James P. Gills

Use of small incisions to control induced astigmatism and inflammation following cataract surgery

ABSTRACT A series of 55 small incision (3 mm) silicone‐implanted cataract cases closed with horizontal sutures and a concurrent series of 48 6 mm to 7 mm incision poly(methyl methacrylate)‐implanted cases closed with radial incisions were compared retrospectively for surgically induced astigmatism. At two to three weeks after surgery, the mean surgically induced astigmatism in the poly(methyl methacrylate) group was more than twice as high as in the silicone group (2.27 D vs 1.07 D, P < .01). In addition, a series of 41 small incision cases and a concurrent series of 61 cases with 6 mm to 7 mm incisions were compared for inflammation as measured by an FC‐1000 laser flare/cell meter. The larger incision cases had significantly higher average cell counts at one day and one week postoperatively (P = .005 and P = .03, respectively) and had significantly higher average flare measurement at one day (P = .01) than the smaller incision cases.

Comparison of the accuracy of the Binkhorst, Colenbrander, and SRK implant power prediction formulas.

The prediction accuracy of the Binkhorst, Colenbrander, and SRK formulas were compared in five series from different sources totalling 654 cases. The SRK formula was superior to both the other formulas by having a smaller average error per case, a smaller range of error from highest minus to highest plus, and a smaller proportion of cases with greater than 2 diopters (D) of error in all five series studied. In four of the five series, the SRK formula also had the greatest proportion of cases with less than 1 D of error. The Colenbrander formula was superior to the Binkhorst formula in all five series with regard to average error, proportion of cases with less than 1 D of error, and proportion of cases with more than 2 D of error. The range of error from highest minus to highest plus was equivalent with the two formulas. All available published literature on the accuracy of implant power prediction formulas was reviewed and appears to support our findings.

Prevention of endophthalmitis by intraocular solution filtration and antibiotics

Gentamicin sulfate was used in a millipore-filtered irrigating solution for 12,000 cases of anterior segment surgery (extracapsular cataract extraction with posterior chamber lens implantation) without one occurrence of endophthalmitis. One instance of endophthalmitis occurred in eight cases in which unfiltered gentamicin sulfate solution was used. No side effects have been associated with the use of the millipore-filtered irrigating solution.

A technique of retrobulbar block with paralysis of orbicularis oculi

In ophthalmic surgeries requiring akinesia of the levator and orbicularis oculi muscles, a modified retrobulbar nerve block utilizing 0.75% bupivacaine hydrochloride with hyaluronidase in adequate dosage greatly reduces the need for a seventh nerve block, thus reducing patient discomfort.

Two-way irrigating needle for cortical cleanup

A 23- or 25-gauge two-way, irrigating-aspirating needle is described. The needle has the shape and conformity of the Simcoe needle, as well as the practical gravity infusion of the Pearce/McIntyre needle.

Football mnemonic for correction of preoperative astigmatism

In cases of up to 3.0 diopters (D) (usually 2.0) of astigmatism, the steep meridian is surgically approached by loosening the sutures (laces) through looser suture tension and shorter, smaller bites. In cases of up to 10.0 D of astigmatism, the wound is underlapped and the tip of the corneal bevel is sutured to the tip of the scleral bevel (Figure 2). The sutures are then buried deep in the wound. The amount of underlapping or underriding is determined by a surgical keratometer. Trial and error is necessary to achieve the correct decay factor, usually 2.0 D. Fig. 2. (Gills) The underlapping technique, showing the suturing of the corneal bevel of the tip of the scleral bed.

SUTURELESS CLOSURE FOR EXCHANGE SURGERY OF INTRAOCULAR LENSES

To the Editor: Surgically induced astigmatism is one of the major obstades to recovering potential visual acuity fully and quickly for patients who have had cataract surgery. Postoperative astigmatism, irritation, and other postoperative complications after exchange of intraocular lenses (IOLs) are more common than after primary cataract extraction and IOL implantation. Several factors affect corneal astigmatism, among them incision site and configuration with respect to the limbus, incision size, suture(s) and the pattern used to dose the incision, and the surgical technique of each operation. Incision configuration and suturing technique, among all the factors, are the major ones that cause astigmatism. In some cases, even a single radial suture can induce significant astigmatism. Sutureless dosure of a cataract wound may be the best way to dose a cataract incision since suturing may cause wound distortion, leakage, and astigmatism. We and many other ophthalmologists have reported successful sutureless primary cataract extraction and IOL implantation and have proved that sutureless cataract surgery causes less astigmatism and other suture-related complications than cataract surgery with suture(s) without major known complications. Based on the success of primary cataract extraction with IOL implantation, we performed IOL exchange surgeries in cases in wh ich primary implantation incisions were dosed without sutures. Some of these surgeries were done in combination with refractive procedures to correct pre-existing astigmatism. The following data are from the patients who had IOL exchange surgery only. Some of the primary surgeries were done by other surgeons; the period after primary surgery ranged from one day to more than four years; the primary surgery may or may not have had suture(s). All IOLs were posterior chamber lenses.