent: 0.01% carbachol or 1.0% acetylcholine. Patients receiving no miotic drug served as a control group. Yttrium-aluminum-garnet (YAG) laser posterior capsulotomy was performed on patients with clinically significant PCO. RESULTS: The percentage of eyes requiring YAG laser capsulotomy was similar for the three groups: 21.6% (25 of 91) for the carbachol group, 18.4% (14 of 62) for the acetylcholine group, and 18.6% (53 of 232) for the control group. A chi-squared analysis indicated that the difference among the groups was not statistically significant. The three groups also had similar average follow-up times between surgery and YAG capsulotomy (carbachol group = 52.2 weeks, acetylcholine group = 47.5 weeks, and control group = 48.3 weeks). CONCLUSION: Intraocular miotics do not increase the incidence of PCO.     

Corneal neovascularization after penetrating keratoplasty

The purpose of this study was to delineate the patient and surgical factors that contribute to the development of corneal neovascularization (CNV) after penetrating keratoplasty (PK). Thirty-six eyes of 36 patients with no antecedent CNV were enrolled in the study. Grafts were sutured to the host with 16 10-0 nylon sutures with the knots buried alternately in either the host or donor corneal stroma. Multiple perioperative factors were recorded for each patient, and at each postoperative visit systematic corneal drawings were used to follow the development of neovascularization. The stroma adjacent to each suture of each graft was given a neovascularization score based on the extent of vessel growth toward the wound interface. Univariate and multivariate analyses were performed, including generalized estimating equations logistic regression where each eye is considered a cluster of observations. Thirty-four patients without preoperative CNV or inflammation were followed prospectively for 6-9 (mean, 7) months after PK. Fourteen eyes (41%) developed some degree of CNV. Indication for keratoplasty, age, gender, phakic status, and size of donor button were not risk factors for CNV development. The most significant risk factor identified for any degree of CNV was placement of the suture knot in the host stroma (p = 0.00007), with the overall relative risk of CNV associated with these knots over 2 (95% confidence interval, 1.1-4.2). Furthermore, the mean recipient size in eyes with postoperative CNV was larger than eyes that did not develop neovascularization (p = 0.015), and active blepharitis was associated with a fivefold increase in the risk of developing CNV to the wound edge (p = 0.008). Embedding suture knots in the host stroma, active blepharitis, and a large recipient bed are significantly associated with postkeratoplasty CNV.     

Corneal sensation after cataract and refractive surgery

Most surgical procedures involving the anterior segment of the eye disrupt the normal organization of corneal innervation. Since denervation of the cornea results in impaired epithelial wound healing, increased epithelial permeability, decreased epithelial metabolic activity, and loss of cytoskeletal structures associated with cellular adhesion, it is important to identify the factors that determine the extent of neural regeneration. Mechanisms of corneal nerve damage and studies of corneal nerve fiber loss and reinnervation after cataract and refractive surgery--epikeratophakia, cryokeratomileusis, keratomileusis in situ, photorefractive keratectomy, laser in situ keratomileusis, and phacoemulsification--are reviewed and the decrease in corneal sensitivity, as a measure of corneal destruction and corneal metabolism, after these surgical procedures is compared.     

