Kenneth J. Rosenthal

ASCRS White Paper: What is the association between clear corneal cataract incisions and postoperative endophthalmitis?

The relationship between unsutured clear corneal tunnel incisions and an increased incidence of infection after cataract surgery remains uncertain; however, there is a growing concern and body of evidence regarding a potential causal association. Although 2 large recent studies from the Bascom Palmer Eye Institute report no greater incidence of endophthalmitis with corneal incisions than with sclerocorneal tunnel incisions, the bulk of the recent literature suggests that post-cataract endophthalmitis is more likely with corneal incisions (Table 1). The concern is fueled by the clear evidence of an increased rate for post-cataract infections since 1994, the timeline for the widespread use of unsutured clear corneal cataract incisions. Indeed, laboratory models indicate that corneal tunnel incisions do not provide hermetic sealing under certain conditions. These investigations suggest that the incisions may be competent at physiologic levels of intraocular pressure (IOP) but fail when IOP is lowered. Critics of the reports, in which human cadaver eyes are used, raise the valid issue that post-mortem eyes lack the corneal endothelial pump mechanism thought to be partly responsible for maintaining incisional self-sealing. Nonetheless, there is a genuine concern regarding the relationship between clear corneal incisions (CCIs) and rates of postoperative infection, suggesting that we carefully evaluate the potential. A recent report in this journal revealed that all cases of endophthalmitis at the Moran Eye Center at the University of Utah from 1996 through 2002 were associated with unsutured clear corneal incisions. During this

Deep, topical, nerve-block anesthesia

Abstract Retrobulbar anesthesia produces profound anesthesia but involves risks such as hemorrhage and ocular tissue damage. Simple topical anesthesia is safer but does not produce the same depth of anesthesia. I have developed a technique that places a lidocaine‐soaked sponge deep in the conjunctival fornices. This deep, topical, “nerve‐block” technique produces a level of anesthesia previously seen only with injection techniques. I present the results of using this technique in 81 cataract extraction and intraocular lens implantation procedures. Supplemental injection was used in only two patients. The technique has advantages over injection and topical methods of anesthesia and is applicable to a variety of surgical procedures.

Transillumination defects following in-the-bag single-piece intraocular lens implantation and trabeculectomy with mini-shunt.

An 80-year-old woman of mixed ethnicity developed significant iris transillumination defects following phacoemulsification with in-the-bag implantation of a single-piece hydrophobic acrylic intraocular lens (IOL) and trabeculectomy with insertion of an Express mini-shunt. With the exception of modest anterior chamber shallowing in the first few weeks postoperatively, the surgery and postoperative course were uneventful. The observed iris defects are thought to have been caused by contact between the IOL-capsule complex and the posterior iris during shallowing of the anterior chamber. No other cases in the peer-reviewed literature have identified iris defects secondary to implantation of a single-piece monofocal hydrophobic acrylic IOL when the optic and haptics remained entirely within the capsular bag.

Technique to avoid cortical entrapment in early insertion of capsular tension rings

I congratulate Koplin et al. on taking further steps to control potential complications of cortex removal in the presence of a capsular tension ring (CTR). Their technique addresses the important problem of cortical entrapment in early CTR insertion, which I have stressed in teaching the CTR insertion technique since performing cases during U.S. Food and Drug Administration clinical trials starting in the late 1990s. In 2002, I introduced a key concept regarding the timing of placement of the CTR. The now well-engrained concept is that the CTR should be placed “as early as necessary, and as late as possible” to avoid the problem of cortical removal, when possible, by insertion after nuclear and cortical removal, on the one hand, versus stabilizing the capsular bag early on, when needed in more profound cases of zonulopathy, to avoid capsule dislocation or loss. In that same paper, I introduced a similar technique to that of Koplin et als as follows: (1) The anterior cortex is removed immediately after capsulorhexis formation using an irrigation/aspiration handpiece. (2) Then, a cohesive ophthalmic viscosurgical device is placed immediately under the anterior capsule rim to displace the anterior and equatorial cortical fibers and nucleus posterior to the equator, creating a sub anterior capsule space. (3) Next, the CTR is introduced immediately under the anterior capsule rim under direct visualization into the newly created space and anterior to the now retroplaced anterior and equatorial cortical strands. I have used this technique for more than 15 years in hundreds of cases with no cortical entrapment, even when the CTR was inserted before removal of the nucleus and the remainder of the cortex. It holds the advantage of making it possible to insert the CTR immediately after capsulorhexis formation before any nuclear manipulation occurs and is invaluable when a high degree of zonular fiber instability is noted at the onset of the surgical intervention. The use of bothmy technique andKoplin et al.s is valuable in preventing cortical entrapment and enables uneventful placement of the CTR when required early in the case.