Ursula Radax

Topical versus peribulbar anesthesia in clear corneal cataract surgery

Purpose: To evaluate the efficacy of topical anesthesia as an alternative to peribulbar anesthesia in clear corneal cataract surgery. Setting: Department of Ophthalmology, University of Vienna, Austria. Methods: In this prospective, double‐blind clinical trial, 36 patients had bilateral cataract surgeries performed from 1 to 3 months apart. Half of the patients had topical anesthesia for the first surgery and peribulbar anesthesia for the second surgery. The other half had peribulbar first and then topical. All surgery was done using a temporal clear corneal approach and bimanual phacoemulsification followed by in‐the‐bag intraocular lens implantation. Subjective pain was assessed using a visual analog scale of no pain (0%) to worst pain imaginable (100%) and intraoperative motility using a rank scale of adverse motility (−5) to ideal patient cooperation (+5). Results: Subjective pain was comparable whether topical or peribulbar anesthesia was used (mean 10.75 versus 10.97%; P > .6). Patient cooperation (motility) was significantly better when topical anesthesia was used (+2.16 versus +1.11; P = .03). There were no significant differences in complications. A peribulbar block was given in addition to the topical anesthesia in two cases. Conclusions: Topical anesthesia is a safe, effective alternative to peribulbar anesthesia in clear corneal cataract surgery.

Long-term results of combined trabeculectomy and small incision cataract surgery

Abstract We did a prospective study of 49 eyes (36 patients) with coexisting cataract and glaucoma who had combined trabeculectomy, phacoemulsification, and implantation of a folded polyHema intraocular lens through the trabeculectomy opening. Preoperatively, intraocular pressure (IOP) was controlled (< 20 mm Hg) in 13 eyes on a mean of 2.2 medications and uncontrolled (> 20 mm Hg) in 36 eyes on a mean of 2.4 medications. Preoperative visual acuity ranged from 20/40 to hand movements. At the end of the follow‐up, IOP was below 18 mm Hg in all eyes (100%), without therapy in 39 (80%) and with reduced therapy in 8 (16%). Two (4%) eyes were controlled on the same medication regimen. Visual acuity improved in 42 patients (86%); 38 (78%) achieved a visual acuity of 20/40 or better. A filtering bleb was observed in 45 eyes (92%). The most common early postoperative complication was fibrin exudation into the anterior chamber. Late complications included posterior synechias and vision‐impairing capsule opacifications. Visual acuity improved after neodymium:YAG laser treatment in all eyes with opacification without further complications. We conclude that the combination of small incision cataract surgery and trabeculectomy is a successful surgical approach for long‐term visual rehabilitation and glaucoma control.

Evaluation of 200 consecutive IOGEL 1103 capsular-bag lenses implanted through a small incision

ABSTRACT We evaluated 200 consecutive IOGEL 1103 capsular bag intraocular lenses. We performed a 5 to 6 mm capsulorhexis and inserted the intraocular lens (IOL) through a 3.5 to 4.0 mm scleral tunnel with a Faulkner folder. Twenty‐two cases were combined with trabeculectomy and ten with keratoplasty using a temporary keratoprosthesis. Mean follow‐up was six months. The implant centered well and resisted capsular shrinkage. Iris touch to the optic was rare and did not provoke persistent pigment dispersion. In one third of the cases a cleft was discernible between the posterior convex 10L surface and the extended capsule despite thorough aspiration of viscoelastic and debris from the retrolental space. In 896 of cases, white flakes of unknown origin were observed at the IOL‐capsule interface. In cases associated with pre‐existing iritis or intraoperative iris trauma (iris manipulation, iridectomy, or synechiolysis in glaucoma patients), fibrin exudation as well as iridoeapsular synechial formation and macrophage precipitation often ensued. Cellular precipitates, as evaluated by biomicroscopy and specular microscopy, were less pronounced and more transient than on poly(methyl methacrylate) IOL. Best case visual acuity results were comparable to those with conventional implants; all eyes attained 20/40 or better and 97% achieved 20/25 or better. The 1103 was easier to implant through a capsulorhexis opening and suited the dimensions of the capsular bag better than the PC‐12 model.