Vitrectomy for retained lens fragments after phacoemulsification

PURPOSE: Posterior lens fragments after phacoemulsification can be a serious complication of cataract surgery. This study is designed to evaluate the clinical features of eyes after pars plana vitrectomy has been performed to remove posteriorly dislocated lens fragments after phacoemulsification. METHODS: The authors performed a retrospective chart review of 126 consecutive eyes of 126 patients with dislocated lens fragments after phacoemulsification, managed with pars plana vitrectomy at Associated Retinal Consultants of Michigan. These eyes were operated on from January 1986 through January 1996. RESULTS: The relation of the intervals between cataract surgery and vitrectomy to various postoperative clinical parameters was studied. Clinical features at presentation included elevated intraocular pressure (IOP over 25 mmHg) in 52.4% of the eyes, uveitis in 69.6%, and corneal edema in 50.8%. Initial visual acuity was 20/400 or worse in 73.8% of the eyes. The mean preoperative visual acuity was 20/278 (median, 20/400), whereas the mean final visual acuity was 20/40 (median, 20/50) after a mean follow-up of 18.9 months. Retinal detachments were found in 20 eyes: 7 before vitrectomy and 13 during or after it. After surgery, 44% of eyes achieved a final visual acuity of 20/40 or better and 90% were 20/400 or better. The distribution of best-corrected final visual acuities among the eyes showed statistically significant differences based on the type of intraocular lens (IOL) used, with posterior chamber IOL greater than anterior chamber IOL, and anterior chamber IOL greater than aphakia. Reasons for a poor visual outcome included persistent corneal edema (four eyes), retinal detachment (two eyes), central retinal vein occlusion (two eyes), age-related macular degeneration (two eyes) glaucoma (one year), and endophthalmitis (one eye). CONCLUSIONS: There were no statistically significant differences between early (< 7 days) and delayed (8 days or more) vitrectomy when increased IOP, corneal edema, choroidal effusions, cystoid macular edema, and visual acuity were analyzed. The use of vitrectomy to remove posteriorly dislocated lens fragments has been shown to be an effective treatment method that significantly reduces the inflammatory response and hastens visual recovery.     

Corneal shape changes after pars plana vitrectomy

BACKGROUND: The modern practice of using artificial light to extend waking activities into the nighttime hours might be expected to precipitate or exacerbate bipolar illness, because it has been shown that modifying the timing and duration of sleep can induce mania in susceptible individuals. With this possibility in mind, we treated a patient with rapidly cycling bipolar illness by creating an environment that was likely to increase and to stabilize the number of hours that he slept each night. METHODS: We asked the patient to remain at bed rest in the dark for 14 hours each night (later this was gradually reduced to 10 hours). Over a period of several years, his clinical state was assessed with twice-daily self-ratings, once-weekly observer ratings, and continuous wrist motor activity recordings. Times of sleeping and waking were recorded with sleep logs, polygraphic recordings, and computer-based event recordings. RESULTS: The patient cycled rapidly between depression and mania and experienced marked fluctuations in the timing and duration of sleep when he slept according to his usual routine, but his sleep and mood stabilized when he adhered to a regimen of long nightly periods of enforced bed rest in the dark. CONCLUSIONS: Fostering sleep and stabilizing its timing by scheduling regular nightly periods of enforced bed rest in the dark may help to prevent mania and rapid cycling in bipolar patients.     

Corneal shape changes after scleral buckling surgery

PURPOSE: A prospective study was conducted to investigate the corneal shape changes due to scleral buckling surgery. These changes were analyzed based on the type of buckling procedures performed. METHODS: A total of 89 eyes from 88 patients were stratified into four groups based on the type of buckling procedures used, including:group A, local buckling; group B, encircling; group C, encircling with vitrectomy; and group D, encircling with additional segmental buckling. These eyes underwent keratometry and videokeratography examinations before surgery as well as at 1, 3, and 6 months after surgery. RESULTS: No statistical significance was observed in the amounts of the induced corneal astigmatism and the refractive cylinder among the four groups. After local or segmental buckling (groups A and D), corneal steepening, which corresponded to the buckle, occurred at a high incidence. After encircling (groups B and C), either peripheral corneal flattening with focal central steepening or flattening on one side with coupled steepening on the opposite side was observed. Such corneal changes persisted for up to 6 months in an irregular and asymmetric configuration. CONCLUSIONS: All four types of circumferential scleral buckling surgery were found to produce prolonged irregular and asymmetric corneal shape changes, whereas the patterns of the changes differed depending on the buckling procedures used.     

