Topical versus peribulbar anesthesia, without sedation, for clear corneal phacoemulsification.

PURPOSE: To investigate patient and surgeon acceptance of topical anesthesia as an alternative to peribulbar anesthesia for clear corneal phacoemulsification. SETTING: Department of Ophthalmology, Whipps Cross Hospital, London, England. METHODS: All cataract surgery was performed using a temporal clear corneal approach, bimanual phacoemulsification, and in-the-bag intraocular lens implantation. The results of 51 patients having surgery under topical anesthesia (amethocaine) were compared with those of 30 patients having peribulbar anesthesia (50:50 mixture of lignocaine 2% and bupivacaine 0.5% with hyaluronidase). No sedation was used in either group. Pain perception on administration of the anesthetic, perioperatively (period immediately surrounding and during surgery), and postoperatively was assessed using a visual analog scale from 0 to 10 (0 = no pain: 10 = worst pain imaginable). A questionnaire was used to assess the degree of patient and surgeon satisfaction. RESULTS: Administration of topical amethocaine was significantly less painful than peribulbar bupivacaine (P = .03). Perioperative pain showed a trend toward being worse in the topical anesthesia group but did not reach statistical significance. There was no difference in the postoperative pain scores of the two groups. The surgical experience was rated very satisfactory by 67% in the topical group and 73% in the peribulbar group. The surgeons reported no difficulties or complications. CONCLUSION: Topical anesthesia was safe and effective for clear corneal phacoemulsification and was well tolerated by patients. The slightly greater awareness of ocular discomfort in the topical group perioperatively did not alter patient satisfaction with the surgical experience when compared with the peribulbar group.

Topical anaesthesia for phacoemulsification surgery.

Although phacoemulsification with only topical anaesthesia is possible, the level of any discomfort perceived by the patient is unknown. Topical anaesthesia eliminates any risk of inadvertent ocular or orbital injury. Twenty-four patients undergoing phacoemulsification under only topical anaesthesia (g. amethocaine 1%) were compared with 23 patients undergoing the same procedure with peribulbar anaesthesia (5 ml lignocaine 2%, 5 ml bupivacaine 0.5% and 75 units hyaluronidase). Perceived pain on administration of the anaesthesia, per-operatively and post-operatively was assessed by a nursing officer using a visual analogue scale (0-10). It was found that there was no difference in pain score between the two groups on induction of anaesthesia. Per-operatively and post-operatively scores were higher in the topical group than in the peribulbar group (p < 0.05, Mann-Whitney U-test), though most of these were within the range 0-3, ('no pain' to 'slight pain'). There was no difference in the amount of analgesia dispensed to the two groups on the ward post-operatively. In conclusion, topical anaesthesia provides adequate anaesthesia for phacoemulsification. Although a small increase in the level of discomfort was observed, the pain levels reported were small and may not be clinically significant when set against the reduced incidence of anaesthetic-related complications.

Postoperative blunt trauma to 7.5 mm scleral pocket wounds.

Two patients received blunt trauma to the operated eye after phacoemulsification cataract surgery. Both patients had a three-step 7.5 mm chord width, 3.0 mm long, curving incision, extending from sclera into clear cornea. One patient had rupture of the scleral tunnel and horizontal suture 20 days after surgery. The intraocular lens was dislocated into and along the scleral tunnel. The second patient had direct trauma four days after surgery, resulting in cheese-wiring of the horizontal nylon 10-0 suture and wound leakage but no other sequelae. Blunt trauma after scleral pocket phacoemulsification cataract surgery may result in clinical wound dehiscence if sufficient force is sustained.

Influence of oral acyclovir on ocular complications of herpes zoster ophthalmicus.

The role of oral acyclovir (ACV) in the management of immunocompetent patients with herpes zoster ophthalmicus remains controversial. We have performed a retrospective, comparative, case-control study of cases seen in the Zoster Clinic at Moorfields Eye Hospital over the last 5 years. A standard proforma was used during this period to collect data on the rash, ocular involvement and treatment. There were 419 immunocompetent patients of whom 77 were treated with oral ACV prior to attending the clinic. We compared these with paired controls matched for age, sex and severity of rash. No difference in the rate of ocular complications between treated and untreated patients could be detected. This suggests that oral ACV as currently prescribed has little or no preventive effect on the ocular complications of ophthalmic zoster.

Possible latent infection with herpes simplex virus in the mouse eye.

Herpes simplex virus (HSV) was isolated from organ cultures of anterior segments of the eyes of mice inoculated with virus on the snout or directly onto the cornea at least 5 weeks previously. The frequency of isolation of the virus was not decreased by treatment of the animals with acyclovir, suggesting that the virus is latent by the criteria usually applied. Peroxidase-antiperoxidase staining of organ cultures that had shed virus showed that viral antigens were predominantly present in the anterior uvea. Inoculation of mouse eye anterior segments in vitro showed that this tissue was the most susceptible to productive infection. These results suggest the possibility that HSV can establish a latent infection in tissues of the anterior segment of the mouse eye.

Severe herpetic keratitis. II. The costs associated with penetrating keratoplasty.