In vivo study of cell reactions on poly(methyl methacrylate) intraocular lenses with different surface properties

Purpose: To evaluate the biocompatibility of three poly(methyl methacrylate) (PMMA) intraocular lenses (IOLs) with different surface properties. Setting: University Eye Clinic, Vienna, Austria. Methods: Cell reactions on the surfaces of unmodified, heparin‐surface‐modified (HSM), and surface‐passivated (SP) PMMA IOLs were documented in vivo using a Zeiss specular microscope. Risk factors for such reactions were also determined. Results: During the first postoperative days, small round and spindle‐shaped cells were found on all IOLs. Cell density was higher in eyes with increased postoperative inflammation. After several days, epithelioid and foreign‐body giant cells were seen on some IOLs. Cells appeared significantly less often on the IOLs with hydrophilic surfaces (HSM) than on those with hydrophobic surfaces (unmodified, SP). Conclusion: The significantly lower incidence of foreign‐body reactions on hydrophilic than on hydrophobic IOL surfaces is consistent with the results of previous studies on hydrogel and silicone IOLs.

Combined small-incision cataract surgery and trabeculectomy--technique and results.

In a prospective study 35 eyes of 25 patients with coexisting cataract and glaucoma underwent trabeculectomy, phacoemulsification and implantation of a folded polyHema intraocular lens through the trabeculectomy opening. Follow-up ranged from 6 to 27 months (mean 13.3). The mean age was 76.4 (68 to 88 years). 22 eyes suffered from primary open angle glaucoma, 10 eyes from a pseudoexfoliation glaucoma and 3 eyes had a chronic angle closure glaucoma. Preoperatively intraocular pressure was controlled in 10 eyes with a mean medication of 2.1 but uncontrolled in 25 eyes (mean medication: 2.5). The preoperative visual acuity ranged from 20/40 to hand motions. Postoperatively intraocular pressure was controlled (<18 mmHg) in all (100%) eyes and without therapy in 32 (91%) eyes. Three (9%) eyes had to be treated with topical timolol twice a day after surgery. Mean intraocular pressure dropped from 21.2±6.0 mmHg preoperatively to 13.5± 2.1 mmHg postoperatively. Vision improved in all but 4 eyes, 25 (74%) achieving a visual acuity of 20/40 or better. The causes for failed improvement or deterioration of vision were senile macular degeneration in 2 eyes and central retinal vein occlusion and vascular optic nerve atrophy in one eye respectively. Postoperative complications included hyphema in 9 (26%) eyes, fibrin effusion to a various extent into the anterior chamber in 19 (54%) eyes and delayed hypotony (<5 mmHg) with chorioidal effusion in 1 (3%) eye. Fibrin effusion was frequently observed in eyes with intraocular pressure below 10 mmHg, iris surgery and hyphema. Finally the complications did not effect the results regarding visual acuity or glaucoma control. In summary we conclude that the combination of small-incision cataract surgery and trabeculectomy is an effective surgical approach to obtain visual rehabilitation and glaucoma control with one single surgical intervention.