Corneal topographic changes after frown and straight sclerocorneal incisions

PURPOSE: To compare the corneal topographic changes following cataract surgery with two types of sclerocorneal tunnel incisions for implantation of 6.0 mm optic poly(methyl methacrylate) intraocular lenses. SETTING: University Eye Hospital, Vienna, Austria. METHODS: This prospective, unmasked, and unrandomized study comprised 48 otherwise healthy eyes scheduled for cataract surgery. A 4.5 mm sutureless frown incision was made in 22 eyes and a 6.0 mm straight sclerocorneal incision with a horizontal 10-0 nylon infinity suture in 26 eyes. Preoperatively and 1 week and 1 and 3 months postoperatively, corneal topography was recorded by the TMS-1 computer-assisted videokeratoscope (Computed Anatomy, Inc.). The data were evaluated by batch-by-batch analyses of the paired differences between the records. The significance of topographic changes was calculated by paired Wilcoxon tests; group comparisons were made using Wilcoxon tests. RESULTS: In both groups, horizontal steepening and lower corneal flattening were consistently 0.4 diopter (D). Upper peripheral corneal flattening at 1 week and 1 and 3 months postoperatively was 0.7, 0.7, and 0.7 D, respectively, in the straight-incision group and 0.7, 0.4, and 0.3 D, respectively, in the frown-incision group. Vertical flattening and horizontal steepening were significant in both groups (P < .01). Group comparisons revealed significant differences in only 15 of 225 areas (P < .05). CONCLUSION: There were no major differences between the two incision groups in surgically induced topographic changes.     

Posterior capsule opacification after cataract surgery in patients with uveitis

PURPOSE: To compare the incidence rate of posterior capsule opacification (PCO) after phacoemulsification and standard extracapsular cataract extraction (P/ECCE) in eyes with antecedent uveitis with the incidence rate in eyes without any history of intraocular inflammation. DESIGN: Review of records of 108 eyes of 78 patients with uveitis and 122 eyes of 106 patients with no uveitis who underwent P/ECCE. Rates of PCO were compared by the log-rank test of differences in the Kaplan-Meier survival curves. Proportional hazards regression models provided estimates of the relative risks of PCO among uveitic compared to nonuveitic eyes. MAIN OUTCOME MEASURES: Performance of neodymium: YAG laser posterior capsulotomy was used as a proxy measure for the main outcome of visually significant PCO. RESULTS: Study patients ranged in age from 6 to 81 years (median, 44.5 years) among those with uveitis and 27 to 96 years (median, 68.5 years) among those without uveitis (P = 0.0001). Crude incidence rates for visually significant PCO were 54% over a mean follow-up of 4.3 years in uveitic cases and 40% over a mean follow-up of 3.9 years among nonuveitic cases (P = 0.02). Estimates of PCO incidence (95% confidence interval) in uveitic eyes derived from the Kaplan-Meier models were 38.5% (range, 28.9%-48.2%) at 1 year and 56% (range, 45.8%-66.3%) at 3 years, and estimates among nonuveitic eyes were 11.5% (range, 6.2%-16.8%) at 1 year and 38.4% (range, 29%-47.8%) at 3 years. These rates of PCO among patients with uveitis and those patients without uveitis differed significantly by the log-rank test (P = 0.004). However, after adjusting for the younger age of patients with uveitis, the rates of PCO were no longer statistically different. CONCLUSIONS: The apparent higher rate of PCO in patients with uveitis is primarily due to their younger age at the time of surgery. A moderately increased independent risk of PCO from uveitis cannot, however, be ruled out by this study.     

Reduced intraocular pressure after phacoemulsification and posterior chamber intraocular lens implantation

PURPOSE: To ascertain whether phacoemulsification with posterior chamber intraocular lens (IOL) implantation causes long-term reduction in intraocular pressure (IOP). SETTING: Private practice, Kempten, Germany. METHODS: Intraocular pressure was measured in both eyes of 120 consecutive patients who were unilaterally phakic after phacoemulsification a mean of 17 months +/- 17 (SD) previously. Mean age of the 36 men and 84 women was 76 +/- 10 years. Data were analyzed using binomial distribution and the Wilcoxon signed-rank test. RESULTS: The median ratio of IOP in the pseudophakic eye to IOP in the phakic eye was 0.83. The IOP was lower in the pseudophakic eye in 96 patients (80%). The median IOP was 12 mm Hg in the pseudophakic eyes and 14 mm Hg in the phakic eyes (P < .001). As measured by the interquartile range, IOP distribution was more centered in the pseudophakic than in the phakic eyes (3 versus 4). The IOP in the pseudophakic eyes remained lower to the last measurement, 5 years postoperatively, and appeared to be independent of patient age. Lower IOP in the pseudophakic eye was consistently present in patients with higher IOP in the phakic eye (16 to 22 mm Hg). CONCLUSION: Phacoemulsification with posterior chamber IOL implantation reduced IOP in most but not all patients with a preoperative IOP of 22 mm Hg or less. This reduction was maintained over several years, with the cause yet to be established. Lower IOP may decrease the risk of subsequent glaucomatous nerve damage in these patients.     

