Prosthetic iris implantation for congenital, traumatic, or functional iris deficiencies.

PURPOSE: To determine the efficacy and safety of surgical implantation of prosthetic iris devices in patients with anatomic or functional iris deficiencies. SETTING: Cincinnati Eye Institute, Cincinnati, Ohio, USA. METHODS: Twenty-five patients were enrolled in an interventional prospective noncomparative case series. Twenty-eight eyes had prosthetic iris diaphragm implantation for traumatic iris defects, congenital aniridia or iris coloboma, herpetic iris atrophy, surgical iris loss, or ocular albinism. Prosthetic iris implantation was performed with phacoemulsification and intraocular lens (IOL) implantation in 20 eyes, secondary IOL implantation in 6 eyes, and IOL exchange in 1 eye. A single pseudophakic eye with disabling glare secondary to traumatic aniridia had secondary prosthetic iris implantation alone. The surgical ease of insertion, intraoperative and postoperative complications, postoperative anatomic results, visual acuity, and subjective glare reduction were evaluated. RESULTS: Patients were followed postoperatively for a mean of 10.2 months (range 1.4 to 25.7 months). All eyes achieved the desired anatomic result. Visual acuity was improved in 22 of 28 eyes (79%), unchanged in 5 eyes, and worsened by a single line in 1 eye. Patients were surveyed postoperatively to determine the change in glare disability. The severity of glare disability was subjectively improved in 23 of 24 patients (96%) who responded to the survey. Intraoperative complications included 3 fractured implants as well as an incomplete or torn capsulorhexis in 3 eyes. Postoperative complications included transient hypotony in 2 eyes, mild persistent inflammation in 1 eye, and macular edema followed by a retinal detachment in 1 eye with recent severe trauma. CONCLUSIONS: Implantation of prosthetic iris devices improved postoperative outcomes by reducing glare disability and, in selected cases, by correcting aphakia. Although operating on traumatized, congenitally aniridic, or uveitic eyes presents special challenges, implantation of prosthetic iris devices appears to be a safe and effective method for reducing the ubiquitous glare in patients with iris deficiency.

Indocyanine green-assisted peeling of the retinal internal limiting membrane during vitrectomy surgery for macular hole repair.

OBJECTIVE: To determine the efficacy and safety of indocyanine green (ICG)-assisted retinal internal limiting membrane (ILM) peeling during macular hole repair. DESIGN: Interventional, noncomparative, prospective case series. PARTICIPANTS: Twenty-four consecutive patients (24 eyes) with stage 3 or 4 macular holes. INTERVENTION: All eyes underwent a pars plana vitrectomy, including peeling of the posterior cortical hyaloid when necessary. Indocyanine green dye (0.5%) was instilled into the posterior vitreous cavity over the macula and left in place for 3 to 5 minutes. After removal of the ICG, the retinal ILM was peeled. Medium- to long-acting gas tamponade was used in all cases, and all patients were asked to position face down for 1 to 2 weeks. MAIN OUTCOME MEASURES: Intraoperative staining properties of ICG, technical ease of peeling of the retinal ILM, postoperative anatomic results, visual acuity, and complications were recorded. RESULTS: Indocyanine green stained the retinal ILM, but did not stain the underlying retina. Indocyanine green staining greatly facilitated the surgeons' ability to visualize and peel the ILM in each case. Peeled tissue was sent for both light and electron microscopic studies, which confirmed that the ICG-stained tissue was truly retinal ILM. Patients were observed after surgery for an average of 123 days (range, 23-195 days). Anatomic closure of the macular hole was achieved in 21 eyes (88%) with a single surgery. Visual acuity improved in 23 of 24 patients (96%) after surgery. There were no intra- or postoperative complications related to ICG use, and there was no clinical or fluorescein angiographic evidence of ICG toxicity. CONCLUSIONS: Indocyanine green stains the retinal ILM. This property facilitates ILM peeling by providing a stark contrast between the stained ILM and the unstained retina. Indocyanine green staining of the ILM appears to be a safe and useful adjunct in vitreous surgery for macular hole repair.

