Tani M. Brown

The grape: an appropriate model for continuous curvilinear capsulorhexis.

The cornerstone of helping surgical trainees achieve a cost-effective level of surgical expertise and competency is provision of adequate supervised training and repetition to consolidate newly learned skills. When helping trainees learn new surgical procedures, surgical tutors often recommend dividing the procedure into the component steps. We believe this philosophy is particularly beneficial in assisting trainees master the continuous curvilinear capsulorhexis (CCC) step of endocapsular phacoemulsification. Trainee surgeons have noted phacoemulsification and capsulorhexis as the most challenging steps of the procedure, and a recent publication suggests that sculpting and fragmentation are the most difficult. Experienced surgeons readily recognize that the most important early step in safe phacoemulsification is a high-quality capsulorhexis. The use of synthetic or animal eyes as well as surgical simulators have been described in learning this step. The attendant costs and limited access of animal models and surgical simulators pose significant problems in phacoemulsification training. We suggest the use of red globe grapes (Vitus vinifera) as an alternative model for CCC training. Grapes and tomatoes have been mentioned, to our knowledge with no literature support, as being useful for practicing capsulorhexis. The grape is readily available, irresistibly cheap, and has an elastic skin

Management of marginal chalazia: a surgical approach

Chalazia are chronic lipogranulomatous inflammatory lesions resulting from the blockage of meibomian gland orifices by their complex oily secretions. Chalazia often present as painless nodules, but infected chalazia may result in preseptal cellulitis. Marginal chalazia are those located at the eyelid margin and usually result from superior extension (of a lower lid chalazion) beyond the lid margin or inferior extension (of an upper lid chalazion) beyond the lid margin. Many treatment options exist in the literature regarding the general management of chalazia, but very little is published regarding the specific management of marginal chalazia. Marginal chalazia are frequently challenging to manage due to their location, and significant debate exists as to what constitutes best practice. CASE REPORT A patient in his early forties presented with a small painless chronic left lower lid margin lesion that had persisted for several months. There was no associated ulceration, telangiectasia, bleeding, tenderness or discharge. The patient described mild lowerlidirritationandfoundthelesioncosmeticallyunattractive. The clinical features were consistent with a lower lid margin chalazion. Lower lid hygiene with bicarbonate of soda lid scrubs along with warm compresses was recommended. Oculentum hydrocortisone 2% was prescribed nocte. This management program, however, did not result in resolution of the marginal chalazion. Surgery was then performed, and this resulted in satisfactory functional and aesthetic results, evident both immediately and at 2 weeks following this procedure. QUESTIONS 1. What different treatment options for marginal chalazia have been described in the literature? Why should curettage be performed? 2. Describe the technique of performing curettage on a marginal chalazion

Upper eyelid laxity.

Dear Editor: We were pleased to read the paper by Mills et al regarding evaluation of upper eyelid position after horizontal surgical tightening in patients with floppy eyelid syndrome (FES). In their study, the main outcome measure was the change in upper eyelid margin reflex distance after standard pentagonal wedge resection, in a series of 24 eyelids in 18 patients. The authors correctly noted a limitation of their study, which was that the degree of eyelid laxity was not graded before surgery. One of the most important etiological factors in eyelid malposition is laxity of the canthal tendons. Therefore, clinical assessment of the medial and lateral canthal tendons (MCT and LCT) is essential to the understanding and management of many eyelid disorders. In 2002, we described a simple and easily remembered clinical grading scheme for assessing the normality of medial and lateral canthal tendon function in the lower lid. Moreover, our grading system described a simple clinical method of assessing pathological laxity of the lower lid, in relation to the MCT and LCT. Over the last 6 years, we have found that our grading scheme has been reliable. It is easily performed in the office, and given the large numbers of patients seen with this abnormality, is historically reproducible. This technique for assessing MCT and LCT laxity for the lower lid is carried out by using digital lid distraction in a lateral and then medial direction. The patient is seated with the eyes in the primary position. The lower lid is grasped lateral to the lower punctum. Having achieved a firm but gentle grasp of the skin and associated underlying orbicularis muscle, the lid is initially moved laterally to assess the MCT laxity, and medially for the LCT, ensuring the punctum remains apposed to the globe. For the upper lid, the examiner likewise ensures that the punctum remains on the globe while distracting the lid laterally (MCT laxity assessment) (Figure 1 [available at http://aaojournal.org]) noting the position of the medial side of the punctum in relation to fixed ocular structures. These structures for upper lid assessment are seen in (Figure 2 [available at http://aaojournal.org]). For medial distraction (LCT laxity assessment), the structures are seen in (Figure 3 [available at http://aaojournal.org]). To our knowledge, there has been no grading scheme produced for assessment of MCT and LCT laxity in the upper lid.

Management of angle-closure glaucoma in East Asian eyes : a response to argon laser iridotomy-induced bullous keratopathy, a growing problem in Japan

We were suitably impressed to read the article entitled “Argon laser iridotomy-induced bullous keratopathy—a growing problem in Japan” by Ang et al ,1 advocating a change in management of primary angle-closure glaucoma (PACG). A case of ours follows, illustrating the point that a large dosage of argon laser may be required to create an iridotomy. In 1993, a 46-year-old woman of East Asian descent presented to another hospital in Sydney, Australia with bilateral acute angle-closure glaucoma. After initial topical and systemic treatment, she underwent bilateral argon laser iridotomies (ALI). Because of her dark irides, this procedure took almost an hour to perform in each eye and was unsuccessful. She then underwent bilateral trabeculectomies, with minimal effect. …