Keratorefractive surgery.

The Council on Scientific Affairs of the California Medical Association presents the following epitomes of progress in ophthalmology. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and clinical importance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, and scholars to stay abreast of progress in medicine, whether in their own field of special interest or another. The epitomes included here were selected by the Advisory Panel to the Section on Ophthalmology of the California Medical Association, and the summaries were prepared under the direction of Alfred C. Marrone, MD, and the panel.

Efficacy and complication rate of 16,224 consecutive peribulbar blocks. A prospective multicenter study.

Although usually safe, retrobulbar anesthesia and peribulbar anesthesia have potentially sight- and life-threatening complications. Although it has been suggested that peribulbar anesthesia is as effective and safer than retrobulbar anesthesia, no large study has addressed the true rate of complications. To determine the efficacy and safety of peribulbar anesthesia, this study prospectively examined 16,224 consecutive peribulbar blocks. Twelve centers in the United States, Germany, and Chile participated in the study. After a peribulbar block was administered, the degree of akinesia, amaurosis, percentage of supplemental blocks required, and side effects and complications occurring after the block and for six weeks were recorded. Perioperative and late optic nerve complications were included. To approximate a real-life situation, ophthalmologists, anesthesiologists, and certified registered nurse anesthetists performed the blocks. Ninety-five percent of patients achieved a 95% or greater degree of akinesia. The incidence of complications in the consecutive cases was low. Orbital hemorrhage occurred in 12 cases (0.74%). There was one globe perforation (0.006%), two expulsive hemorrhages (0.013%), one grand mal seizure (0.006%), and no cases of cardiac or respiratory depression or deaths. Peribulbar is as effective as retrobulbar anesthesia and appears to lead to fewer sight- and life-threatening complications, even when slightly different peribulbar techniques are used. This is especially true when the anesthetic is administered with a 1 1/4-inch or shorter needle with the eye in the primary position, followed by ten to 15 minutes of ocular compression.

Posterior peribulbar anesthesia: an alternative to retrobulbar anesthesia.

Peribulbar anesthesia is a safe alternative to retrobulbar anesthesia for ophthalmic surgery. Because the anesthetic is deposited outside the muscle cone, the potential for intraocular or intradural injection is greatly minimized. Furthermore, intraconal hemorrhage and direct optic nerve injury is avoided. We illustrate the details of our technique for posterior peribulbar anesthesia and describe our experience in over 3,000 cases.

Relaxing incisions with augmentation sutures for the correction of postkeratoplasty astigmatism.

We performed a prospective study of relaxing incisions with augmentation sutures in 21 patients who were unable to wear spectacles or contact lenses after penetrating keratoplasty because of high astigmatism. The mean preoperative astigmatism was 9.37 diopters (range, 4.50 to 14.50 diopters), and the mean postoperative astigmatism was 3.73 diopters (range, 0.00 to 7.00 diopters). The net decrease in astigmatism was 6.56 diopters (range, 1.00 to 11.00 diopters), which represents a 67% decrease in astigmatism. The mean vector corrected change in astigmatism was 8.40 diopters (86%). These results were compared with those of our previous study of relaxing incisions without sutures. Overall, there was a significantly greater decrease in astigmatism (67% vs 47%, P = .009) when augmentation sutures were placed 90 degrees away from the relaxing incisions. Furthermore, in patients with more than 8.50 diopters of astigmatism, relaxing incisions with sutures yielded a much greater reduction in astigmatism compared with relaxing incisions without sutures (70% with sutures vs 39% without sutures, P = .002). We recommend relaxing incisions with augmentation sutures as the initial surgical procedure in eyes with more than 8.50 diopters of astigmatism.

Anterior clear spaces in keratoconus.

Anterior clear spaces were observed prospectively at slit-lamp examination in 26 of 69 consecutive eyes (38%) with keratoconus. Two corneal buttons with this finding were examined by light and electron microscopy and revealed breaks in Bowman's layer. Anterior clear spaces should be considered in the spectrum of clinical findings in keratoconus.

Posterior peribulbar anesthesia: an alternative to retrobulbar anesthesia.

Posterior peribulbar anesthesia is a safe alternative to retrobulbar anesthesia for ophthalmic surgery. Because the anesthetic is deposited outside the muscle cone, the potential for intraocular or intradural injection is greatly minimized. Furthermore, intraconal hemorrhage and direct optic nerve injury is avoided. We illustrate the details of our technique for posterior peribulbar anesthesia and describe our experience in over 1,600 cases.

Periorbital osteosarcoma: an unusual case report and review of the clinical and histopathological features.

We will describe a case of a rapidly growing osteoma of the orbit in a young boy presenting with orbital cellulitis. The subsequent discussion elucidates the clinical and radiographic features of osteoma and attempts to clarify the confusing terminology surrounding the histopathology of the three main types of osteoma. Patients with osteoma of the skull should be referred for appropriate gastrointestinal studies to rule out the occurrence of Gardner's syndrome.

Clinical and histologic findings in opportunistic ocular infections. Part of a new syndrome of acquired immunodeficiency.

White retinal opacities and ocular inflammation may be two of the early signs of a new syndrome of acquired immunodeficiency. This syndrome primarily affects young homosexual men and is characterized by acquired cellular immunodeficiency in infections with multiple opportunistic microorganisms in addition to Kaposi's sarcoma. The apparently innocent ocular findings may be the first harbingers of this devastating syndrome.

Development and prediction of postpsychotic depression in neuroleptic-treated schizophrenics.

Data were collected during a year-long multicenter collaborative trial comparing short-acting fluphenazine hydrochloride with long-acting fluphenazine decanoate in a group of schizophrenic patients being maintained in the community. We examined the emergence and course of depressive symptomatology, operationally defined by the Hamilton Depression Scale total score. Of 211 patients, approximately 25% had depression develop within five months after discharge. Depressed patients had a more chronic psychiatric history and, contrary to the hypothesis that depression is a favorable prognostic indicator, they were more likely to relapse. There were no differences in incidence of emergent depression between the two drug treatment groups.

The treatment of psychotic major depressive disorder with drugs and electroconvulsive therapy.

A retrospective chart review of 54 patients demonstrating depression with psychotic symptoms was accomplished with the use of Research Diagnostic Criteria (RDC) for diagnosis of psychotic major affective disorder. Patients received adequate trials of either tricyclic antidepressants alone, antipsychotics, the two in combination, or electroconvulsive therapy (ECT). Antidepressants alone were found to be ineffective or only partially effective in treating psychotic depression unless somatic or depressive declusions were the only psychotic symptoms. Antipsychotics alone were usually effective in providing at least a partial response, particularly with psychotic symptoms. Excellent responses of the depressive and psychotic elements were provided with ECT, ECT with antipsychotic medication, and the combination of antidepressant and antipsychotic medications. These latter treatments may be the most appropriate for depression with psychotic features.

A comparison of two unilateral ECT electrode placements: efficacy and electrical energy considerations.

The authors compared the treatment outcomes and ECT energy requirements of 10 patients treated with the Muller unilateral placement method (secondary electrode in the frontal position) with those of 10 matched patients treated with the unilateral placement described by d'Elia (secondary electrode lateral to the vertex). Both groups showed a similar dramatic clinical improvement after ECT; however, the mean watt seconds required for the Muller method was nearly four times that for the d'Elia procedure. The treating physicians reported that the patients treated by the d'Elia method had fewer anterograde and retrograde memory disturbances and that they were alert and oriented sooner after ECT.