Indocyanine green-assisted peeling of the retinal internal limiting membrane.

OBJECTIVE: To determine whether indocyanine green (ICG) stains and facilitates peeling of the retinal internal limiting membrane (ILM). To investigate the different staining properties of the posterior cortical hyaloid, retinal ILM, and the retina after ILM removal. DESIGN: Autopsy eye study. MATERIALS: Eleven human cadaveric eyes. METHODS: Open sky vitrectomy including removal of the posterior cortical vitreous was performed. A 0.5% ICG solution was then injected into the posterior vitreous cavity over the macula. The dye was allowed to settle on the macula for 5 minutes and was then removed by mechanical aspiration. Peeling of the ILM was initiated with a bent needle and completed with intraocular forceps. Specimens were submitted for light and electron microscopy. MAIN OUTCOME MEASURES: Staining properties and ease of peeling of retinal ILM were evaluated. Retinal ILM removal was confirmed by histopathologic and electron microscopic examination. RESULTS: ICG contact with the retinal surface resulted in bright green staining of the ILM. This stain greatly facilitated ILM peeling by improving direct visualization of the membrane. The underlying retina did not stain, thus providing a clear distinction between the stained ILM and the unstained retina. Continuous circular peeling of the ILM was easily completed with this technique. Light microscopic and ultrastructural studies confirmed removal of the ILM. CONCLUSIONS: ICG solution distinctly stains the nearly invisible retinal ILM in human cadaveric eyes. ICG staining greatly facilitates ILM peeling by providing a stark contrast between the stained ILM and the unstained retina.

Nd:YAG laser photo-induced adhesion of the corneal epithelium.

We retrospectively studied eight patients with recurrent corneal erosions treated with the Nd:YAG laser using 0.4- to 0.5-mJ pulses applied to the region of Bowman's layer through an intact epithelium. All eight patients had resolution of their symptoms after treatment. Mean follow-up time was 21.2 months (range, 12.6 to 36.6 months). A patient who was scheduled for diagnostic enucleation for a posterior choroidal mass consented to undergo this laser treatment with varied energy settings six days before his enucleation. His cornea was studied with specular microscopy, light microscopy, and transmission electron microscopy. Light microscopy of the cornea disclosed rare 100-microns defects in Bowman's layer with subjacent compaction of the anterior stromal lamellae. Electron microscopy showed minute foci of disruption in Bowman's layer with new collagen formation. Fine fibrils connected the basal epithelial cells to the new collagen. Nd:YAG laser photo-induced adhesion of the corneal epithelium may represent an effective treatment alternative for patients with recurrent corneal erosions.

Silastic catheterization of the axillary vein in neonates: an alternative to the internal jugular vein.

The axillary vein is a suitable alternative to the jugular venous system for tunnelled silastic catheterization in neonates, and should be included in the armamentarium of the surgeon who treats neonates. It is technically easy and is comparable to the internal jugular vein in terms of complications. Proper positioning of the catheter tip can sometimes be problematic, but without a resultant increase in morbidity or mortality.

Ciprofloxacin-resistant bacterial keratitis.

Ciprofloxacin, a new broad-spectrum antibiotic effective against a variety of gram-positive and gram-negative bacteria, has recently become available in topical ophthalmic solution (3 mg/ml) for the treatment of bacterial keratitis. It has rapidly become the drug of choice in treating bacterial keratitis. We treated three patients with bacterial corneal ulcers that were resistant to ciprofloxacin, yet were effectively treated with other topical antimicrobial agents. The initial culture results are important in the therapy of corneal ulcers.

Spinal anesthesia reduces the hazard of apnea in high-risk infants.