Kleinschnitt-Kataraktchirurgie ohne Naht: Bericht über 100 konsekutive Fälle

ZusammenfassungDie herkömmliche Kleinschnitt-Kataraktchirurgie mit flexiblen Silikon- und Hydrogellinsen reduziert die erforderliche Schnittweite auf 3,5 bis 4 mm. Dadurch kann der Vorteil der Phakoemulsifikation voll genützt werden. Trotz verbesserter Nahttechniken ist ein induzierter Astigmatismus in der früheren postoperativen Phase jedoch unvermeidlich. Die Unterbrechung der limbalen Spange schließt einen Spätshift des Astigmatismus in die Horizontale nicht aus.Durch eine geeignete lamellierende Präparationstechnik ist es möglich, die limbale Spange unversehrt zu lassen und einen Ventilmechanismus zu schaffen, der einen spontanen und dauerhaften Wundverschluß bewirkt. Dadurch wird sowohl der nahtinduzierte Frühpeak als auch ein Spätshift des Astigmatismus vermieden. Darüberhinaus ist auch bei intraoperativen Zwischenfällen jederzeit die Dichtigkeit gewährleistet.In 100 Augen wurde über einen 4 × 4 mm Lamellenschnitt eine flexible Linse implantiert (Phakoflex®, Iogel® 1003; Prodigy®-Injektor, Faulkner-Faltpinzette). Durch Einsatz eines geeigneten Instrumentars konnte die Schnittführung optimiert werden, sodaß die anfänglich gelegentlich begegneten Probleme des Infusionsflüssigkeitausstromes und des Hornhautstromaödems während der Phakoemulsifikation und Aspiration gemeistert werden konnten. In zwei Fällen erwies sich die Wunde am Operationsende als undicht, sodaß eine Naht gelegt wurde. Während der ersten postoperativen Tage zeigte sich fallweise eine leichte Stromaschwellung im kornealen Wundbereich. Von zwei Augen abgesehen, die wegen geringfügiger Leckage am Operationsende mit Luftinjektion und Hochlage versorgt worden waren, blieben alle Wunden auf Dauer dicht. Die Hornhautkrümmung entsprach bereits am ersten postoperativen Tag weitgehend der präoperativ vorgegebenen. Eine Woche postoperativ war die Refraktion stabil und meist auch die endgültige Sehschärfe erreicht.Die no-stitch Technik optimiert die visuelle Rehabilitation wie auch die Sicherheit des Eingriffes. Präzision ist jedoch erforderlich, um lokales Hornhauttrauma und Endothelzellverlust möglichst gering zu halten. Auch bei nur geringfügiger Leckage am Operationsende sollte ein Nahtverschluß erfolgen, da sich eine innere Lufttamponade als nur temporär wirksam erwiesen hat.SummaryConventional small-incision cataract surgery with flexible lenses allows to reduce the incision width to 3.5 to 4 mm and thereby to take full advantage of the benefits of phacoemulsification. Despite sophisticated techniques suturing of the wound carries the risk of inducing early postoperative astigmatism. Also, a late astigmatic shift cannot be excluded, as the limbal arc is still compromised.A 4 × 4 mm lamellar self-sealing incision was designed. The limbal arc is spared, and, at the end of surgery, the ventile is locked by tonisizing the anterior chamber. As a suture is dispensable, early astigmatism is no more induced, and the intact limbal arc counteracts late astigmatic shifting. Moreover, tightness of the wound will be effectuated at any time during surgery in case of an intraocular pressure rise.100 eyes thus operated on received a flexible lens implant (Phakoflex®, Iogel® 1003; Prodigy®-Injector, Faulkner-Folder). Improvements in technique and instrumentation helped to avoid corneal stress folds and infusion fluid outflow initially encountered, thereby reducing endothelial cell loss and local corneal oedema. In two eyes the wound was sutured due to a major leakage at completion of surgery. Except two other eyes that had received an air bubble as an inner tamponade of a discretely leaking wound at the end of surgery, no filtering bleb or postoperative hypotony occurred.Local corneal oedema vanished within days. K-readings revealed to remain virtually unchanged compared to preoperative values. After one week refraction was stable and, in most cases, final visual acuity was attained.The no-stitch technique applied optimizes visual rehabilitation and enhances safety of surgery. However, precision is required to minimize local corneal trauma and endothelial cell loss. An even discretely leaking wound should be sutured, as the sealing effect of an air bubble may be only temporary.

No-stitch, small incision cataract surgery with flexible intraocular lens implantation

Abstract Small incision cataract surgery has several advantages over conventional surgery, including faster postoperative visual rehabilitation. We evaluated 100 consecutive cases of no‐stitch, small incision surgery with a square sclerocorneal tunnel and a flexible intraocular lens. Permanent self‐sealing of the wound seemed to increase intraoperative safety considerably. With the specific incision used, corneal trauma and irrigation fluid outflow were minimal. Refraction and K‐readings stabilized within the first postoperative week, which is when most eyes attained best final visual acuity. No early peak or protracted drift of astigmatism occurred. Minimally leaking wounds in three eyes were left unsutured; a transient filtering bleb was observed in two of these eyes after resorption of an intracameral air bubble. Our results support the theoretical concept and justify the use of no‐stitch, small incision surgery.