We report a study on 100 patients with severe herpetic keratitis. Overall, one in three of the study group required a penetrating keratoplasty (PK). These patients required a mean of 18 days as an inpatient and 15 outpatient visits in the year the PK was performed; these figures fell to 1 inpatient day and 8 outpatient visits in the second year after surgery. The financial cost of such therapy is discussed.

Severe herpetic keratitis. I: Prevalence of visual impairment in a clinic population.

We report a prevalence study of the best visual acuity in the affected eye of 100 selected patients with herpetic keratitis seen during a two-year period. Sixty-two patients retained an acuity of 6/9 or better without requiring penetrating keratoplasty (PK). The prevalence of reduced visual acuity severe enough to warrant PK was 33%. Patients requiring PK for whom full clinical records were available suffered a mean of 6.8 episodes of keratitis. In this group of patients the vision of 18 fell from 6/6 to 6/60 over a mean period of 8.5 years. Once visual acuity was permanently reduced to 6/12, 78% of patients proceeded to lose vision to 6/60. Unilateral visual impairment occurs in at least a third of patients with severe herpetic keratitis. Once vision falls permanently to 6/12, the long-term prognosis for vision appears to be poor.

Requirements and characteristics of 500 consecutive patients consulting an ophthalmic medical practitioner.

This paper reports the results of a prospective survey on 500 consecutive patients consulting an ophthalmic medical practitioner. The reason for consultation, and results of refraction and examination were analysed. The majority required only a refraction. One in 8 visits was for primary ophthalmic health care other than refraction. An abnormality of the visual system (other than refractive error) was present in 19% of patients. Five per cent required referral to their general practitioner.

Phenylephrine-induced reversible cataract in the mouse.

Topical 10% phenylephrine will produce lens opacities in several strains of mouse. These lens opacities resolve spontaneously within 24 hours, leaving an apparently normal eye. Phenylephrine-induced lens opacification in the mouse can be prevented by covering the eye with ointment, suggesting that the underlying mechanism is transcorneal dehydration.

Does herpes simplex virus establish latency in the eye of the mouse?

Clinically scarred and neovascularised corneas observed after zosteriform spread of herpes simplex virus (HSV) to the eye of the mouse were found to contain chronic inflammatory cells with a loose retrocorneal membrane. Goblet cells were found in the corneal epithelium. The trigeminal ganglia of such animals were latently infected with HSV. Whereas HSV was not isolated from eye-washings of diseased eyes, it was isolated from some anterior segments after culture in vitro for up to 13 days. When anterior segments were halved sagittally, HSV could not be isolated from the halves assayed immediately, whereas it was isolated from some of the other halves after organ culture. The possibility of ocular latency is discussed.

Herpes simplex virus isolation in chronic stromal keratitis: human and laboratory studies.

The corneal discs of 41 patients with scarring reminiscent of herpetic infection were organ cultured for HSV isolation. Of the 41 patients, 34 had a definite history of herpetic keratitis, from 10 of whom (29.4%) HSV was isolated. There were no clinical features which distinguished between these groups; there was however an indication that those from whom HSV was not isolated had been previously treated with substantial amounts of topical acycloguanosine. In three patients of 12 patients when the disc was separated into 7 parts using a punch technique, virus was isolated exclusively from those portions demonstrating clinical scarring. Electron microscopy (EM) demonstrated HSV particles in stromal cells in the cultured corneas of seven patients. In two of the patients no virus was detected prior to culture with EM. In one patient HSV antigen was not found using peroxidase-antiperoxidase (PAP) staining prior to subsequently positive organ culture. Studies were made to determine how HSV accedes to the corneal stroma using a murine model in which keratitis occurs by zosteriform spread of HSV following inoculation of the snout. Preliminary evidence using PAP staining indicates that the virus reaches the stroma at the same time as the epithelium, via the sensory nerves. Evidence of HSV persistence in anterior segments was obtained in the same model, in contrast to which no virus could be isolated following direct inoculation into the cornea. It is speculated that for virus to set up a longterm association with the stromal keratocyte, it must be introduced via the sensory nerve.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence of conjunctival colonization by bacteria capable of causing postoperative endophthalmitis.

Increased awareness of the range of pathogens capable of causing postoperative endophthalmitis prompted a study of the conjunctival flora in 100 patients admitted for intraocular surgery. Bacteria capable of causing endophthalmitis were present in 74% of these patients, a much higher proportion than previously documented. No correlation was found with blockage of the nasolacrimal duct.

Function of an ophthalmic "accident and emergency" department: results of a six month survey.

A retrospective analysis was carried out of all patients attending the casualty department of Southampton Eye Hospital during 1 February to 31 July 1983. During the six month period 8092 patients made a total of 13 544 visits. Of these patients, 6178 were attending the hospital for the first time and 1914 had previously been seen in the outpatient clinic; many did not fall into the category of "accident and emergency." Some 37% of patients were managed by the ophthalmic nurse alone. The findings show that the department was providing a service far in excess of its defined function, which suggests that the structure of the acute ophthalmic services may require change. Certainly the value of the ophthalmic nurse was beyond question, her active participation in management allowing the doctor more time with the more complex clinical problems and thus enhancing efficiency.