Reduction of pupillary constriction during cataract surgery using suprofen.

The efficacy of a new nonsteroidal anti-inflammatory agent, suprofen, for reducing pupillary constriction during cataract surgery was ascertained in a double-masked, multicenter, clinical study. Prior to surgery 1.0% suprofen or a placebo was instilled; the surgeon's normal regimen of mydriatics and cycloplegics was used. Suprofen (209 patients) was far more effective than the placebo (203 patients) in maintaining a dilated pupil prior to intraocular lens (IOL) implantation (or instillation of a miotic). The mean pupillary area prior to IOL implantation was 6.3 sq mm larger (20% larger) in patients treated with suprofen than in patients receiving the placebo. The investigators' subjective evaluations of the adequacy of pupil size for IOL implantation and of the difficulty of IOL implantation favored patients treated with suprofen over those receiving the placebo.

Argon laser debridement of the posterior capsule: a potential treatment for posterior capsule opacification after extracapsular cataract surgery.

We treated an opacified membrane on the anterior surfaces of the posterior capsule of two cynomolgus monkeys that had undergone extracapsular cataract extraction and intraocular lens insertion. After development of opacification of the posterior capsule, argon laser energy was employed in an attempt to debride the capsules while maintaining structural integrity of the capsule. With this technique, small areas of destruction of the membrane on the anterior surface of the posterior capsule were created with preservation of the capsule.

Management of the posterior capsule before and after the YAG laser.

A retrospective chart review of 2,514 consecutive posterior chamber implants was carried out to assess the management of the posterior capsule when vision loss dictated intervention. The capsulotomy technique used between May 1977 and March 1983 was pars plana posterior capsulotomy (227 eyes). All posterior capsulotomies performed after April 1, 1983 were with the YAG laser (342 eyes). Comparison of the complications with the two methods showed considerable differences. Anterior segment problems appear greater following YAG laser posterior capsulotomy than pars plana posterior capsulotomy, whereas posterior segment complications appear similar in both techniques. Comparison of CME following both techniques indicates that a delay of 6 months or more between cataract surgery and posterior capsulotomy is advisable.

Cystoid macular edema in pseudophakia.

Cystoid macular edema after cataract surgery, with or without intraocular lens implantation, has been reported to develop in more than 50% of patients as detected by fluorescein angiography. It is associated with reduced visual acuity in up to 8% of cases. Analysis of ongoing clinical trials at the Wilmer Institute indicates that clinically significant cystoid macular edema develops in a lower percentage of cases (2% total incidence and 0.3% persistent cystoid macular edema) if the intraocular lens implantation was uncomplicated. The factors associated with cystoid macular edema and the importance of considering clinically significant rather than just fluorescein-proven cystoid macular edema are discussed. Results of intraocular lens studies reported to the Federal Drug Administration are updated, and results of an ongoing study of prostaglandin inhibitors at the Wilmer Institute are reported.

A simple wick for fluid drainage during anterior segment surgery.

A wick, fashioned from a Mentor Merocel instrument wipe, serves as a simple and effective means for drainage of irrigation fluids during intraocular surgery.

Posterior chamber intraocular lenses at the Wilmer Institute: a comparative analysis of complications and visual results.

Intraocular lens (IOL) implantation is now accepted as the most effective means of aphakic correction in selected patients undergoing cataract surgery. In terms of final rehabilitation, however, complications such as corneal oedema, retinal detachment, and cystoid macular oedema remain problematic. Results of prospective concurrent trials of IOL implantation performed at the Wilmer Institute are presented, with particular reference to the posterior chamber intraocular lens and with specific emphasis on postoperative complications.

Neodymium-YAG laser for posterior capsulotomy.

We used the neodymium-YAG laser to perform discission of the posterior capsule in 49 eyes of 47 patients who had undergone previous extracapsular cataract extraction. The visual results were encouraging, with an improvement in visual acuity of one or more Snellen lines in 45 eyes and an improvement of three or more Snellen lines in 33 eyes. The complications included increases in intraocular pressure in 28 eyes. Intraocular pressures between 21 and 40 mm Hg were detected in 21 eyes and exceeded 41 mm Hg in another seven. In 14 of the 16 eyes in which intraocular pressure increased to more than 30 mm Hg, the maximum intraocular pressure was detectable within three hours after treatment. Other complications included damage to the intraocular lens in 12 of 30 eyes with implants and rupture of the anterior hyaloid face with forward displacement of vitreous into the anterior chamber in six of 19 eyes without implants. One of these eyes later developed a rhegmatogenous retinal detachment. A transient laser-induced hemorrhage occurred in one eye.

Acute monocular visual loss secondary to anterior communicating artery aneurysm in a patient with sickle cell disease.