Corneal astigmatism after clear corneal and corneoscleral incisions for cataract surgery

PURPOSE: To compare the astigmatism induced by clear corneal incisions (CCIs) and corneoscleral tunnel incisions (CSIs) for cataract surgery over 6 months. SETTING: Rotterdam Eye Hospital, rotterdam, The Netherlands. METHODS: Thirty-five patients having phacoemulsification were recruited prospectively; 15 had CCIs and 20, CSIs. Corneal topography was performed by computerized videokeratoscopy preoperatively and 6 months postoperatively. The change in keratometric astigmatism was calculated using the absolute magnitude and vector analysis methods. RESULTS: There was no significant difference between the change in astigmatism produced by the two incisions (Student's t-test). CONCLUSION: The CCI for cataract surgery did not produce significantly greater astigmatism than the CSI. Concern over CCIs having a greater risk of increasing corneal astigmatism is unfounded and does not justify withholding the technique from patients it could benefit.     

Non-Hodgkin lymphoma of brain occurring after cardiac transplantation

This case report concerns a case of NHL which affected a 56 year-old patient after cardiac transplantation. The patient was hospitalized because of worsening congestive failure. Despite maximal medical treatment the patient continued to be in NYHA Class III-IV and underwent orthotopic cardiac allograft transplantation. The NHL developed in the CNS eighteen months after surgery and had a very quick lethal progression.     

Corneal wound healing after laser in situ keratomileusis in rabbits

BACKGROUND: The aim of this study was to characterize the cell biology of wound healing in rabbit corneas subjected to laser in situ keratomileusis (LASIK). METHODS: Rabbit corneas underwent LASIK with various multizone photoablations or only a lamellar keratotomy followed by repositioning of the flap. We looked for indications for an active wound healing process. Immunohistochemistry for the extradomain A cellular fibronectin (EDA-cFn) or tenascin (Tn) and routine histology were examined. RESULTS: Four days after LASIK or lamellar keratotomy followed by repositioning of the flap, epithelial plugs and prominent keratocytes as well as Tn and EDA-cFn immunoreactions-indicative of a wound-healing process-appeared in the wound margins. Epithelial plugs were less conspicous, and prominent, presumably activated, keratocytes were no longer identified at the wound margin at 2.5 and 5 months after wounding. However, EDA-cFn and Tn immunoreactivities could still be observed. Only the stromal cells located in the periphery of the flap and in relatively close contact with the epithelium were surrounded by scar tissue expressing immunoreactivity for EDA-cFn or Tn. The central corneal stroma was devoid of scar tissue. CONCLUSION: Results indicate that the wound healing reaction after LASIK takes place only at the periphery of the microkeratome wound, leaving the central optical zone clear.     

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.     

Hodgkin''s disease occurring in a child after liver transplantation

Broiler chicks were treated by oral gavage on the day of hatch with a continuous-flow competitive exclusion culture (PREEMPT). At 4 h, 1 day, or 2 days posttreatment, chicks were challenged by oral gavage with 10(2) or 10(4) Salmonella CFU to determine the effects of challenge time on Salmonella cecal colonization. Cecal propionic acid concentrations in two trials increased (P < or = 0.001) within 1 day posttreatment in chicks given PREEMPT, and the increases were indicative of the establishment of the PREEMPT bacteria. Salmonella cecal populations decreased (P < or = 0.001) on average 6 log10 units in these two trials in chicks challenged 4 h posttreatment with 10(4) Salmonella CFU. In a third trial propionic acid did not increase significantly until 2 days after treatment, and there was no decrease in Salmonella colonization when chicks were challenged at 4 h after treatment. However, there were decreases in that same trial when chicks were challenged at 1 and 2 days after treatment. The early establishment of PREEMPT followed by challenges with 10(2) and 10(4) Salmonella CFU resulted in 3% and 3%, respectively, of the ceca testing Salmonella-culture-positive, compared to 28% and 95%, respectively, culture-positive ceca in untreated chicks. The results from this study indicated that in most instances young broiler chicks can be protected against cecal colonization when challenged with 10(2) and 10(4) Salmonella CFU as early as 4 h posttreatment on the day of hatch with the PREEMPT bacteria.