General anesthesia in premature babies is associated with a significant risk of life-threatening apnea. Spinal anesthesia in the high-risk infant is simple, safe, and effective, but the incidence of apnea with its use has not been previously determined. The total absence of apnea in 84 high-risk infants suggests that surgery below the umbilicus under spinal anesthesia can safely be performed on an outpatient basis in preterm infants or babies with a history of apnea. Ketamine as an adjunctive agent adds no apparent risk. The technique is relatively easy, surgery is not compromised, and parental acceptance is high.

A 40-year multinational retrospective study of 880 Swenson procedures.

This report reviews the experience of pediatric surgeons in seven cities in North American and Western Europe where the Swenson procedure was performed on 880 patients. Information on the diagnosis, treatment, complications, and long-term results was collected by reviewing the hospital records, the treating physicians' office records, and by interviewing the patients in person or by telephone. A follow-up evaluation was obtained on 814 patients. The patients' ages at the time of the resection ranged from four days to 50 years. The length of follow-up averaged 10.3 years, while the longest follow-up was 39.5 years. The overall postoperative mortality was 2.4% during the entire 40 years of the study. The postoperative mortality has decreased to 1.25% for the last 20 years. Significant factors influencing postoperative mortality included Down's syndrome, the patient's age at the time of the operation, and leak of the distal colonic anastomosis. Most of the patients followed for over 5 years have normal bowel habits, report one to three bowel movements per day, and have no soiling. No patient has urinary incontinence or impotence.

Diagnostic dilemmas of mediastinal cysts.

Children with foregut cysts of the mediastinum can present at any age with nonspecific respiratory symptoms or dysphagia. Chest radiograph and barium esophagram are recommended for initial evaluation, but they fail to identify some lesions. In other cases, an obvious mass may be confused with a solid neoplasm. We have operated upon 34 infants and children with mediastinal bronchogenic cysts and esophageal duplications from 1968 through 1985. This review of their clinical course and radiographic imaging studies emphasizes some of the diagnostic pitfalls that lead to operative delay. Twelve (35%) of these patients were asymptomatic. The correct diagnosis was delayed longer than 3 months from the onset of symptoms in 14 of the 22 symptomatic children. Fifteen of these presented with pneumonia or symptoms or airway obstruction. In 11, the cyst was in a perihilar or subcarinal location, areas in which a lesion can be "hidden" behind the cardiac silhouette. Five children with esophageal duplication had severe neonatal respiratory failure, chest pain, hematemesis or dysphagia. The immediate preop chest radiograph revealed a mass in 29 of 34 cases. However, the lesion was initially missed or never seen in eight of those who were symptomatic. Esophagram, performed in 23, was diagnostic in only six and was normal in four. Prior to 1979 when CT scanning became available at this institution, 11 of 19 children (57%) underwent extensive work-up, but the preop diagnosis was correct in only 50%. Since 1979, only 4 of 15 (26%) have required similar evaluation, and the preop diagnosis has been correct in all.(ABSTRACT TRUNCATED AT 250 WORDS)

Dose-response studies of penicillamine and related compounds in reducing skin--tensile strength of rats.

Penicillamine (I) and certain related compounds are known to reduce the skin tensile strength (sts) of rat dorsal skin when they are given in the diet. This effect seems significant to studies of the biochemistry of collagen and of diseases of collagen, perhaps including the arthritides. The reduction of sts appears to be caused by diminution of collagen crosslinking. The effects of several such compounds were studied after intraperitoneal (ip) injection, in order to determine structure-activity relationships divorced from possible anorexic or gastrointestinal complications seen after oral dosing, and to examine the relation of ip dose to response. A cyclopentyl analog (II) of I was at least as active as I, showing that structural variants of I can be active when given ip. A dimethylthiazolidine (V) and a zinc chelate (III, rather toxic) of I were nearly as active as I, showing that probable in vivo precursors of I can be obtained that will be active when given ip. The disulfide of I and a zinc chelate of cysteine were inactive. Maximum response for several compounds seemed to occur at intermediate dose levels, with larger or smaller doses affording less sts reduction.