A patient with sickle cell disease had acute monocular visual loss with no visible vitreal or retinal abnormalities. A large aneurysm of the anterior communicating cerebral artery was found, with direct compression of the optic nerve. This represents a very rare presentation of a relatively common lesion. Consideration should always be given to compressive lesions as the cause of acute monocular visual loss in the absence of visible vitreal, retinal, or optic nerve disease.

Management of persistent hyperplastic primary vitreous.

Instruments designed for pars plana vitrectomy can be used to manage selected complicated congenital cataracts such as those with persistent hyperplastic primary vitreous (PHPV). We have applied closed-eye vitrectomy techniques through a limbal approach in seven eyes with PHPV. A clear pupillary space was achieved in all cases and two of the seven eyes achieved useful vision. The management of children with complicated congenital cataracts such as those with PHPV is discussed.

Intraocular lenses: experience at The Wilmer Institute.

Nine hundred and thirty-eight consecutive primary intraocular lens (IOL) implant cases performed at The Wilmer Institute during the past six years by two surgeons were reviewed. Progressive corneal endothelial cell loss and an increased rate of late-onset corneal oedema were detected in the group with the Morcher (European) four-loop iris-clip Binkhorst IOLs. A higher rate of clinically-significant cystoid macular oedema developed in eyes with the American-manufactured four-loop Binkhorst lens, presumably from chronic iritis caused by contaminants on the IOLs. Our short-term results with the American-manufactured Shearing-type IOLs implanted at the time of extracapsular cataract extraction are encouraging, with 96% of cases achieving 20/40 vision or better, excluding those with known macular degeneration or amblyopia. Analysis of data submitted to the United States Food and Drug Administration (FDA) indicates that most of the four classes of intraocular lenses (anterior chamber, pupillary-supported, iridocapsular, and posterior chamber) are safe and effective at one-year follow-up. During the past three years there has been a gradual shift of preference in the type of IOLs being implanted--away from pupillary-supported and iridocapsular IOLs and, in part, from anterior chamber IOLs, to posterior chamber IOLs. A continued conservative approach to IOL implantation is recommended.

Persistent hyperplastic primary vitreous. Surgical treatment.

Instruments designed for pars plana vitrectomy can be used to manage selected complicated congenital cataracts such as those with persistent hyperplastic primary vitreous (PHPV). We have applied closed-eye vitrectomy techniques through a limbal approach in seven eyes with PHPV. A clear pupillary space was achieved in all cases and two eyes achieved useful postoperative vision. The management of children with complicated congenital cataracts, such as with PHPV, is discussed.

Methods for evaluation of medical therapy of senile and diabetic cataracts.

Loss of transparency in the human lens can be documented by a variety of methods including: (a) slit lamp photography with or without corrections for depth of focus; (b) retroillumination photography alone or coupled to densitometry; (c) high resolution targets projected into the eye and visualized by an ophthalmoscope; (d) drawings and/or measurements of lens opacities; (e) visual acuity determinations after visualization of the macular area and complete eye examination. The advantages and practical uses of each method were reviewed with reference to its value in determining the progression of cataracts in humans. Diabetes accelerates cataract development as determined from graphic plots of cataracts classified after surgical extraction vs the patient's age. Using similar methods high aspirin dosages administered through many years were found to decelerate cataract progression. Drugs for preventing development of diabetic cataracts in animals include inhibitors of aldose reductase or glycosylation such as sulindac (Clinoril), sorbinil or aspirin.

Hermansky-Pudlak syndrome: albinism with lipofuscin storage.

The Hermansky-Pudlak Syndrome, a "tyrosinase positive' form of oculocutaneous albinism, is a triad comprising albinism, a hemorrhagic diathesis and ceroid-lipofuscin storage. A pedigree is presented showing consanguinity with a pattern of pseudodominance. Electroretinography in two isolated Hermansky-Pudlak subjects was distinctly abnormal, showing decreased rod and cone responses (as well as abnormal flicker fusion responses) in one patient, and reduced photopic and scotopic responses in another. The decreased ERG responses are discussed with reference to the known retinal abnormalities in both generalized oculocutaneous albinism and Batten's disease, another ceroid-lipofuscin storage disorder.

Malignant glucagonoma syndrome: response to chemotherapy.

A 58-year-old white woman with known metastatic glucagonoma had widespread necrolytic migratory erythema characteristic of the glucagonoma syndrome. She did not respond to conventional chemotherapy with streptozocin. After one course of dacarbazine therapy, she had remission of the glucagonoma clinically with regression of tumor metastases as defined by liver scanning. After 10 months and additional courses of dacarbazine therapy, she remains in clinical remission. Plasma glucagon levels have decreased although they remain at two to four times the upper limit of normal. On several occasions there was resolution of this patient's rash after intravenous glucose in the absence of supplemental amino acids. We conclude that dacarbazine is an effective mode of chemotherapy for malignant glucagonoma.