Evaluation of the first 100 consecutive PhacoFlex silicone lenses implanted in the bag through a self-sealing tunnel incision using the Prodigy inserter

Abstract We evaluated the performance of the PhacoFlex silicone lens with open polypropylene loops and the disposable Prodigy inserter in a series of 100 consecutive no‐stitch cases. Loading the lens into the PRO‐1 A inserter model was easy, as was inserting it through a 4 × 4 mm self‐sealing sclerocomeal tunnel incision. If the chamber was deep and the capsular fornix expanded, unfolding the polypropylene loops was safe and direct bag placement was always possible. If the capsular bag was insufficiently distended, however, the posterior loop tended to entangle with wrinkles in the posterior capsule, jeopardizing the capsule’s integrity. With a round and well‐centered 4 mm to 5 mm capsulorhexis, centration was good provided the lens was completely within the bag. Even with proper bag placement of the haptics, however, the optic occasionally decentered slightly and tilted because of secondary capture in the capsulorhexis opening. With an incomplete capsulorhexis or a jagged‐edged capsulotomy, malpositioning was not uncommon. This was due to secondary displacement of one haptic into the sulcus or partial capture of the optic by the anterior capsule leaf. Because of the flexibility of the polypropylene loops, the lenses tended to decenter and tilt following capsular shrinkage.

Ocular findings in asymptomatic amateur boxers

A group of 25 active, asymptomatic, amateur boxers were examined to evaluate the nature and incidence of ocular pathologic conditions in amateur boxing. An approximately age-matched group of 25 men who were not boxers was used as a control group. The number of fights varied from 1 to 220 (mean 39.4), and the number of spar rounds from 20 to 600 (mean 192.5). Visual acuity was 20/20 in all subjects of both groups, except for one boxer with kerato-conus. Intraocular pressure was below 20 mmHg in all eyes. In 19 (76%) boxers, pathologic anatomic findings were attributed to contusion trauma. Lesions of the anterior eye segment included injuries of the lid in 3 eyes (12%), angle abnormalities in 5 (20%), and slight lens opacities in 5 (20%). Posterior vitreous detachment was observed in 3 (12%) boxers and peripheral retinal scars were seen in 15 (60%). In 6 (24%) 3eyes, retinal tears or atrophic holes were detected. In the 7 (28%) boxers with lesions of the anterior eye segment, the posterior segment was also affected in 6 (85%). In the control group, an atrophic hole was found in one (4%) patient with no other ocular pathologic findings. It is strongly recommended that the following conditions be implemented in amateur boxing: (1) the use of head gear and thumbless boxing gloves even for short spars; (2) the use of thumbless gloves instead of thumb-attached gloves; (3) the use of the sparring head gear for bouts; and (4) dilated retinal examination before beginning amateur career and periodic ophthalmologic examinations, including a dilated vitreoretinal examination, as a mandatory part of the license examination.

Technik und Ergebnisse der Kleinschnitt-Kataraktchirurgie bei gleichzeitiger Trabekulektomie oder Keratoplastik („Modifizierte Triple-Prozeduren“)

ZusammenfassungDie Kleinschnitt-Technik mit faltbaren Silikonoder Hydrogellinsen hat gegenüber den herkömmlichen Techniken der Kataraktchirurgie gerade in der Kombination mit einer Filteroperation oder einer Hornhautverpflanzung (sogenannte Triple-Prozeduren) entscheidende Vorteile: Die Trabekulektomieöffnung muß für die Linsenimplantation nicht über den Lammellierungsbezirk hinaus erweitert werden, bei Kombination mit einer Keratoplastik können unter zwischenzeitlichem Einsatz einer speziellen Keratoprothese Kataraktoperation und Linsenimplantation im geschlossenen System durchgeführt werden. Die Vorteile liegen, abgesehen vom geringeren Aufwand und der rascheren Rekonvaleszenz, in der Verringerung von wundheilungsbedingter Entzündung und nahtinduziertem Astigmatismus, wodurch die Gefahr der Filterkissenfibrose oder Transplantateinheilungstörung minimiert wird.Technik und Ergebnisse von 46 Fällen mit gleichzeitiger Trabekulektomie und 9 Fällen mit gleichzeitiger Keratoplastik werden vorgestellt.SummaryThe advantages of small-incision cataract surgery with foldable silicone or hydrogel lenses over conventional cataract surgery become especially important when combined with a filtering procedure or a corneal transplantation (socalled “triple procedures”). Widening of the trabeculectomy opening for lens insertion is thereby restricted to the lamellated area. Using a temporary silicone keratoprothesis, cataract removal and lens implantation are allowed to be performed in a fully closed system when combined with keratoplasty. Apart from enhanced reconvalescence, the advantages consist in minimal postoperative inflammation and, as a result, in reduced fibrosis of the filtering bleb or improved transplant healing.Technique and results of 46 cases with combined trabeculectomy and 9 cases with combined keratoplasty are demonstrated.