Robert M. Feibel

Current concepts in retrobulbar anesthesia

Recently there have been major advances in the field of retrobulbar anesthesia. New agents which allow prolonged anesthesia and akinesia have been introduced. Several new techniques to administer retrobulbar anesthesia have been developed. The toxicity of local anesthetics and the complications arising from such injections have been studied, and ways to avoid and manage them have been expanded.

Postcataract Ptosis: A Randomized, Double-masked Comparison of Peribulbar and Retrobulbar Anesthesia

PURPOSE A randomized, double-masked study of 317 patients was conducted to determine if the incidence of postcataract ptosis is greater with retrobulbar or two-injection peribulbar injection anesthesia. METHODS Surgery consisted of a planned extracapsular extraction with posterior chamber lens implantation, and no superior rectus bridle suture was used. Ptosis was quantitatively documented preoperatively and postoperatively at 1, 2, 5, and 90 days by the surgeon, photographically at 90 days by a masked observer, and subjectively by the patients. Postcataract ptosis was defined as a drop in the lid margin of 2 mm or greater after correcting for any change in the fellow eye. RESULTS The incidence of ptosis at 90 days in patients given peribulbar anesthesia was 5.8% and in patients given retrobulbar anesthesia 5.5%, and this difference was not statistically significant (P = 0.90). Eighteen percent of patients in both groups reported a change in the appearance of their eyelids. There was a moderate, positive correlation among patients who reported a change in their lid position and objective measurements of ptosis. Preoperative clinical measurements of vertical lid fissure width and levator function, and the appearance of the lid crease or superior sulcus were not predictive for the development of postoperative ptosis at 90 days; the best predictor was the presence of ptosis in the immediate postoperative period. CONCLUSION The incidence of postcataract ptosis is the same whether two injection peribulbar or retrobulbar anesthesia is used.

Transient central retinal artery occlusion after posterior sub-Tenon's anesthesia

Two cases of transient central retinal artery occlusion were observed preoperatively after uneventful sub-Tenons infusion of local anesthetic for cataract surgery and intraocular lens implantation. In these eyes, the retinal circulation reperfused spontaneously before surgery and there were no visual sequelae. A third case was observed in an eye after strabismus surgery with sub-Tenons anesthesia. The patient was left with profound visual loss in this eye. The cause of this complication is unknown, but possible factors include mechanical pressure from the bolus of the anesthetic solution or localized vasoconstriction from the anesthetic, producing a decrease in ocular blood flow. Suggestions to avoid this problem include not inserting the cannula too posteriorly, not injecting forcibly against resistance, and using the minimum volume of anesthetic possible.

Anisocoria in the pigmentary dispersion syndrome.

We studied four patients with anisocoria and the pigmentary dispersion syndrome. In all patients, the larger pupil was on the side of the greater iris transillumination. The amount of anisocoria was between 0.5 and 1.5 mm and was the same in both the light and dark. There was no blepharoptosis, and all pupils dilated normally with cocaine. All of the patients were young men with myopia, and one patient had increased intraocular pressure.

John Vetch and the Egyptian ophthalmia

During the Napoleonic Wars from 1798-1815, severe epidemics of keratoconjunctivitis affected the military and civilian populations of Western Europe. This disease was known as the Egyptian ophthalmia because it was first described in troops stationed in Egypt. Most physicians believed this condition was not infectious, but caused by various climatological factors. John Vetch, a British physician, emphasized that this disease was spread by direct conveyance of pus from the diseased to the healthy eye. His insistence that the ophthalmia was contagious, and his suggestions for prevention and treatment were milestones in the history of ophthalmology.

Edward J. Curran and the concept of relative pupillary block

The historical development of the concept of relative pupillary block and its role in the pathogenesis of angle-closure glaucoma is reviewed. Prior to 1920, the mechanism of action of iridectomy in glaucoma was not understood, its indications unclear, and its technique unsatisfactory. Edward J. Currans original statement of this concept, and its cure by peripheral iridotomy, were outstanding contributions to the treatment of glaucoma. The controversial responses of other ophthalmologists are related.

Count Sir Luigi Preziosi and his glaucoma operation: The development of early glaucoma filtering surgery

Count Sir Luigi Preziosi (1888-1965) was a famous ophthalmologist from the island Republic of Malta. He received his ophthalmic training in Rome and the United Kingdom. He practiced ophthalmology in Malta for 45 years and was a professor at the University of Malta. Like many physicians in Malta, he was active in the politics and governance of his country, serving as president of the Senate, president of the National Congress to draft a new constitution, and, finally, as president of the National Assembly of Malta. His most important ophthalmologic contribution was the development of the thermal sclerostomy filtering operation for glaucoma, which he first described in 1924. He referred to this operation initially as electro-cautery puncture and later simply as Preziosis operation. Many surgeons considered this procedure an advance over the other available filtering operations such as sclerectomy, iridencleisis, and trephination. The operation was then further developed in 1957 by Harold G. Scheie of the University of Pennsylvania. Scheie referred to his procedure as peripheral iridectomy with scleral cautery, and it was a standard filtering operation for glaucoma for many years until the development of trabeculectomy.

Fred Loe, MD, and the History of Trachoma

Trachoma has been one of the most blinding diseases in the history of ophthalmology. From its initial description in antiquity until the late 1930s, no specific treatment or effective cure had been known, and the only expedient had been to destroy the diseased tissue containing the infectious agent, rendering the disease inactive. Virtually all medical, mechanical, and surgical treatments were unsatisfactory, with cure rates of approximately 20%. Therapy for trachoma had barely advanced from the measures used by the ancient Egyptian, Greek, and Roman physicians. All prior therapies became obsolete in 1938 when Fred Loe, MD, working on an American Indian reservation, introduced sulfanilamide as a treatment of trachoma, achieving a 90% cure rate. One of the most unusual aspects of Loes career was that he had no formal training in ophthalmology and was completely self-taught as an ophthalmologist.

Glaucoma as a possible risk factor for the development of pseudophakic cystoid macular edema

road to suprachoroidal filtration (increaseduveoscleral outflow), and decrease of the subconjunctival bleb, which will hypothetically avoid late hypotony and/ or blebitis. Today, the Ex-PRESS implant is successfully used under the scleral flap to simplify trabeculectomy and/or deep sclerectomy. Our paper reports the longterm results of the first insertion technique under the conjunctiva. The results had not been reported, and we thought it was important to provide the such information to the glaucoma community. However, our results should not discourage surgeons from using Ex-PRESS implants under the scleral flap. We hope many papers will soon show its usefulness, efficacy, and safety.dDelphine Rivier, MD, Sylvain Roy, MD, MSc, André Mermoud, MD

Sub-Tenon’s injection for posterior segment surgery

Abstract The following three letters address an article that appeared in the January 2000 issue of the Journal: Li HK, Abouleish A, Grady J, et al. Sub-Tenons injection for local anesthesia in posterior segment surgery. ( Ophthalmology 2000;107:41–6 )